- Save your digital work frequently, and also before you leave a computer, even if you think you'll be back shortly. If you have many small specimens to write up in the same report, you may want to save every 2 to 3 specimens. It doesn't matter how much time and effort you spend on something if you're just going to let it disappear in the next glitch.
- Double-check your report, especially if you copy-pasted and adapted a previous report rather than using a template with blank fields or making your report from scratch.
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. For the procedure, use the same term as the operating report whenever possible.
- Microscopic description. 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.
- If the diagnosis does not clearly account for all conditions that were requested, suspected or asked to be ruled out by the referring clinician (such as stated on the requisition form), you need to classify the specimen as "positive for" versus "negative for" for each such condition, or give a reason for why an evaluation thereof could not be made.
- 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.
- Prospective review: If your report is likely to undergo double-reading by another pathologist before sign-out, it should either be more detailed, because the doctor who will do the double-reading then gets an idea of your thought process, including what you have looked for versus what may still need to be evaluated. If you know who will do the prospective review for a report of yours, you may alternatively convey your thought process by other means such as directly talking to that person.
- Highly suspected locations, such as given from the referral.
- Difficulty in obtaining the specimen, such as a CT-guided biopsy versus a skin shave.
- 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.
cannot be excluded
cannot be excluded
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.
It is alright to consider the diagnosis of a pathology report to be a combination of the clinical picture and what can be seen on the specimen. For example, if the microscopy picture is uncertain, you may to a certain degree tend towards the diagnosis that best fits the clinical picture. However, mention differential diagnoses if they are still significantly possible, and would confer a different treatment or another substantially different consequence.
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.
As there are generally local practices about how to write reports, it is recommended to have either a personal or practice-specific repository of report templates that you can copy-paste for various cases. When doing so, however, use marks or empty spaces for relevant findings that are frequently changed in the template. Such marks should be conspicuous, so that the report clearly looks unfinished if you haven't tailored it to the case at hand (such as "...measuring _____."). Thereby, you avoid omissions or even wrongly entered information from templates.
The most important findings are preferably moved to near the top of the report if feasible.
Example of report format:
|A. Organ, side/site, procedure:
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".[note 2]
Generally describe what can be seen rather than processes (such as preferring "an abundance of" rather than "proliferation of").
If using a dictation device, avoid "no", and instead use "negative for" (and "positive for" in opposite cases), since there's a risk of "no" not being transcribed and thereby creating the opposite meaning.
Avoid "evidence of" unless you feel comfortable with the legal implications of its meaning in the report.
Whenever there is text needing formatting (text size, font type and/or UPPER vs lower case), it is generally most efficient to do it all at once after all the text is written.
In skin cancers, use "peripheral" or "radial" margins (whereas "lateral" margin should be reserved for the margin opposite to the medial margin).
- . 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