Assessment of completion of forms requesting skin biopsies

An Bras Dermatol. 2012 Jan-Feb;87(1):115-8. doi: 10.1590/s0365-05962012000100014.

Abstract

Background: Information contained in request forms for histopathological examinations is essential for interpreting tissue changes observed in microscopy.

Objective: To determine the adequacy of information provided on forms requesting skin biopsies.

Method: Assessment, in two health institutions, of 647 forms requesting skin biopsies in order to determine the completeness on the forms of the clinical details/items considered necessary for undertaking skin biopsies.

Results: Of the total 18 items on the forms, 7 were found to relay complete information in under 10% of the forms and only 9 items were correctly completed in over 80% of the requests.

Conclusion: We concluded that information on many of the essential items required for a correct interpretation of the anatomopathologic examination was missing from the request forms.

MeSH terms

  • Biopsy
  • Brazil
  • Clinical Laboratory Information Systems
  • Diagnostic Tests, Routine
  • Forms and Records Control / standards*
  • Laboratories, Hospital / standards
  • Medical Records / standards
  • Skin Diseases / diagnosis*