Audit of Histopathology Request Forms in a Teaching Hospital: Assessing the Adequacy of Clinician-Provided Information for Diagnosis

Abstract

Context: The laboratory request form is the first contact a patient has with the laboratory and it is where important information about the patient is required by the pathologist to make their input in the management of the patient. Insufficient patient information can lead to delay in issuing pathology reports and could be a source of diagnostic error.

Objective: The study aimed to evaluate the adequacy of information on the request forms accompanying histopathology samples submitted to the Department of Morbid Anatomy and Histopathology, LAUTECH Teaching Hospital, Ogbomoso, Nigeria.

Settings and Design: This was a retrospective study in the Department of Morbid Anatomy and Histopathology, LAUTECH Teaching Hospital, Ogbomoso, Nigeria.

Methods and Materials: There was a standardized histopathology request form that all the departments across the hospital used to send their requests for histopathological examination. Each request form was assessed for the presence and completeness of the necessary items in the forms.

Statistical analysis used: Data obtained was analysed using both Microsoft Excel and Statistical Package for Social Sciences 23.0 (SPSS version 23.0). Results were presented in tables.

Results: Most of the specimens received were breast tissues (22.8%). Most requests were from the surgery department accounting for 57.0%. Doctor’s contact number was the least completed information (74.4% missing). Patient contact numbers were missing in 45.8% of requests made. Clinical information was not provided in 11% of the request forms. In 83.2% of the forms, clinical information provided was not adequate. None of the request forms contained all the necessary information required for histopathological diagnosis. There was a significant statistical association between nature of specimen and key variables like contact number of clinicians, clinical information and adequacy of clinical information with p-value of 0.05.

Conclusion: This study showed clinicians did not supply adequate information in most of their requests for histopathology services. There is need to sensitize clinicians on importance of providing adequate information in histopathology request forms.