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ANZ J Surg ; 78(9): 796-9, 2008 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-18844912

RESUMO

BACKGROUND: Colorectal cancer (CRC) pathological reporting deficiencies have been shown to be common, with deviations from the suggested minimum dataset. Information from both surgeon and pathologist is necessary for a complete report. These deficiencies have been shown to be correctable with the use of synoptic reporting. We carried out an audit on a random sample of CRC pathological reports from the first 6 months of 2004 in Victoria, Australia, with the aim of documenting current CRC pathological reporting deficiencies. METHODS: A random sample of pathological reports for CRC was obtained from the Cancer Council of Victoria. One hundred and sixteen of these reports were reviewed by a team of surgical and pathology trainees. Presence or absence of the various fields of the 1999 National Health and Medical Research Council minimum dataset for CRC reporting was recorded. RESULTS: There were deviations from the minimal dataset. Most notable was the absence of the information on the apical node, the presence of distant metastasis and perineural invasion. CONCLUSIONS: The opportunity exists for improvement in the pathological reporting of CRC in Victoria through the uniform introduction of synoptic reporting.


Assuntos
Neoplasias Colorretais/patologia , Prontuários Médicos/normas , Serviço Hospitalar de Patologia/normas , Patologia Clínica/normas , Austrália , Documentação/normas , Controle de Formulários e Registros , Humanos , Auditoria Médica
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