Difference between revisions of "Reporting"

From patholines.org
Jump to navigation Jump to search
(Started)
 
(Expanded)
Line 5: Line 5:
  
 
Following are general notes on reporting in pathology.  
 
Following are general notes on reporting in pathology.  
 +
 +
==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''':<ref name=melanoma>{{cite web|url=https://www.aimatmelanoma.org/diagnosing-melanoma/pathology/example-melanoma-pathology-report/|title=An Example of a Melanoma Pathology Report|website=Melanoma Foundation|accessdate=2019-09-24}}</ref>
 +
:*Dimensions of original tissue
 +
:*Generally the weight of larger samples
 +
:*Dimensions of pathologic components
 +
 +
===Microscopic evaluation===
 +
*Preferably, a summary of findings and diagnosis.<ref name=melanoma/>
 +
*Findings
 +
*Diagnosis or most probable diagnoses
 +
*In case of malignancy or suspected malignancy:
 +
:*Depth or most distant invasion of malignant findings.<ref name=melanoma/> 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==
 
==Depth==

Revision as of 09:38, 24 September 2019

Author: Mikael Häggström [note 1]

Following are general notes on reporting in pathology.

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:[1]
  • Dimensions of original tissue
  • Generally the weight of larger samples
  • Dimensions of pathologic components

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:

  • 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

Notes

  1. Acronyms/abbreviations increase reading speed only if the reader is familiar with the abbreviated terms:
  1. 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

  1. 1.0 1.1 1.2 . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.

Image sources