# A Quality Improvement Intervention to Enhance Documentation on Histopathology Request Forms

## TL;DR

This study improved the completeness of histopathology request forms through targeted interventions, leading to better diagnostic accuracy and patient care.

## Contribution

The study demonstrates a successful quality improvement intervention using the PDSA cycle to enhance documentation completeness in histopathology.

## Key findings

- Clinical history documentation increased from 0% to 62% after interventions.
- Radiological findings documentation improved from 44.4% to 95%.
- Digital solutions and ongoing training are recommended to sustain improvements.

## 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.