The Complete Surgical Pathology Report

Abstract

An essential component of the postanalytic phase of a pathology test is a timely, concise, complete, and easy to read and understand report. The information provided in the pathology report is useful for optimal patient management as it provides not only accurate diagnosis but also information that may be prognostic or predictive. The purpose of a specimen procurement may be defeated if the pathology report is inaccurate, verbose, incomplete, difficult to read, or difficult to understand. An incomplete or ambiguous pathology report for cancer resection may not only delay patient management (as clarification of the report may be sought by the treating clinicians), but may be misunderstood with potentially significant consequences. Hence, the importance of a complete report cannot be overemphasized. The need for standardized reporting was identified more than two decades ago. The Association of Directors of Surgical Pathology (ADASP) highlighted the importance of standardization of surgical pathology reports, including the use of a “checklist” approach for recording information needed for patient treatment and prognosis. While most of the recommendations by ADASP have been adopted by most in the pathology community, there have been recent studies highlighting the need for improvement in the standardization and completeness of pathology reports. In fact, a recent College of American Pathology (CAP) Q-Probes study found that almost 30 % of pathology reports lacked at least one or more required elements.