Machine? Medical director? What to put in cytology reports |
January 2011 Ann T. Moriarty, MD Sticks and stones will break my bones, but names will never hurt me. The beginning of wisdom is to call things by their right names. There is wisdom in every culture, and though a name may not hurt like a stick or stone, as the English proverb claims, painful issues can arise if the names of laboratory professionals are not placed properly in a cytology report. Or, to paraphrase the Chinese, it is wise to identify activities with the right names in the report. But it is often hard to know what names need to be included and where those names need to be placed in the report. Does the name of the screening cytotechnologist need to appear on a Pap test report? Can the medical director sign a document and include his or her name even if the director did not review the case personally? If an automated system is used, does the name of that device need to be acknowledged on a report, and what about the name of the cytotechnologist who did the verification? What if a cytotechnologist performs an assessment on site of sample adequacy—does that cytotechnologist’s name need to appear in the final report later generated by a pathologist? What is necessary for documentation of location, identifiers, names, and signatures on a cytology report? Report signatures Automated or image-guided screening Screening and on-site adequacy evaluations For FNA procedures where a preliminary intraprocedural assessment of adequacy is made, the result of this assessment needs to be documented. The name of the individual performing that evaluation and the result of the intraprocedural assessment are not required on the final report. The laboratory does need to maintain this information in its records, however, and ensure that it can be linked to the final report.5 The laboratory medical director Accurately and properly identifying individuals’ roles and responsibilities in a cytology report is not just about meeting laboratory accreditation requirements. Names on a report allow health care providers to seek consultation from the laboratory professionals who are most knowledgeable and who can be most helpful regarding an individual patient’s findings. As Confucius said: “If names are not correct, language will not be in accordance with the truth of things.” References 1. 21 CFR 11.50 Signature manifestations. 2. 21 CFR 11.200 Electronic signature components and controls. 3. College of American Pathologists Cytopathology Checklist CYP.05332. 4. College of American Pathologists Cytopathology Checklist CYP.05316. 5. College of American Pathologists Cytopathology Checklist CYP.05350. 6. Prey MU. Computer assisted screening. In: Solomon D, Nayar R, eds. The Bethesda System for Reporting Cervical Cytology. New York, NY: Springer; 2004. 7. College of American Pathologists Cytopathology Checklist CYP.05325 (FNA Adequacy Assessment). Dr. Moriarty, chair of the CAP Cytopathology Committee, is with Ameri-Path-Indiana, Indianapolis. Dr. Howell, a member of the CAP Cytopathology Committee, is professor and chair, Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, Sacramento. |