Difference between revisions of "Reporting"
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Factors supporting a relatively more comprehensive report: | Factors supporting a relatively more comprehensive report: | ||
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*Lack of '''explanation''' from existing evidence. For example, an inflamed appendix that fits the medical history does not need detailed mention of harmless incidental findings. | *Lack of '''explanation''' from existing evidence. For example, an inflamed appendix that fits the medical history does not need detailed mention of harmless incidental findings. | ||
+ | *'''Double-reading''': If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed. This applies particularly to the inclusion of negated findings, because the doctor who will do the double-reading then knows that you have looked at those locations. | ||
Multiple instances of the same type of pathology (such as lung nodules) can often simply be reported as such, at least with a particular mention of the largest or the most severe example thereof. | Multiple instances of the same type of pathology (such as lung nodules) can often simply be reported as such, at least with a particular mention of the largest or the most severe example thereof. |
Revision as of 06:57, 19 December 2019
Author:
Mikael Häggström [note 1]
Further reading: |
Following are general notes on reporting in pathology.
Contents
Components
Selection and trimming
From the stage of selection and trimming, a histopathology report should preferably include:
- Case:
- Patient identification and/or sample number
- Type of tissue sample as described on container
- Gross pathology:
- Dimensions of original tissue[1]
- Directions or other features of any inked surfaces.Template:Ink note
- Generally the weight of larger samples[1]
- Dimensions of pathologic components[1]
Microscopic evaluation
- Preferably, a summary of findings and diagnosis.[1]
- Findings
- Diagnosis or most probable diagnoses
- In case of malignancy or suspected malignancy:
- Depth or most distant invasion of malignant findings.[1] Depending on location, it may need to exclude important pathways, such as vascular, neural and/or through capsules or other layers.
- Whether the resection is radical or not.
Depth
Factors supporting a relatively more comprehensive report:
- Lack of explanation from existing evidence. For example, an inflamed appendix that fits the medical history does not need detailed mention of harmless incidental findings.
- Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed. This applies particularly to the inclusion of negated findings, because the doctor who will do the double-reading then knows that you have looked at those locations.
Multiple instances of the same type of pathology (such as lung nodules) can often simply be reported as such, at least with a particular mention of the largest or the most severe example thereof.
Certainty
The same word used describing the certainty of findings can refer various probabilities, differing between pathologists as well as clinical situations. The following is a suggestion of words, in an attempt to sort them from most to least probable:
(is) |
probably |
likely |
suggestive |
suspicious |
maybe |
possibly |
(non-lethal condition) cannot be excluded |
not likely |
(lethal condition) cannot be excluded |
not |
Sizes
Whenever possible, give numerical quantities of sizes, rather than descriptions that are subjective (such as "small" or "large") or variable (such as "apple-sized").
Tailoring
The information contained in the reporting sections in Patholines assume that the clinician has requested the exam for the topic of the article at hand, but should be tailored to any particular questions or requests by the clinician. Any relevant findings beyond the issues or questions raised by the clinician should also be mentioned.
The most important findings can be moved to near the top of the report if feasible, but doctors performing subsequent double-reading may prefer a consistent anatomic order.
If a certain grammatical rule has a risk of making the report less clear to the reader, ignore it.
Restrict acronyms/abbreviations to those who are certainly well known among all doctors, such as "cm".[notes 1]
See also
- Patholines:Editorial guidelines, contains guidelines on how to write reporting guidelines in Patholines.
- Patholines:Disclaimers
Notes
- ↑ Acronyms/abbreviations increase reading speed only if the reader is familiar with the abbreviated terms:
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources