Breast biopsy pathology request forms: are the radiologists completing them correctly and legibly?

Introduction

Radiologists rightly feel that imaging request forms should be completed correctly. Pathologists also require a minimum dataset to be completed on all histopathology requests. The breast screening radiologists and pathologists initiated an audit of wide-bore needle breast biopsy pathology request forms.

Standard

One hundred per cent of pathology forms should be completed correctly and legibly.

Methods

Forty breast wide-bore core biopsy pathology forms were reviewed. The principle data collected included patient demographics, clinical details and requesting doctor information. Forms were scored for legibility. Each item of data from each form was collected and compared against the standard.

Results

The initial audit showed multiple minor deficiencies in form completion. Only 67.39% of total request details were completed correctly and 82% of request forms were easily legible. The radiologists did not appreciate the significance of a number of the pathology fields. These results were reviewed with the pathologists. Cross-checking by imaging assistants was introduced. A re-audit was performed, showing improvement; 84.9% of total request details were now completed correctly and all forms were legible.

Conclusion

Correct completion of pathology forms is essential. Breast radiologists may not always appreciate all of the data required by their local pathologists.