Clinician compliance with laboratory regulations requiring submission of relevant clinical data: A one year retrospective analysis

Summary Background The College of American Pathologists (CAP) recognizes the need for clinical data in the interpretation of specimens submitted for histopathologic evaluation. Anecdotal evidence indicates that clinician compliance with requests for clinical history is variable. Design Quality assurance data from August 1, 2010 to September 31, 2011 were searched for all cases listing no clinical history. Four consecutive weeks of surgical pathology request forms were also reviewed for the presence or absence of clinical history and its accuracy. Results 21,700 cases were accessioned in the study period and 1293 (5.9%) requisitions contained no clinical history. The four-week review documented that 143 of 1698 (8.4%) requisitions had no clinical history and 12 cases contained incorrect history (0.7%). Conclusions Between 5.9% and 8.4% of requisitions contain no clinical history. In 0.2% of cases, clinical history was incorrect. Compliance with the CAP policy for clinical history appears poor.