Effect of using templates on the information included in histopathology reports on specimens of uterine cervix taken by loop excision of the transformation zone

Aim-To determine the change in information relayed from histopathologists t o clinicians by using templates for reporting specimens of uterine cervix s ampled by loop excision of the transformation zone (LETZ). Methods-Minimum datasets for the information required from LETZ specimens r eceived from the colposcopy clinic, Royal Infirmary, Edinburgh, were incorp orated into templates on the clinical service computer (Pinnacle) of the pa thology department, University of Edinburgh. Pathologists completed hard co py versions, which were transcribed into the computer templates for report generation. The effect of the changes on the quality of the pathology repor ts was studied. The number of cases in which each item in the dataset recei ved comment in template generated reports was compared with that in traditi onal prose reports compiled before the use of the templates and in prose re ports issued after the introduction of the templates. Questionnaire studies were undertaken of clinicians' and pathologists' opinions of the template reports. Results-In the template reports nearly all items received comment in almost 100% of cases. In the prose reports issued both before and after the templ ates were in use, most items were mentioned in a significantly lower propor tion of cases. Clinicians thought the template reports were clearer and the information could be more readily assimilated than from the prose versions . Conclusions-The use of template reports in these types of specimen allowed more consistent and detailed information transfer. The change appeared to r esult from the use of the templates rather than from increased awareness of the items to be reported.