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A pathology report contains a patient’s diagnosis. This report is crucial in deciding the best possible treatment plan.
The report includes technical language intended for other medical professionals. A member of the care team can help explain it if needed.
A pathologist writes the report after examining cells and tissues under a microscope and interpreting the results of laboratory tests.
Pathology reports from different centers may vary in appearance. But they contain the same types of information.
This section includes the patient’s name, birthdate, medical record number, and biopsy date. Pathology departments have numbering systems to label the specimen, the tissue removed for examination.
This section lists the source or location of the specimen, such as “simple excision, left knee” or “skin biopsy, right arm.”
This section describes how the tissue looks to the naked eye: size, weight, color, and number of samples.
This section describes how the cells look under the microscope. It details how their appearance compares to normal cells.
This section provides the diagnosis. Information may include:
This section includes the important details of the case.
Pathologists use this section to explain any issues that might be unclear. Some pathology reports also contain additional data that can help the care team prepare the best treatment plan possible.
The report includes the name and signature of the pathologist.
Reviewed: August 2018