Safe reading of chemical pathology reports: the RCPAQAP Report Assessment Survey

Abstract

Pathology reports are a vital component of the request-test-report cycle communicating pathology results to doctors to support clinical decision making. This should be done in a comprehensive, safe and time-efficient manner. As doctors may receive reports from different laboratories these goals can be achieved more readily if reports are formatted in the same way. This study evaluates the formatting of paper reports produced by Australian laboratories for numerical biochemistry results. As part of the RCPAQAP Liquid Serum Chemistry program in 2015, laboratories were invited to supply a routine paper report displaying the results. A total of 37 reports were received for analysis. These reports were assessed for variation in a range of components and, where possible, against relevant Australian standards and guidelines. In summary, there was a wide variation in most of the report components assessed including test names, result alignment, result flagging, sequence of data elements on the page, date formatting and patient name formatting. In most components there was also variation from the Standards. In order to ensure safe result transmission by printed reports there is a need to promote the adoption of current reporting standards and monitor compliance with similar external quality assurance programs.