DefinePK

Abstract

Background: Incomplete and inconsistent histopathology documentation in bladder tumor cases can lead to diagnostic delays, suboptimal treatment planning, and compromised patient outcomes. The use of standardized and structured proforma has been proposed as a solution to improve documentation accuracy and adherence to guidelines. Aim: This audit aimed to evaluate whether implementing a structured proforma enhances the completeness and accuracy of histopathology documentation for bladder tumors. Method: A closed-loop audit was conducted at Safari Hospital, Rawalpindi, Pakistan to evaluate the completeness of histopathology documentation for bladder tumors. The initial audit reviewed 25 handwritten reports to identify documentation gaps. A standardized proforma was then introduced and a re-audit was performed on 31 cases. Compliance rates were assessed and compared using percentages and frequencies. A paired t-test was used to measure the statistical significance of improvements. Results: The implementation of a standardized proforma led to a significant improvement in histopathology documentation. Tumor number, site, and appearance, previously absent, achieved 100% compliance. Documentation of tumor clinical stage increased from 4% to 51.6%, and completion of resection improved from 12% to 80.6%. Muscle biopsy requests were documented in 51.6% of cases, compared to 20% earlier. These improvements were statistically significant (p = 0.000), highlighting the benefits of a standardized proforma for better diagnosis and treatment planning. Conclusion: The use of standardized histopathology templates enhances the quality and completeness of bladder tumor reports, leading to more informed clinical management. Further research should explore its long-term impact on patient outcomes and electronic health record integration.