Reporting
Author:
Mikael Häggström [note 1]
Following are general notes on reporting in pathology.
Depth
Factors supporting a relatively more comprehensive report:
- Double-reading: If your report is likely to undergo double reading, it needs to be more detailed, particularly in the inclusion of findings you have negated, because the doctor who will do the double reading then gets to know that you have looked at those locations.
- 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.
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 |
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.
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