ANATOMIC PATHOLOGY
BOX 356100
University of Washington Medical Center
Harborview Medical Center
Seattle Cancer Care Alliance
Seattle, Washington
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Page 1 of 4
SECTION:
Pathology Computer Systems
PROCEDURE:
Addendum vs. Amendment
DATE:
June 11, 2008
POLICIES AND PROCEDURES
Adopted
Reviewed
Reviewed
Reviewed
Under Revision
| 4/5/02
| 3/6/07
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| 10/15/01
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| 3/15/05
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PURPOSE:
To ensure addenda and amendments are issued appropriately on finalized cases in
PowerPath.
POLICY:
An addendum is used when the clinical history or any diagnostic information needs to be
revised. An amendment is used to change information in the header and/or footer of the
report, with one exception (see 2b and 2c).
PROCEDURE: (refer to Policy)
1. Addendum: an addendum does not alter the original report; it adds the revision or
additional information as a new section at the end of the report and creates a new
signature line after the addendum text. It is used to change, add or correct the
following:
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Clinical Data
Gross Description
Microscopic Description
Laboratory tests
Final Diagnosis
Frozen Section Diagnosis
Comment
2. Amendment: an amendment alters the original report and adds a new signature line
(if a different pathologist is verifying) immediately after the original verifying
pathologist’s electronic signature.
a)
To correct data in the header or footer of the report, contact the Lead
Transcriptionist at UWMC, Manager of Operations at HMC, or the
Administrative Coordinator at SCCA to issue an amendment using Demographic
Correction. Examples include:
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Correcting the spelling of Patient Name
Adding the patient’s Middle Initial
Wrong Patient Name
Correcting the Sex or Date of Birth
Correcting a Physician Name
Adding or deleting a Physician Name
Changing the Collected or Received Date
Please refer to the “Correcting/Deleting erroneously accessioned cases” policies
and procedures for more details.
b)
If a non-CG case was accessioned to the wrong MRN and was finalized, contact
the Lead Transcriptionist at UWMC, Manager of Operations at HMC, or the
Administrative Coordinator at SCCA to issue an amendment using Demographic
Correction.
Change the “FINAL DIAGNOSIS:” heading to “AMENDED FINAL
DIAGNOSIS:” (by adding the word “AMENDED”) and enter the following
statements above the original diagnosis text on the report:
AMENDED FINAL DIAGNOSIS:
******************************************
THE ORIGINAL DIAGNOSIS BELOW DOES NOT BELONG TO THIS
PATIENT. PLEASE DISREGARD. THE SPECIMEN BELONGS TO A
DIFFERENT PATIENT; CORRECTED REPORTS HAVE BEEN
DISTRIBUTED.
******************************************
Sign out the amendment. Issue another amendment to enter the correct patient’s
information. Delete the above statements under the “AMENDED FINAL
DIAGNOSIS:” heading, leaving only the original diagnosis text. Then enter the
following statements under the “COMMENT:” heading (may need to type this
out) below the amended final diagnosis:
COMMENT:
*******************************************
This report was delayed because the case was initially accessioned to a different
person. Patient records have been corrected.
*******************************************
Sign out the amendment.
c)
If a CG case was accessioned to the wrong MRN and was finalized, contact the
Manager of Operations at HMC to issue an amendment using Demographic
Correction.
In the dictionary tab of the resulting screen, select the category “CYTOLOGIC
DIAGNOSIS”. Double click the finding “Amended Cytologic Diagnosis” to add
it to the report. The text will read:
*******AMENDED CYTOLOGIC DIAGNOSIS*******
THE ORIGINAL DIAGNOSIS ABOVE DOES NOT BELONG TO THIS
PATIENT. PLEASE DISREGARD. THE SPECIMEN BELONGS TO A
DIFFERENT PATIENT; CORRECTED REPORTS HAVE BEEN
DISTRIBUTED.
**********************************************
Sign out the amendment. Issue another amendment to enter the correct patient’s
information. In the dictionary tab of the resulting screen, select the category
“CYTOLOGIC DIAGNOSIS” and delete the above finding, leaving only the
original diagnosis text. Then select the category “COMMENTS”, open the
“Amendment/Addendum Comments” folder and choose the following finding:
************AMENDED COMMENTS************
This report was delayed because the case was initially accessioned to a different
person. Patient records have been corrected.
*********************************************
Sign out the amendment.
3. Contact Aleksandra Lazarevic, Coding and Billing supervisor, at 598-5024 if the case
had been billed before the amendment was issued.
4. Questions? Contact Pathology Computer Support by sending a tech request at
http://www.pathology.washington.edu/tech/trd/.
_____________________________
Rosy Changchien
Clinical Systems Manager
June 11, 2008
*Contact Information as of 6/11/08:
UWMC
 Program Support Supervisor – Amanda Thomson, 598- 6418
HMC
 Manager of Pathology Operations -- De Lora Archer, 744-5556
SCCA
 Administrative Coordinator – Susan Milewski, 288- 6388