ANALYSIS OF INFORMATION DOCUMENTED IN HISTOPATHOLOGY REQUEST FORMS IN A TERTIARY CARE TEACHINGHOSPITAL OF A RURALAREA - A RETROSPECTIVE STUDY

Introduction: The utility of a histopathology report are highly dependent on the quality of clinical details provided to the pathologist. Acomplete request form enables precise correlation between histo-morphological findings and the patient's clinical presentation. This enhances diagnostic accuracy and minimizes the risk of misinterpretation. Materials And Methods: Aretrospective study was conducted including all histopathology request forms submitted in the department of Pathology during the year 2023 in a tertiary care teaching hospital in a rural area. Results: Among the 1096 forms collected, 4.5% did not have the name of the patient legibly written. Designation and department of the consultant signing the request was missing in 95.1 %. Clinical findings was not entered in 51.8% of the forms. In 30.2% cases even the clinical diagnosis was found to be missing. In 80.9% of cases, relevant investigation results like imaging reports was not entered. In 97.6% surgical findings or treatment details were not provided. Most of the forms had only personal details and the nature of the specimen mentioned Conclusion: The gross shortcomings in provision of information including patient identifiers, clinical findings and diagnostic details would lead to an incompetent result from the pathologist. This study throws a light into the need for improved adherence to documentation standards. Addressing these issues periodically in an institution and conducting training programs about standard guidelines are essential for improving the quality of reports.