Need for a Patient-centric Approach When Writing Pathology Reports

Pathology ReportsPatient-centered care (sharing the management of an illness between the patient and the doctor) in general is very important for effective healthcare as it will increase adherence to management protocols, reduce morbidity and improve the quality of life of patients. The reason why patient-centered care is effective in pathology is that it helps patients understand their illness and participate in clinical decision-making through collaboration with the pathologists. However, this is possible only if patients can comprehend the pathology reports. This is why practices try to follow a patient-centric approach in such reports.

A 2014 study by a group of researchers at the University of Washington revealed that there is less adoption of patient-centered approaches in pathology reports. Most of the reports do not target patients as audience. It was also found that a significant number of patients lack the ability to comprehend this technical and complex document. The themes included in the proposed improvements in reports were content standardization, variation in terminology, clarity of communication and quality improvement. The study concluded that there are limited resources available to help patients comprehend the reports and efforts to enhance patient-centered communication are required to address this aspect of patient care.

Another study was published in 2014 by a group of American researchers, which evaluated the readability of pathology reports for common urologic cancers such as prostate, bladder, kidney, and testicular cancer to find out the sources of confusion that could be resolved through modified patient-centered reports. The study found that the reading levels of such reports are above the average reading capability of most American people. Though the removal of descriptive pathologic terms and the replacement of complex medical terminology with lay terms improved the readability for certain urologic oncology reports, it lessened the clarity of other reports.

The report that follows a patient-centered approach will include the patient’s chief concern or request, his/her illness experience, details about the disease (history of present past illness, review of systems, physical exam, laboratory exams and more), patient profile and individual life cycle phase, family history, genogram, culture and ecosystem, patient-doctor relationship, assessment, general discussion and proposed management plan. In short, pathology practices should adopt a patient-friendly approach while transcribing medical reports to ensure better patient care and improved patient satisfaction.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.