- Save your digital work frequently, and also when you leave a desk, even if you think you'll be back shortly.
Selection and trimming
From the stage of selection and trimming, a histopathology report should preferably include:
- Patient identification and/or sample number
- Type of tissue sample as described on container
- Specimen chronology, often A, B, C, etc., at least where there are multiple specimens from the same case. With multiple specimens, preferably write out the chronology for all of them first, so that you don't miss reporting any of them later.
- Specimen type and/or surgery type, such as "appendix, appendectomy", for clarification. This is not necessary at all departments.
- Findings. This is not always necessary, but should be included if the diagnosis is uncertain. One systematic approach is to describe findings from largest to smallest ones. For example, a description of a tumor can start with the demarcation of the tumor, followed by texture, cell shapes, nucleus shapes and chromatin appearance.
- Diagnosis or most probable diagnoses.
- In case of malignancy or suspected malignancy:
- Depth or most distant invasion of malignant findings. 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.
Factors supporting a relatively more comprehensive report, particularly in the inclusion of negated 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, because the doctor who will do the double-reading then knows that you have looked at those locations.
- Highly suspected locations, such as given from the referral.
- Defensive precautions, which appears to be more common among doctors in the Unites States compared to for example Europe.
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.
Where findings are made, general statements of clearing a region should still be given, such as: "There is a 18.0 cm curvilinear well-healed thin scar in the left thorax. Otherwise, there are no puncture marks or healed surgical scars on the torso." The main exception is for aspects that are barely worth mentioning, in which case the description of the finding may imply that the aspect has been considered in general.
cannot be excluded
cannot be excluded
effectively ruling out
When something looks very much like a specific entity but you are not sure, preferably use "-like" (or when feasible, "-oid" such as squamoid for squamous-like cells).
When the clinical picture strongly favors a certain condition, and the pathology favors it as well, findings are generally described as "consistent with". Sometimes, "bordering on" can be described when the picture almost fits specified criteria of a specific diagnosis.
For both findings and diagnoses, is preferable to write "negative for..." rather than "no..." to emphasize the possibility of false negative findings.
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines. However, synoptic reports are generally not needed for tumor metastases.
Whenever possible, give numerical quantities of sizes, rather than descriptions that are subjective (such as "small" or "large") or variable (such as "apple-sized").
The information contained in the reporting sections in this resource assume that the clinician has requested the exam for the topic at hand, but should still 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 reporting templates in this resource do not cover every recurring situation, so it is often more efficient to create your own repository of report templates that you can copy-paste for various cases. When doing so, however, have marks for relevant items that are frequently changed in the template, which should be readily seen as unfinished in the report if you haven't tailored it to the case at hand (such as "...measuring _____."), so as to avoid omissions or even wrongly entered information from templates.
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 that rule in that situation.
Restrict acronyms/abbreviations to those who are certainly well known among all doctors, such as "cm".[notes 2]
Generally describe what can be seen rather than processes (such as preferring "an abundance of" rather than "proliferation of").
In skin cancers, use "peripheral" or "radial" margins (whereas "lateral" margin should be reserved for the margin opposite to the medial margin).
- Patholines:Editorial guidelines, contains guidelines on how to write reporting guidelines in Patholines.
- . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
- Studdert D. M.; Mello M. M.; Sage W. M.; DesRoches C. M.; Peugh J.; Zapert K.; Brennan T. A. (2005). "Defensive medicine among high-risk specialist physicians in a volatile malpractice environment ". JAMA 293 (21): 2609–2617. doi:10.1001/jama.293.21.2609. PMID 15928282.
- Steurer J.; Held U.; Schmidt M.; Gigerenzer G.; Tag B.; Bachmann L. M. (2009). "Legal concerns trigger PSA testing ". Journal of Evaluation in Clinical Practice 15 (2): 390–392. doi:10.1111/j.1365-2753.2008.01024.x. PMID 19335502.
- David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019