Unveiling documentation deficiencies: a clinical audit of histopathology request forms at a tertiary care hospital.

Introduction: Accurate histopathology request forms are essential for effective diagnosis and treatment. This audit assessed the completeness of these forms at Fauji Foundation Hospital, aiming to identify and address documentation gaps.

Methods: A retrospective review of 300 histopathology request forms from January to June 2024 was conducted. Forms were evaluated for completeness in patient details, hospital admission, biopsy information, and clinical notes. SPSS software was used for data analysis, and an educational intervention was implemented based on initial findings.

Results: The audit revealed high compliance for patient profile details but low reporting of patient contact information (39.7%). While hospital admission and biopsy details were well-documented, clinical notes were incomplete in 27.3% of cases. Post-intervention improvements included better documentation of patient contact details and biopsy nature.

Conclusion: The audit highlights the need for thorough and accurate histopathology request forms. Improved documentation practices, supported by ongoing education, are crucial for enhancing diagnostic accuracy and patient care.