The gross description must be clear and include the pertinent findings for each individual specimen. It can be dictated as a free text or within templates. These templates can consist of pre-built, standard paragraphs with blanks in which the user can speak descriptive phrases, words, or numerical measurements.
A template creation tool, such as auto text, helps users reduce documentation time, trains laboratory personnel, and sets departmental reporting standards for gross descriptions and final diagnoses in pathology reports. The templates produced can improve readability, reduce description errors, and streamline report production.
Below are some useful tips for creating effective templates:
- Avoid stringed variables.
- Do not put too many fields in the template. For example, instead of [] x [] x [] cm, use [_x_x_x] cm.
- Dictate measurements as follows: “five point zero by one point two by zero point five” which will appear as "5.0 x 1.2 x 0.5" on the description.
- Create multiple templates for organs.
- Create multiple templates for an organ.
- Examples of auto texts for thyroid: “Thyroid with tumor” or “Thyroid for Goiter.”
- Format templates to the LIS.
- Create templates that match the format (font type, text size, and text attributes) of departmental LIS.
- Create tips and instructions for new users.
- Use tips inside of the brackets to help remember grossing protocol details. This can be useful for new surgical pathology technologists, residents, or pathologists’ assistants.
- Use default values.
- The templates can be configured with default values inside the brackets. The foot pedal, keyboard, mouse, or voice to cycle past that field will remove the brackets and leave the default value as text in the report.
The following pages show examples of gross dictation templates for different types of specimens.
