Structured pathology reporting improves the macroscopic assessment of rectal tumour resection specimens.
We examined whether introduction of a structured macroscopic reporting template for rectal tumour resection specimens improved the completeness and efficiency in collecting key macroscopic data elements. Fifty free text (narrative) macroscopic reports retrieved from 2012 to 2014 were compared with 50 structured macroscopic reports from 2013 to 2015, all of which were generated at John Hunter Hospital, Newcastle, NSW. The six standard macroscopic data elements examined in this study were reported in all 50 anatomical pathology reports using a structured macroscopic reporting dictation template. Free text reports demonstrated significantly impaired data collection when recording intactness of mesorectum (p<0.001), relationship to anterior peritoneal reflection (p=0.028) and distance of tumour to the non-peritonealised circumferential margin (p<0.001). The number of words used was also significantly (p<0.001) reduced using pre-formatted structured reports compared to free text reports. The introduction of a structured reporting dictation template improves data collection and may reduce the subsequent administrative burden when macroscopically evaluating rectal resections.
Department of Anatomical Pathology, Pathology North, John Hunter Hospital, Newcastle, NSW, Australia. Electronic address: simon.king@hnehealth.nsw.gov.au.
Simon
S
King
Senior Project Manager, Royal College of Pathologists of Australasia, Surry Hills, Sydney, NSW, Australia.
Margaret
M
Dimech
Department of Anatomical Pathology, Pathology North, John Hunter Hospital, Newcastle, NSW, Australia.
Susan
S
Johnstone
D001706:Biopsy; D006801:Humans; D008499:Medical Records; D010336:Pathology / Q000592:standards*; D012004:Rectal Neoplasms / Q000473:pathology*; D058028:Research Report
RCPA Macroscopic Cut-up Manual; Rectal cancer; dictation template; key data elements; macroscopic description; rectal resection; structured macroscopic report; synoptic report