title: Clinician compliance with laboratory regulations requiring submission of relevant clinical data: A one year retrospective analysis.
abstract: BACKGROUND
  The College of American Pathologists (CAP) recognizes the need for clinical data in the interpretation of specimens submitted for histopathologic evaluation. Anecdotal evidence indicates that clinician compliance with requests for clinical history is variable.
  
  
  METHODS
  Quality assurance data from August 1, 2010 to September 31, 2011 were searched for all cases listing no clinical history. Four consecutive weeks of surgical pathology request forms were also reviewed for the presence or absence of clinical history and its accuracy.
  
  
  RESULTS
  21,700 cases were accessioned in the study period and 1293 (5.9%) requisitions contained no clinical history. The four-week review documented that 143 of 1698 (8.4%) requisitions had no clinical history and 12 cases contained incorrect history (0.7%).
  
  
  CONCLUSIONS
  Between 5.9% and 8.4% of requisitions contain no clinical history. In 0.2% of cases, clinical history was incorrect. Compliance with the CAP policy for clinical history appears poor.
authors.affiliation: Department of Pathology, University of Utah School of Medicine and ARUP Laboratories, Salt Lake City, UT, United States. layfiel@aruplab.com
authors.forename: Lester J
authors.initials: LJ
authors.lastname: Layfield
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Factor
authors.forename: Elke A
authors.initials: EA
authors.lastname: Jarboe
mesh_terms: D003299:Cooperative Behavior; D003951:Diagnostic Errors / Q000517:prevention & control; D019983:Guideline Adherence / Q000592:standards*; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards*; D008499:Medical Records / Q000592:standards*; D010340:Pathology, Surgical / Q000379:methods / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000379:methods / Q000592:standards*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013997:Time Factors