Skip to main content
SpringerLink
Log in

Clinical History and Clinical Correlation

  • Chapter
  • First Online:
Error Reduction and Prevention in Surgical Pathology

  • 552 Accesses

Abstract

The surgical pathologist’s highest priority is his responsibility to the patient. The importance of clinical information and clinical correlation is recognized by pathologists and regulatory agencies. Such information is vital in leading to a diagnosis that is accurate and appropriately specific. In addition, appropriate clinical information may aid in triage of material for ancillary studies, allowing for economical workup of complex cases. Obtaining accurate clinical information is best accomplished by easy access to the electronic health record, but phone conversations and personal communications are sometimes necessary. With the ever-increasing use of ancillary testing in surgical pathology, clinical correlation is more dependent on the construction of comprehensive surgical pathology reports that reconcile all available clinical and laboratory data. Thus, the pathologist also bears responsibility for documenting clinical history and correlation. Failure to do so may have clinical and medicolegal consequences.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 129.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Rosai J. Introduction. In: Rosai J, editor. Rosai and Ackerman’s surgical pathology. 10th ed. Philadelphia: Elsevier; 2011. p. 1–23.

    Google Scholar 

  2. Lester SC. Requests for pathologic evaluation. In: Lester SC, editor. Manual of surgical pathology. 3rd ed. Philadelphia: Elsevier; 2010.

    Google Scholar 

  3. Oprea-Ilies GM, Majmudar B. Clinical history and specimen adequacy: clinicians are from mars and pathologists are from venus. In: Roberts CP, Broomfield DP, editors. Avoiding common obstetrics and gynecology errors. Philadelphia: Lippincott, Williams & Wilkins; 2011. p. 243–8.

    Google Scholar 

  4. Oprea-Ilies GM, Majmudar B. Frozen sections: use and misuse. In: Roberts CP, Broomfield DP, editors. Avoiding common obstetrics and gynecology errors. Philadelphia: Lippincott, Williams & Wilkins; 2011. p. 249–55.

    Google Scholar 

  5. Rambo ON. The limitations of histologic diagnosis. Prog Radiat Ther. 1962;2:215–24.

    CAS  PubMed  Google Scholar 

  6. College of American Pathologists Accreditation Program. Laboratory general checklist. In: 2017 inspection checklist. Northfield: College of American Pathologists; 08.21.2017: www.cap.org/accreditation.

  7. College of American Pathologists Accreditation Program. Anatomic pathology checklist. In: 2017 inspection checklist. Northfield: College of American Pathologists; 08.21.2017: www.cap.org/accreditation.

  8. College of American Pathologists Accreditation Program. Flow cytometry checklist. In: 2017 inspection checklist. Northfield: College of American Pathologists; 08.21.2017: www.cap.org/accreditation.

  9. College of American Pathologists Accreditation Program. Hematology and coagulation checklist. In: 2017 inspection checklist. Northfield: College of American Pathologists; 08.21.2017: www.cap.org/accreditation.

  10. Comprehensive accreditation manual for laboratory and point-of-care testing. Oakbrook: The Joint Commission; 2013.

    Google Scholar 

  11. Clinical and Laboratory Standards Institute (CLSI). Accuracy in patient and sample identification. In: CLSI Standard GP33. 2nd ed. Wayne: Clinical and Laboratory Standards Institute; 2019.

    Google Scholar 

  12. International Organization for Standardization. ISO 15189:2012 medical laboratories – requirements for quality and competence; section 16- pre-examination. Geneva: International Organization for Standardization; 2012.

    Google Scholar 

  13. Department of Health and Human Services Health Care Financing Administration. Clinical laboratory improvement amendments of 1988-standard: cytology. Fed Regist. 1992;57(40):7146 [42CFR493.1274(c)(2)].

    Google Scholar 

  14. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement amendments of 1988; final rule. Fed Regist. 2003:1034[42CFR493.1242(a)].

    Google Scholar 

  15. Carter DK. Regulatory compliance. In: Nakhleh RE, Fitzgibbons PL, editors. Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield: College of American Pathologists; 2005. p. 9–31.

    Google Scholar 

  16. Brown RW. Preanalytic variables: specimen submission and handling. In: Nakhleh RE, Fitzgibbons PL, editors. Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield: College of American Pathologists; 2005. p. 45–9.

    Google Scholar 

  17. Powsner SM, Costa J, Homer RJ. Clinicians are from Mars and pathologists are from Venus. Arch Pathol Lab Med. 2000;124:1040–6.

    CAS  PubMed  Google Scholar 

  18. Schnitt SJ, Collins LC. Specimen processing, evaluation, and reporting. In: Schnitt SJ, Collins LC, editors. Biopsy interpretation of the breast. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 448–64.

    Google Scholar 

  19. Nakhleh RE, Jones B, Zarbo RJ. Mammographically directed breast biopsies: a College of American Pathologists Q-Probes study of clinical physician expectations and of specimen handling and reporting characteristics in 434 institutions. Arch Pathol Lab Med. 1997;121(1):11–8.

    CAS  PubMed  Google Scholar 

  20. Idowu MO, Hardy LB, Souers RJ, Nakhleh RE. Pathologic diagnostic correlation with breast imaging findings: a College of American Pathologists Q-Probes study of 48 institutions. Arch Pathol Lab Med. 2012;136(1):53–60.

    Article  PubMed  Google Scholar 

  21. Lechago J. The frozen section: pathology in the trenches. Arch Pathol Lab Med. 2005;129:1529–31.

    PubMed  Google Scholar 

  22. Kilpatrick SE. Principles of musculoskeletal tumor diagnosis and management. In: Kilpatrick SE, editor. Diagnostic musculoskeletal surgical pathology. Philadelphia: Elsevier; 2004. p. 1–18.

    Google Scholar 

  23. Suriawinata AA, Antonio LB, Thung SN. Liver tissue processing and normal histology. In: Odze RD, Goldblum JR, editors. Surgical pathology of the GI tract, liver, biliary tract, and pancreas. 2nd ed. Philadelphia: Saunders; 2009. p. 963–78.

    Chapter  Google Scholar 

  24. Foucar K. Morphologic review of blood and bone marrow. In: Foucar K, Reichard K, Czuchlewski D, editors. Bone marrow pathology. 3rd ed. Chicago: ASCP Press; 2010. p. 29–51.

    Google Scholar 

  25. Burger PC. Clinical and radiological considerations. In: Burger PC, editor. Smears and frozen sections in surgical neuropathology. Baltimore: PB Medical Publishing; 2009. p. 11–20.

    Google Scholar 

  26. American Thoracic Society, European Respiratory Society. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Resp Care Crit Med. 2002;165(2):277–304.

    Article  Google Scholar 

  27. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: a College of American Pathologists Q-Probes study of 1,004,115 cases from 417 institutions. Arch Pathol Lab Med. 1996;120:227–33.

    CAS  PubMed  Google Scholar 

  28. Burton JL, Stephenson TJ. Are clinicians failing to supply adequate information when requesting a histopathological investigation? J Clin Pathol. 2001;54(10):806–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Zuk JA, Kenyon WE, Myskow MW. Audit in histopathology: description of an internal quality assessment scheme with analysis of preliminary results. J Clin Pathol. 1991;44(1):10–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Zardawi IM, Bennett G, Jain S, Brown M. Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital. J Clin Pathol. 1998;51(9):695–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Nakhleh RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology: a College of American Pathologists Q-Probes study of 771,475 surgical pathology cases from 341 institutions. Arch Pathol Lab Med. 1999;123(7):615–9.

    CAS  PubMed  Google Scholar 

  32. Renshaw AA, Gould EW. Impact of immediate access to the electronic medical record on anatomic pathology performance. Am J Clin Pathol. 2013;140:109–11.

    Article  PubMed  Google Scholar 

  33. Nakhleh RE. Error reduction in surgical pathology. Arch Pathol Lab Med. 2006;130(5):630–2.

    PubMed  Google Scholar 

  34. Sinard JH, Morrow JS. Informatics and anatomic pathology: meeting challenges and charting the future. Hum Pathol. 2001;32:143–8.

    Article  CAS  PubMed  Google Scholar 

  35. Nakhleh RE. Strategies for error reduction and prevention in surgical pathology. In: Nakhleh RE, Fitzgibbons PL, editors. Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield: College of American Pathologists; 2005. p. 33–40.

    Google Scholar 

  36. Association of Directors of Anatomic and Surgical Pathology. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Am J Clin Pathol. 2006;126:337–40.

    Article  Google Scholar 

  37. Nakhleh RE. What is quality in surgical pathology? J Clin Pathol. 2006;59:669–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Rex Healthcare, Raleigh, NC, USA

    Keith E. Volmar

Authors
  1. Keith E. Volmar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Keith E. Volmar .

Editor information

Editors and Affiliations

  1. Mayo Clinic Florida, Jacksonville, FL, USA

    Raouf E. Nakhleh

  2. Rex Healthcare, Raleigh, NC, USA

    Keith E. Volmar

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Mayo Foundation for Medical Education and Research

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Volmar, K.E. (2019). Clinical History and Clinical Correlation. In: Nakhleh, R., Volmar, K. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-18464-3_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-18464-3_7

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-18463-6

  • Online ISBN: 978-3-030-18464-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation