A Quality Improvement Intervention to Enhance Documentation on Histopathology Request Forms.

Area of Science:

• Medical Diagnostics
• Healthcare Quality Improvement
• Pathology

Background:

• Incomplete histopathology request forms can negatively impact diagnostic accuracy and patient care timelines.
• Standardized documentation is crucial for effective histopathology reporting.

Purpose of the Study:

• To assess the completeness of histopathology request form documentation.
• To implement and evaluate a structured quality improvement program to enhance documentation.

Main Methods:

• A clinical audit using the Plan-Do-Study-Act (PDSA) cycle at a tertiary care hospital.
• Two audit cycles reviewed 250 and 150 histopathology request forms, respectively.
• Interventions included a standardized form, clinician engagement, and improved form accessibility.

Main Results:

• Significant improvements were noted in all documentation parameters.
• Clinical history documentation increased from 0% to 62%; presenting complaints from 3.2% to 73%.
• Physical examination findings rose to 96%, radiological findings to 95%, and laboratory results to 81%.

Conclusions:

• A structured quality improvement approach effectively enhanced histopathology request form documentation completeness.
• Sustained improvement requires ongoing audits, clinician training, and digital solutions.