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Documentation of Nursing Diagnosis

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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Addressing the Diagnostic Miscommunication in Pathology.

Lorna Mirham^1,2, Jessica Hanna³, George M Yousef^1,4

¹Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.

American Journal of Clinical Pathology

|April 28, 2021

Summary

Pathology reports can be difficult to understand, leading to miscommunication among doctors and patients. Improving clarity, consistency, and direct communication is essential for better treatment decisions.

Keywords:

Knowledge translation Miscommunication Pathology report

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Area of Science:

Medical Communication
Pathology Reporting

Background:

Pathology reports are vital communication tools but often present understanding challenges.
Communication barriers between pathologists, clinicians, and patients can hinder treatment decisions and lead to medical errors.

Purpose of the Study:

To review miscommunication issues in pathology reporting.
To propose solutions for enhancing communication effectiveness.

Main Methods:

Literature review focusing on communication barriers in pathology.
Analysis of factors contributing to report misinterpretation.

Main Results:

Up to 33% of clinicians experience difficulties understanding pathology reports.
Jargon, varying staging systems, and uncertainty expressions contribute to misinterpretation.
Active communication and direct pathologist-patient interaction show promise.

Conclusions:

Enhanced communication among pathologists, clinicians, and patients is necessary.
Key improvements include report clarity, consistency, quantified diagnostic confidence, and avoiding misnomers.