How to Write a Pathology Report

Pathology reports are conducted on tissue specimens, such as a biopsy for cancer, a removed appendix and autopsies also use pathology reports to assist in finding cause of death. To write a pathology report you will first need to the patients’ clinical history which indicates all previous medical conditions and family history illnesses; you will need the diagnosis also known as the assessment which indicates the reason for the pathology report and other pertinent information, such as the gross examination which describes the specimens size, appearance, shape and all other information obtained during testing to compile an accurate and well written pathology report.

Difficulty: Moderately Challenging

Instructions

Things You'll Need:

• Patient information
• Gross examination
• Microscopic examination
• Diagnosis
• Pathologist signature
• Address

1. Include the patients’ information: first name, middle initial, last name, date of birth and the date of the pathology testing on the top left side of the pathology report.

2. List the gross examination information. This will include the weight, size, shape and color of the tissue specimen you tested.

3. List the microscopic examination information about how the tissue specimen sample appears under the microscope; this includes any comparisons or distinct differences the specimen has with normal cells.

4. Explain the diagnosis; this includes the type of cancer or tumor, describe how quickly the cancer may spread, the stage of the cancer whether it is malignant or benign.

5. List any additional notes you would like the primary physician to review, such as information related to previous testing of tumors or biopsies and request for additional testing.

6. Sign the pathology report; in order for the report to be valid it must be signed by the pathologist.

7. Include the name and address of the facility the pathology testing was completed.

Tips & Warnings

• Check your report for errors

Resources

• Understanding Pathology Reports

[dobguy1]

on 8/5/2009 great article