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    Sample Pathology Report

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    The pathology report summarizes the examination of a tissue specimen from a patient. It includes information about the patient and specimen, the pre-operative diagnosis, the pathologist's diagnosis based on examining the specimen visually and microscopically, any notes on additional testing or details of the findings, and a description of the specimen. The pathologist's name and date the report was completed are also included.

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    Sample Pathology Report

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    86 views1 page
    The pathology report summarizes the examination of a tissue specimen from a patient. It includes information about the patient and specimen, the pre-operative diagnosis, the pathologist's diagnosis based on examining the specimen visually and microscopically, any notes on additional testing or details of the findings, and a description of the specimen. The pathologist's name and date the report was completed are also included.

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    The pathology report summarizes the examination of a tissue specimen from a patient. It includes information about the patient and specimen, the pre-operative diagnosis, the pathologist's diagnosis based on examining the specimen visually and microscopically, any notes on additional testing or details of the findings, and a description of the specimen. The pathologist's name and date the report was completed are also included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    86 views1 page

    Sample Pathology Report

    Uploaded by

    youtube premium
    The pathology report summarizes the examination of a tissue specimen from a patient. It includes information about the patient and specimen, the pre-operative diagnosis, the pathologist's diagnosis based on examining the specimen visually and microscopically, any notes on additional testing or details of the findings, and a description of the specimen. The pathologist's name and date the report was completed are also included.

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    SAMPLE PATHOLOGY REPORT

    Specimen and patient identification


    PATIENT: Patient Name DATE OF BIRTH: 01/01/1960
    MEDICAL RECORD NUMBER: Patient’s hospital number GENDER:

    SPECIMEN COLLECTION DATE/TIME: 01/01/2019 12:00h CASE NUMBER: Pathology case number
    SPECIMEN RECEIPT DATE/TIME: 01/01/2019 13:00h

    SPECIMEN LABEL(s): Specimen site and medical procedure (such as “Appendix, appendectomy”)

    PATIENT HISTORY: Information the clinical team think the Pathologist should know about the
    patient, especially as it pertains to the specimen being evaluated.

    PRE-OPERATIVE DIAGNOSIS: The current clinical diagnosis relating to the specimen. If the true diagnosis is
    not yet known, the clinical team may provide a list of possible diagnoses (a
    "differential diagnosis").

    DIAGNOSIS: The final diagnosis made by the Pathologist based on examination


    of the tissue specimen visually (grossly) and microscopically, and
    in combination with relevant clinical information.

    NOTE: The note (sometimes called comment) includes information that may be
    helpful to the clinical team. This could be a more detailed description of
    what the Pathologist saw in the specimen, an outline of other diagnoses that
    were considered, or information that can help with diagnosis and treatment.

    SPECIAL TEST RESULTS: The pathology diagnosis may require extra testing such as special tissue stains.
    The results from this additional testing could be included here in the report.

    GROSS DESCRIPTION: This is a description of the specimen when it was received by pathology. The
    description includes measurements (size and sometimes weight), markers of
    orientation, anatomic features and any pathologic findings that can be
    identified by sight or touch. The gross description also includes a list of all parts
    of the specimen that have been submitted for examination under the
    microscope.

    NAME OR SIGNATURE OF PATHOLOGIST WHO COMPLETED REPORT


    Date and Time Pathology Report Completed

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