Identifying the Patient from a Bone Marrow Biopsy Report
A bone marrow biopsy report should always contain patient identification information including the patient's full name, date of birth, medical record number, and a unique specimen identification number to ensure proper patient identification.
Essential Patient Identification Elements
Bone marrow biopsy reports must include several key identifiers to ensure proper patient identification:
Primary Identifiers
- Patient's full name
- Date of birth
- Medical record number (MRN)
- Unique specimen identification number
- Collection date and time
- Ordering physician
Secondary Identifiers
- Patient's age and gender
- Hospital/clinic location
- Ward/department (for inpatients)
- Date of report generation
Components of a Complete Bone Marrow Report
A properly labeled bone marrow biopsy report should contain:
Header Information
- Institution name and logo
- Laboratory accreditation information
- Report title (e.g., "Bone Marrow Aspiration and Biopsy Report")
- Patient demographics (as listed above)
- Specimen details (site, date collected, received)
Clinical Information
- Relevant clinical history
- Indication for bone marrow examination
- Current medications affecting bone marrow
- Previous relevant diagnoses
Technical Details
- Biopsy site (typically posterior iliac crest)
- Quality and adequacy of specimen
- Processing methods used
Verification Process
To ensure you have the correct patient:
- Check for at least two patient identifiers (name and DOB or MRN) 1
- Verify that the specimen label matches the report header
- Confirm the collection date is appropriate for the clinical context
- Check that the ordering physician is correct
Special Considerations
- For lymphoma staging, ensure the report contains information about infiltration patterns and percentage of involvement 1
- For myelodysplastic syndromes, verify patient identifiers before reviewing cellularity, blast percentage, and cytogenetic findings 1
- For multiple myeloma, confirm patient identity before reviewing plasma cell percentage and clonality 2
Common Pitfalls to Avoid
- Relying on a single identifier: Always check at least two independent identifiers
- Assuming specimen ownership: Verify patient information even when handed the report directly
- Overlooking collection date: Ensure the report is current and relevant to present clinical situation
- Accepting incomplete labeling: Request proper identification if any key elements are missing
Quality Assurance Considerations
- Reports should follow standardized formats according to institutional and accreditation requirements
- Patient identifiers should appear on each page of multi-page reports
- Electronic reports should maintain all identification information in printable format
- Any amendments to reports should maintain original patient identification
By following these guidelines, you can ensure proper patient identification when reviewing bone marrow biopsy reports, which is critical for appropriate clinical decision-making and patient safety.