Journal of Pathology Informatics Journal of Pathology Informatics
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ORIGINAL ARTICLE
Year : 2016  |  Volume : 7  |  Issue : 1  |  Page : 40

Rates of provision of clinical information in the skin biopsy requisition form and corresponding encounter visit note


1 Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
2 Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA
3 Department of Dermatology; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA

Correspondence Address:
Nneka I Comfere
Department of Dermatology; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2153-3539.189705

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Background: The skin biopsy requisition form (RF) serves as a key communication tool for transfer of relevant information related to skin biopsy between clinicians and pathologists. Clinical information in the skin biopsy RF is frequently missing or incomplete. Objective: To determine the rates of provision of critical clinical information necessary for histopathologic interpretation in the skin biopsy RF and encounter visit note (EVN). Methods: A retrospective review of 300 RFs and corresponding EVNs from May 1 to 7, 2012, in a tertiary care dermatology practice. Results: Age (100%), lesion location (100%), and clinical impression (93%) were the most commonly supplied elements in the RF and EVN. Clinical elements that were commonly not provided in the RF but present in the EVN included sampling method - partial versus complete (46%), duration of lesion (54%), morphology of lesion (97%), clinical symptoms (63%), clinical photos (63%), previous clinical (97%), and dermatopathologic diagnoses (82%). Limitations: Retrospective study design. Conclusions: These data suggest that while missing critical clinical information in the RF is often present in the EVN, some information is still not present in either source.


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