Pathology reports
Revision as of 19:42, 29 April 2025 by Michael (talk | contribs) (→Dealing with errors and when to use an amendment)
Pathology reports are what pathologists produce when finishing a case. Sign out is the finalization of a case. This article discusses both.
The term sign out is from when one used to actually sign the reports.
The key point in report writing is that the report should be precise, complete and easy-to-understand. Many pathology reports, unfortunately, are misunderstood by surgeons; one study suggests that it is 30%![1]
Standards
Based on a PubMed search,[2] the first papers on the topic of standards were written in 1992![3][4]
There is no universal standard; however, there is a push to standardize by the Association of Directors of Anatomic and Surgical Pathology,[5] among others.
Standards appear to lead to uniformity and consistency.[6]
Something close to a standard is laid-out in by Goldsmith et al.[7]
Checklists
Main article: CAP checklists
The College of American Pathologists (CAP) has checklists for cancer - CAP protocols.
It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine. Good evidence suggests that surgical checklists reduces adverse events.[8] Pilots have been using checklists since the 1930s.[9]
Standard diagnostic notation
Site, operation/procedure:
- Tissue type diagnosis.
Example:
Gallbladder, cholecystectomy:
- Acute cholecystitis.
Formatting recommendations used on Libre Pathology
Diagnosis
- The tissue type/site usually should be what the clinician submitted it as.
- Lay terms are preferred in some circumstances (e.g. stomach instead of gastric), as the patients often read their pathology reports.
- The tissue type should be the first thing in the diagnostic line if it is not obvious from the diagnosis, e.g. gastric body-type mucosa.
- If several diagnoses are made, the most clinically important diagnosis should be listed first.
- Each diagnostic line should end with a period or semicolon.
- It is best to avoid no and not, as these may be lost at transcription or overlooked.[12]
- Negative and without are preferred.
Uncertainty
- Uncertainty in reports can be conveyed with various terms.
- There is no standard but the interpretation (by clinicians and pathologists) of various phrases have been compared by Lindley et al. using a scale of 0 (uncertain) to 100 (certain):[13]
- Cannot rule out (55) and indefinite for ... (52) convey the highest level of uncertainty among attending clinicians.
- Suggestive of ... (57) conveys a lesser level of uncertainty.
- Consistent with ... (76) seems to be ignored by many.
Abbreviations
- Abbreviations should not be used, e.g. LEEP should be written-out as loop electrosurgical excision procedure.
- Patients often read their reports. Abbreviations muddle things.
Microscopic
- AKA microscopy.
- Describes how the tissue looks under the microscope.[14]
Notes:
- One should not assume it is going to be read by the clinician.
- If it is essential to read, a comment in the diagnosis section, that says see microscopic, is advisable.
- Immunostains should be reported as a comment in the diagnosis section.
- Many labs report IHC in the microscopic section.[7]
- Internal reviews/consults should likewise not be found here; they should be in a comment in the diagnosis section.
Report sections/elements
Addendum
- Formally called report addendum.
- Used to add material to the report.
- Generally, the new material should not substantially contradict the opinion offered by the report.
Amendment
- Formally report amendment.
- Used to change the diagnosis or significant interpretations in the report.
Dealing with errors and when to use an amendment
Main article: Quality
- If an addendum would add information to the report that contradicts other information already in the report: it should be an amendment (not an addendum).[15]
It is good practice when amending an report to:
- Clearly state the revised diagnosis.
- Clearly note that the diagnosis was changed.
- Clearly state what the diagnosis was previously.
- Have another pathologist confirm the revised diagnosis.
- Communicate directly with the most responsible physician - make them aware of the change.
- Document the communication.
See also
References
- ↑ Powsner, SM.; Costa, J.; Homer, RJ. (Jul 2000). "Clinicians are from Mars and pathologists are from Venus.". Arch Pathol Lab Med 124 (7): 1040-6. doi:10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2. PMID 10888781.
- ↑ URL: Pubmed search for standardization, surgical pathology report.
- ↑ Rosai J, Bonfiglio TA, Corson JM, et al. (March 1992). "Standardization of the surgical pathology report". Mod. Pathol. 5 (2): 197–9. PMID 1574498.
- ↑ Frable WJ, Kempson RL, Rosai J (March 1992). "Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report". Mod. Pathol. 5 (2): 102a–102b. PMID 1574486.
- ↑ URL: http://www.adasp.org/papers/position/Standardization.htm. Accessed on: 6 September 2012.
- ↑ Leslie KO, Rosai J (November 1994). "Standardization of the surgical pathology report: formats, templates, and synoptic reports". Semin Diagn Pathol 11 (4): 253–7. PMID 7878300.
- ↑ 7.0 7.1 Goldsmith, JD.; Siegal, GP.; Suster, S.; Wheeler, TM.; Brown, RW. (Oct 2008). "Reporting guidelines for clinical laboratory reports in surgical pathology.". Arch Pathol Lab Med 132 (10): 1608-16. doi:10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2. PMID 18834219.
- ↑ Soar J, Peyton J, Leonard M, Pullyblank AM (2009). "Surgical safety checklists". BMJ 338: b220. PMID 19158173. http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173.
- ↑ Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: http://www.amazon.com/dp/0805091742. ISBN-13 978-0805091748.
- ↑ URL: phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html. Accessed on: 10 January 2014.
- ↑ URL: http://www.ossweb.com/article-bullets.html. Accessed on: 10 January 2014.
- ↑ Renshaw, MA.; Gould, EW.; Renshaw, A. (Sep 2010). "Just say no to the use of no: alternative terminology for improving anatomic pathology reports.". Arch Pathol Lab Med 134 (9): 1250-2. doi:10.1043/2010-0031-SA.1. PMID 20807042.
- ↑ Lindley, SW.; Gillies, EM.; Hassell, LA. (Oct 2014). "Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver.". Pathol Res Pract 210 (10): 628-33. doi:10.1016/j.prp.2014.04.006. PMID 24939143.
- ↑ URL: http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports. Accessed on: 24 April 2014.
- ↑ Babwah JP, Khalifa M, Rowsell C (November 2014). "Analysis of addenda in anatomic pathology as a quality monitoring initiative". Arch Pathol Lab Med 138 (11): 1514–9. doi:10.5858/arpa.2012-0412-OA. PMID 25357114.