• Image-Guided Biopsy
• Histology
• CLINICAL AUDIT

In his excellent review on macroscopic pathology, Shepherd refers to the lack of adequate clinical information on pathology requisition forms.1 This is a common rant among pathologists and I wonder if this lacuna is partly because of clinicians’ lack of awareness of the specific information that is needed (with dermatology, nephrology and neurology/neurosurgery being honourable exceptions). The only paper which specifically guides physicians on how to fill up requisition forms is in veterinary medicine!2 The one similar paper in human medicine was a satire.3

I provide, for the benefit of my clinical colleagues, especially those in training, the reasoning behind pathologists’ need for relevant clinical data. Most pathology requisition forms will need only one or two pertinent lines. In many cases, just the site of the biopsy/excision with the provisional clinical diagnosis is sufficient. Only some cases will need minimal additional data for a complete and clinically useful pathology report.

The usual housekeeping rules apply: patients’ name, age and gender. This is for identification purposes and not least, for medico-legal reasons. The exact site of biopsy must be stated as certain entities - and specific therapy - are associated with specific anatomical areas.

The number of specimen bottles must match the number of specimens written on the form. Lost specimens can lead to grief and to lawsuits!

Document the exact time that …