How to write a pathology report

Written by viktoria carrella
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A pathology report contains four different sections: diagnosis, gross description, microscopic description and comments. The diagnosis section gives information about the area of the body, the procedure completed and the diagnosis. The gross description offers information on the way the tissue looks to the pathologist as well as a summary of where the samples were taken from and even what inks or dyes were used. The microscopic description tells what the pathologist sees under a microscope, and the comments section gives room for any other information not filled in above.

Skill level:
Moderate

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Things you need

  • Typewriter or computer with pathology report loaded
  • Printer and paper
  • Pathologist's information and notes

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Instructions

  1. 1

    Type in Diagnosis, then type in the procedure that was completed, followed by a comma. Type in the diagnosis; for example, the lump found is differentiated.

  2. 2

    Hit enter twice, type in Gross Description, then type in the way the tissue or specimen appears. You can also create a short summary of the exact area the sample was retrieved from; for instance, the lump was removed from the medial section of the thyroid gland. Also include information such as the surface colour and weight of the specimen and the marginal measurements.

  3. 3

    Hit enter twice, type in Microscopic Description, and enter the record of what is seen under the microscope when viewing the specimen. For example, type in that the specimen offers good differentiation, the separate glands are completely lined with hyperchromatic nuclei, and the mitotic rate is around 8 per 12 high power fields. The information is very technical at this point.

  4. 4

    Hit enter twice, then type Comment. Clarify information or tell other doctors what studies you are still waiting on for the diagnosis.

Tips and warnings

  • If your computer doesn't have a special program for pathology reports, use Microsoft Word.

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