Report Adjustments Post Finalization
- Abby Diepeveen
If changes to an existing report need to be made, you will need to re-open the specific patient encounter. After the encounter has been reopened, you can adjust the tissue measurements or diagnosis as needed, but you will need to create a new report to reflect the specific change. The following are types of reports you can create post finalization:
Amendment
Addendum
Correction
Diagnosis Change
Second Opinion
Screener
Amendment
A revised (or amended) report is issued when the final diagnosis changes or other important pathologic information becomes available. The reasons for the revision must be explained in the report and the clinician(s) notified, because a revised report may significantly affect patient care.
Addendum
An addendum is additional information added on to your report after it was finalized and sent by your pathologist to your other doctors. An addendum is usually created to tell you and your other doctors the results of additional tests that were performed such as immunohistochemistry or molecular analysis.
Correction
A correction is used when changes to patient demographics, procedure information, or specimen information are needed. These changes must be made by the laboratory or digital slide production facility. You can use the “Encounter Notes” section to communicate with the slide production facility about needed changes.
Diagnosis Change
This type of report will be created when an actual diagnosis is changed, whether that be from a Gleason score change (3+3 to a 3+4) or if a diagnosis was changed from malignant to benign or vice versa. The pathologist has the option to provide a reason for the diagnosis change and must create a new report after the change has been recorded.
Second Opinion
You will create a “Second Opinion” report if you are performing a second opinion for a patient encounter on the request of the patient, clinic, or a pathologist. You can also request a second opinion from another pathologist, if desired, from the “Consult” section.
Screener
A screener report is a preliminary report that’s done by a different pathologist than the one that will actually sign out the final report. It helps the pathologist that gives the final diagnosis.