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


CONCLUSIONS
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.
Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA.
Meredith A
MA
Olson
Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA.
Christine M
CM
Lohse
Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
Nneka I
NI
Comfere
Computerized provider order entry; dermatopathology; electronic health record; encounter visit note; requisition form
Am J Clin Pathol. 2016 Dec;146(6):727-735
28028116
Arch Pathol Lab Med. 1999 Jul;123(7):615-9
10388918
Int J Dermatol. 2014 May;53(5):549-57
24116717
Clin Lab Med. 2016 Mar;36(1):31-9
26851662
J Cutan Pathol. 2015 May;42(5):333-45
25757028
Diagn Interv Imaging. 2014 Jan;95(1):69-75
23999241
Am J Clin Pathol. 2015 Apr;143(4):593-7
25780013
J Am Acad Dermatol. 2010 Feb;62(2):257-61
19962786
J Am Acad Dermatol. 2015 Feb;72(2):353-5
25592344