Information Adequacy in Histopathology Request Forms: A Milestone in Making a Communication Bridge Between Confusion and Clarity in Medical Diagnosis
Fariba ABBASI1,2, Yasaman ASGHARI3, Zahra NIAZKHANI4,5
1Solid Tumor Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, URMIA, IRAN
2Department of Pathology, School of Medicine, Urmia University of Medical Sciences, URMIA, IRAN
3Student Research Committee, Urmia University of Medical Sciences, URMIA, IRAN
4Nephrology and Kidney Transplant Research Center, Clinical Research Institute, Urmia University of Medical Sciences, URMIA, IRAN
5Health Care Governance, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, ROTTERDAM, THE NETHERLANDS
Keywords: Information adequacy, Clinical information, Patient safety, Medical errors, Request form
Information contained in request forms for histopathological examinations plays a critical role in the microscopic interpretation of
tissue changes. Despite its importance, studies have shown inadequacies in the information communicated by clinicians. This study aimed to
determine how well the necessary information is provided on the histopathology request forms and to compare its variability among different
departments of a hospital.
Material and Method: A retrospective, 3-month, cross-sectional study was conducted to evaluate all consecutive histopathology request forms
received from different departments of a tertiary, academic hospital for three months, regarding the documentation of 12 criteria.
Results: None of the 2040 requests received had all the required items. Four items of specimen description, laboratory and imaging findings, and
physician contact number were available only in less than 12.5% (range between 0.05 to 12.45%) of the requests. However, four other items of
patient name and contact number, physician name, and anatomical site of the lesion were documented in more than 90%. The median number
of the documented items was the highest in the surgery and orthopedics (9 items) and the lowest in the pulmonology department (7 items).
Comparison between departments showed that the documentation of items in the surgery department were significantly better than that of the
ENT, urology, and internal medicine departments (p<0.001). Also, the internal medicine department was significantly different from all other
departments (p<0.001) except neurosurgery (p=0.88).
Conclusion: Our results point out a serious gap in the adequacy of pathology request forms, especially clinical items. Given the implication of
such information to ensure patient safety, further studies are recommended to evaluate the impact of educational and supportive computerized
interventions such as clinician education and barcoding and specimen tracking systems to help fill in the required items completely.
Nowadays, histopathological examination of specimens is
not only an auxiliary means of diagnosis, but also a useful
method to assist clinicians with appropriate therapy, proper
prognosis prediction, and critical decisions in patient
. In the past, the quality of laboratory
examinations was determined by the accuracy of the
analytical phase 4
. Following the improvements in the
analytical techniques, these are no longer the main cause
of errors in the laboratory testing processes 4-6
research shows that up to 60-77% of total laboratory
errors happen in the pre-analytical phase 7-9
. One of the
main sources of the errors in this phase is the inadequacy
of the information provided on the lab request forms by
requesting clinicians 2,5
Histopathology request forms are the main means of
communication between clinicians and pathologists by
including patient demographics and clinical information
and the details of test requests, specimens, and requesting
physicians. Each of the items in the request forms
has its own critical role in this communication. For
example, documenting patient age and gender can help
histopathologists in the differential diagnosis of lesions 3.
Also, providing patients’ correct full names can help to find
more information about their previous medical history or
the results of other diagnostic procedures through health
information systems 3. Besides these, the adequacy of
especially clinical information such as clinical history and
differential diagnosis on the request forms can impact the
turn-around time of histopathology examinations and
their on-time interpretation 10.
Despite the importance of these items, studies have
documented inadequacies in the communication of such
information, pointing out many errors in the completion of
the request forms 3,5,6,11,12. Insufficient, inaccurate,
and illegible information in these forms are only some
of the associated errors. It has even been reported in
a study that up to 10% of the samples received in the
pathology laboratories were not accompanied by their
request forms 2. Such errors happen mainly because the
requesting clinicians usually overlook their primary role
and underestimate their responsibility in the pre-analytical
quality assurance of the diagnostic procedures 2,3,5.
Errors in the request forms can result in detrimental
patient and process outcomes such as the inappropriate
interpretation of morphological changes in tissues and
even misdiagnosis, which in turn poses serious threats to
the patients’ safety, or they might lead to extra tests such
as unnecessary staining and delayed test interpretation
10,12-14. They are also responsible for the waste of both
money and the pathologists’ valuable time 3,12-15.
It is noteworthy to mention that histopathologists do not see
patients personally. Therefore, they are greatly dependent
on complete and detailed patient information on the request
forms that accompany the histopathological specimens for
making an accurate diagnosis 2,16. When the responsibility
to care for a patient is handed off from a requesting
physician to a histopathologist, any communication
breakdown in transferring the required demographics and
clinical information can affect the correct interpretation
and definitive diagnosis 4-6. Meanwhile, if the requesting
physicians continue to underestimate the importance
of their role and the required items on the request forms,
such errors will continue to happen. Therefore, identifying
and understanding such errors and planning effective
interventions to tackle them are critical. When trying to
review the adequacy of data items in the histopathology
requests provided by clinicians in the healthcare context and
the magnitude and types of such errors, we unfortunately
could not find any relevant report. Therefore, we aimed to
evaluate the completeness of information on the request
forms accompanying histopathology samples, and its
variation among different departments, in a pathology
laboratory of a tertiary care hospital.
This was a retrospective, cross-sectional study in a 490-
bed tertiary care teaching hospital in Urmia, Iran. The
hospital is the main referral hospital in the region and
has broad specialty and subspecialty departments. There
was a standardized histopathology request form that all
the departments across the hospital used to send their specimens to the pathology department. The items that
were the focus of this study were available in this form for
documentation. The optimal sample size for this study
based on the statistical equation (with α=0.05, d=0.05, and
p=0.8) was calculated to be 260 request forms per month,
considering 4% drop-out. During a 3-month period
between 21st of December 2017 till 21st of March 2018, we
examined all consecutive pathology request forms received
at the pathology laboratory of the hospital from different
inpatient wards of the hospital. Hardcopies of these requests
were retrieved from the archive and manually studied
according to the purposes of the present study. Similar to
the previous studies 2,12,16,
and also the study feasibility
in our setting, requests for cytological examination and
also those received from the outpatient clinics of the
hospital were all excluded (although we acknowledge that
they are also subject to misinterpretation without clinical
information). Each request form was visually assessed for
the presence and completeness of the following necessary
items: patients’ full name, age, gender and contact
number, clinical history, provisional/differential diagnosis,
anatomical site of the specimen, specimen description,
relevant laboratory, imaging and endoscopic findings,
and the full name and contact number of the requesting
clinicians, as studied in other studies 3,14,16,17
The study was approved by the ethics committee of the Urmia
University of Medical Sciences (ethics reference number
IR.UMSU.REC.1395.592) and performed according to
the Helsinki Declaration. Patients’ and the requesting providers’
confidentiality was maintained.
We used appropriate descriptive statistics to report our
results. The statistical differences were determined by the
X2 test. Because some comparisons involve many small
cell frequencies, leading to more than 20% of the expected
frequencies to be less than 5, we also calculated Fisher’s
exact test. Moreover, we used the Kruskal-Wallis test,
followed by non-parametric pairwise group comparisons
of post-hoc for significant results to compare departments,
because the assumptions of the one-way ANOVA test
were not met. A p-value of less than 0.05 was considered
significant. Statistical analysis was performed using the
Statistical Package for Social Sciences (SPSS, version 17).
From 2040 pathology request forms, 46.7% (952) were sent
from the surgery department followed by 28.3% (577) from
the internal medicine and 11.2% (229) from Ear, Nose, and
Throat (ENT) departments.
None of the request forms received had all the required
items. The clinician contact number was the least
completed one (99.95% missing), followed by imaging
findings (94.80%), description of the specimens (87.94%),
and laboratory findings (87.54%). Three other important
clinical items of clinical history consisting of the
differential/provisional diagnosis, and the anatomical site
of the specimen were not mentioned in 19.96%, 17.4%,
and 7.15% of cases, respectively. Even patient identifiers of gender and age were missing in 27.75% and 8.04% of
cases. There were significant differences among different
departments regarding the documentation of the following
items: patients’ age, gender and contact number, clinical
history, provisional/differential diagnosis, anatomical site
of the specimen, laboratory findings (all with p<0.001),
description of the specimen (with p=0.006), and clinician
name (p=0.01) (Table I). Table I shows the details of the
department(s) from which the difference originates.
Click Here to Zoom
|Table I: Completion rates of the required items on the pathology request forms sent from different departments.
Comparing subspecialty wards of internal medicine
together, there were also differences in the completion of
the items such as clinical history, differential diagnosis, and
anatomical site of the specimens (supplementary material).
In these subspecialties, the missed clinical history of
patients in the request forms varied between 9.3% of
cases in the gastroenterology (GE) ward to 57% in the
pulmonology ward. Imaging findings were absent in more
than 90% of cases in all internal medicine wards (range
between 90 to 95.65% missing). All the request forms sent
from the rheumatology ward lacked any description of
the specimens sent. This item was also missing in more
than 97.1% of cases in all other internal medicine wards
(range between 97.1-100% missing). Even, no differential
diagnosis was provided in 48.1 % of the request forms sent
from the oncology ward, 43.5 % from the nephrology, 39.5%
from the GE, and 30% from the rheumatology wards. The
anatomical site of the specimens was not available in 25.6%
of the request forms of the GE, 22.11% of the oncology, and
21.73% of the nephrology wards.
The median number of documented items (Interquartile
Range (IQR)) was 9 (8-9) (minimum of 0 and maximum
of 11 out of 12 required items). The median number of
documented items was highest in surgery and orthopedics
(9 (8-9)) and the lowest in the internal medicine
department (8 (6-8)) (Table II) (Figure 1). Among the
subspecialty wards, the gastroenterology ward had the
highest median number of the documented items (9 (7-9)) and the pulmonology ward the least (7 (5-8)). Comparison
between departments with the post-hoc test showed that
the documentation of items in the surgery department
were significantly better than that of the ENT, urology,
and internal medicine departments (p<0.001). Also, the
internal medicine department was significantly different
from all other departments (p<0.001) except neurosurgery
(p=0.88). However, subspecialty wards in internal medicine
department were similar to each other (p=0.06).
Click Here to Zoom
|Table II: Comparison between different departments and subspecialty wards regarding the median number of documented items
on the pathology request forms.
Our results showed that the completeness of information
on the request forms in our study was suboptimal: none
of the request forms contained all the required study items
that were vital for the interpretation of the results and final
diagnosis by pathologists. It also showed that different
departments had varying request form completion rates.
The gaps in the adequacy of the request forms were more
notable in the internal medicine wards compared with the
surgical wards. This is somehow in contrast to the literature
comparing internal medicine wards with surgery, in which
physicians more often completed clinical details and
diagnosis than surgeons did 12
. As most of our samples
were from the surgery ward, it seems that the workload
is not an important factor in the incomplete filling of the
requests. Also, a very surprising result in our study was
the availability of some items only in less than 12.5% of
the requests, including the description of specimens,
laboratory tests, and imaging findings. There were even
gaps in the documentation of critical information such as
clinical history and differential diagnosis.
Gaps in the documentation of essential data items in the
request forms can profoundly impact the effectiveness of
pathology tests and their contribution in proper patient
diagnosis and management 18. Despite its importance,
several researchers have so far documented the paucity of
relevant clinical and non-clinical details being provided
on laboratory specimen request forms 2,19. Similar to
another study 2, we found that all the request forms had
some sort of data gaps. Other studies have reported that
only as low as 3% of the request forms studied had all the
required information 16,20. Such low data completion
rates affect the histopathology interpretations in many
different ways and undermine the contribution of pathology
tests to manage patients effectively 21. For example,
radiology findings enhance the value of clinical data and
assist in the interpretation of histopathologic findings.
Similarly, the lack of clinical items limits the interpretation
of the histopathology results because clinical diagnosis,
clinical history, and clinical findings commonly serve as a
screening method for selecting possible histopathological
diagnoses. In our study, only the four items of patient name,
patient phone number, anatomic location of the lesion, and
the name of requesting physician were mentioned in more
than 90% of the request forms. Other studies have found
more than 90% completion for the four items of patient
name and gender, name of requesting clinician, and date
of biopsy 2,8. In another study, patient name, age and
address, specimen description, and clinical history were found to have been documented in more than 90% of the
cases 12. In our study, the patient name was missing in
2% of the cases. In such cases when the requesting wards
are known, normally the pathology personnel immediately
contact the wards to solicit the information, and if such
critical information is still unknown the request is rejected.
Also, patient age was recorded in only 82% of the request
forms similar to 86.4% found in the study of Adegoke et
al. 4. Besides its implication for accurate interpretation
of the results, this missing information can lead to a big
challenge for proper research and epidemiological studies,
and therefore its proper completion should be emphasized.
Among all data items in the request forms, adequate clinical
history and provisional/differential diagnosis are especially
important, mainly because they have a critical role in the
correct interpretation of the pathology results. These data
help to define the need for, and the nature of, special studies
that can be performed on the specimen for an accurate
diagnosis. Unfortunately, clinical history and differential
diagnosis were absent in 19.95 and 17.4% of the cases,
respectively, in our study. In the study by Nakhle et al., with
a 77% rate of errors of discrepant or missing information
items, the most common deficiency was “no clinical
history or diagnosis present on the requisition slip,” which
represented 40% of all deficiencies 22. Other studies also
reported missing rates of 50 to 85.3% for the clinical history
20,23. Although our figure is much lower than those and
also the 34% of the cases with no clinical history reported
by Sharif et al. 3, our rate is still much higher than those
studies reporting 6.1% and 5.4% srates of missing clinical
details and diagnosis, respectively 12,16. The differential
diagnosis was absent in 20.4% of our request forms. Burton
and Stephenson reported a missing rate of 46.9% of the
forms regarding this item 12. In another study, 19.1%
of the forms lacked a diagnosis, and among those with a
diagnosis, only an abbreviation was provided in 37.3% 5.
Such clinical notes enable pathologists to further narrow
down the differential diagnosis in their interpretations and
therefore should be the focus of future interventions to
A surprising finding was the presence of the contact number
of the requesting physician in merely one form out of 2040
request forms. Compared to our results, lower rates of 23%
and 33.3% missing regarding this item were found in two
other studies 3,12. The absence of this item can delay the
pathology reporting process in cases where more clinical
information is needed for pathologists; and then, trying to
find the clinician’s phone number to get the information
would be a time-wasting exercise. It should also be noted that the urgent results could rapidly be conveyed back to
the requesting clinician if the clinician’s contact number is
present on the request forms.
Our setting is a teaching hospital; then, it is natural to
imagine the individuals signing the request forms are
aware of the importance of filling out the requests correctly.
However, unfortunately, the results we found were not
very compelling. This may be due to the lack of standard
and updated forms. To remedy the current situation, we
recommend developing newer standard pathology request
forms with the contribution of the requesting clinicians,
and also to develop guidelines for the pathology reception
staff in order to deal with these gaps, such as rejecting
the samples without accompanying complete request
forms. This will especially hold true for cases where their
clinical data are vital for correct interpretation. Many
other interventions can also improve the practice of
providing complete sets of data to pathologists. One of
the effective interventions is to plan educational sessions
for clinicians and intense communication with them in
order to emphasize the importance of the correct and
complete filling of the request forms. A study found that
after educating clinicians with various interactive media,
there were significant improvements in the completion
rate of required data items such as age, hospital number,
clinician name, clinical diagnosis, and specimen type 24.
Other effective means can be the use of computerized lab
test request systems that can guide the requesting clinicians
to properly send a complete pathology lab request 25.
Moreover, barcoding and specimen tracking systems such
as radio frequency identification (RFID)-based systems
have been found useful in this regard 26,27. With the
help of such systems, many required items, and especially
demographics and lab and radiology findings, can
automatically be filled in by available data in the patients’
electronic medical records and therefore clinicians can
focus on the communication of essential clinical items on
the request forms.
Although this study was limited to only one hospital,
it is likely that the results are similar for other academic
hospitals in the country. However, we recommend
conducting further studies in other settings to document
the magnitude of such gaps in the request forms. Another
limitation of this study was our inability to assess the effect of
these poorly completed request forms on proper diagnosis and patients’ management due to the retrospective nature
of data collection. Due to the same reason, we were
also unable to evaluate the cases individually in their
own context to see whether or not there was enough
information depending on the disease (e.g., clinical and
radiological information) for pathologists to make a better
diagnosis. This is mainly relevant because using the contact
information, many contacts are made to solicit further
information from patients and the requesting wards, but
no information was available on such workarounds despite
being very time-consuming for the pathology department.
One more issue to note is that missing clinical information
may yield a misdiagnosis depending on the diseases as well,
so depending on the cases the requirement of the clinical
information would change. For example, dermatopathology
cases require detailed differential diagnosis but rarely
radiologic findings. Therefore, it is necessary that the
cases are evaluated individually and in their context to see
whether there is enough information or not.
Our results show several weaknesses and gaps in the
completion of the pathology request forms in routine
care. Although our study was conducted almost four years
ago, no changes have unfortunately been made in the
handling of the requests and samples despite complaints
from pathologists and pathology department personnel,
mainly because their importance and magnitude (and
likely effects on correct diagnosis) are not well-known
and perceived seriously by requesting physicians and the
leaders. Such gaps can have many detrimental effects on
the correct interpretation of the findings in the pathology
specimens and consequently on patient safety. We hope
that with official documentation of such inadequacies,
this subject would be brought to the forefront of future
quality improvement initiatives in pathology departments.
Moreover, besides informing and educating the clinicians
for diagnostic improvement and accuracy and handling
the patient’s safety issues, one of the important factors is
to use communication and tracking technologies such
as hospital and laboratory information systems, and bar
coding or RFID systems as potential solutions for specimen
identification, tracking, and management in pathology.
In the end, it would be informative if future studies
document the impact of such information gaps on proper
management of patient care and also the impact of effective
interventions to tackle information inadequacies.
We are very grateful to the head of our pathology department at
Urmia University of Medical Sciences for the permission to access the
data of thePathology ward archives. This article was extracted from
the thesis of Yasaman Asghari, a medical student at Urmia University
of Medical Sciences (ethics number IR.UMSU.REC.1395.592). The
authors declare that they have no financial or any other conflict of
Conflict of Interest
The authors declare no conflict of interest.
Concept: FA, YA, Design: FA, YA, Data collection or processing: YA,
Analysis or Interpretation: FA, YA, ZN, Literature search: FA, YA,
ZN, Writing: FA, ZN, Approval: FA, YA, ZN.
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