Abstract:

Introduction: The quality and completeness of the skin biopsy requisition form (SBRF) is critical for accurate histopathological diagnosis. There are shortcomings in the provision of clinical information on the SBRF in the era of electronic medical records (EMR). The purpose of this study was to check the validity of the previous findings and further characterize practices of and training in the completion of the SBRF in the era of EMR. Methods: Dermatologists of the Dallas-Fort Worth Dermatological Society were contacted by email to participate in a voluntary, anonymous online survey. Results: 75 of 187 (40.1%) of invited dermatologists responded to the survey. The majority of respondents were male (45/75, 60%) and used EMR for all of their clinical encounters (65/75, 86.67%) and the completion of the SBRF (44/75, 58.67%). However, 35 of 75 dermatologists (46.67%) reported only sometimes, rarely, or never checking the SBRF for accuracy, even though the majority of SBRFs were completed by medical assistants (52/100, 52%). Only 25 of 75 (33.33%) dermatologists reported receiving training in how to complete the SBRF electronically. 18 of 68 (26.47%) dermatologists reported that automatically-generated clinical descriptions were created with EMR systems they used. Conclusions: Methods to train dermatologists and clinical staff in the completion of the electronic SBRF should be prioritized. In addition, user-friendly EMR systems that can facilitate an accurate description of the patients presentation rather than generic, canned phrases of clinical diagnoses may improve the dermatologist-dermatopathologist communication loop.

Financial Disclosure:
No current or relevant financial relationships exist.

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Haley Heibel, MD