Unveiling documentation deficiencies: a clinical audit of histopathology request forms at a tertiary care hospital

Area of Science:

• Medical Diagnostics
• Pathology
• Healthcare Quality Improvement

Background:

• Accurate histopathology request forms are vital for precise diagnosis and effective patient treatment.
• Documentation gaps in these forms can impede diagnostic workflows and patient care.
• This study addresses the need to evaluate and enhance the completeness of histopathology request forms.

Purpose of the Study:

• To audit the completeness of histopathology request forms at Fauji Foundation Hospital.
• To identify specific areas of documentation deficiency.
• To provide a basis for targeted improvements in form completion.

Main Methods:

• A retrospective review of 300 histopathology request forms submitted between January and June 2024.
• Evaluation of forms for completeness regarding patient demographics, hospital admission, biopsy details, and clinical notes.
• Data analysis using SPSS, followed by an educational intervention to address identified gaps.

Main Results:

• High compliance was observed for patient profile details.
• Significant deficiencies were noted in patient contact information (39.7% reporting) and clinical notes (27.3% incomplete).
• Post-intervention, improvements were seen in documenting patient contact details and biopsy nature.

Conclusions:

• Thorough and accurate histopathology request forms are essential for optimal patient care.
• Addressing documentation gaps through improved practices and ongoing education is critical.
• Enhancing form completeness directly supports diagnostic accuracy and patient management.