A Quality Improvement Intervention to Enhance Documentation on Histopathology Request Forms
Year: 2025
Type: article
Abstract: Introduction Incomplete histopathology request form documentation can compromise diagnostic accuracy and delay patient management. This study aimed to assess and improve documentation completeness using a structured quality improvement approach. Methods A clinical audit was conducted at a tertiary care hospital using the Plan-Do-Study-Act (PDSA) cycle. In the first audit cycle, 250 histopathology request forms were reviewed for completeness. Based on the findings, targeted interventions were implemented, including a standardized request form, clinician engagement, and improved accessibility to forms. A second audit cycle assessed 150 forms to evaluate the impact of these interventions. Results Significant improvements were observed across all documentation parameters. Clinical history documentation increased from 0% to 62%, while presenting complaints improved from 3.2% to 73%. Physical examination findings were recorded in 96% of cases compared to 73.6% initially, and radiological findings improved from 44.4% to 95%. Laboratory investigation results increased from 41.2% to 81%, while drug/medication history documentation rose from 6% to 48%. Specimen details also showed improvement, with biopsy time documentation increasing from 3.2% to 66% and provisional diagnosis documentation rising from 49.2% to 78%. Conclusion A structured quality improvement approach led to significant enhancements in documentation completeness. Ongoing audits, clinician training, and digital solutions are recommended for sustaining these improvements.
Source: Cureus
DOI: 10.7759/cureus.81317
Authors: Farrukh Ansar, Mohammad S Rauf, Muhammad Kinwan Khan, Uzma Rauf, Muhammad Bilal Ahmad, Ayesha Ishtiaq, Muhammad Zuama Zafar Butt, Fatima Abdul Hameed, Sabahat Ali, Amna Amin
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4408950399