Understanding Your Report
The “Pathology Report” is a very important document that describes the Pathologist’s findings of the examination of tissue or other materials that were submitted by your physician. This can be a skin biopsy from a dermatologist’s office, a pap test from an OB/Gyn office, a colon biopsy from a colonoscopy or any number of specimens that may have been removed or biopsied during surgery.
There are several sections in a typical Pathology Report. Some sections may or may not appear on your report, or may appear in a different order, depending on the type of report and the source from which it was received. They are listed in order of a typical report from MicroPath Laboratories.
- Patient Information – This provides standard patient information including the referring physician, collection date and received date.
- Specimen Source – This provides the location of the body from which the tissue was removed.
- Clinical History – Any previous information given about a patient, specimen and/or site.
- Macroscopic Description – This section describes the appearance of the material sent to pathology. It includes a description of the various different organs or samples, how they were submitted and how they were labeled.
- Microscopic Diagnosis – This section is the heart of the report. It is where the pathologist lists the diagnoses for each specimen.
- Test Requested – The specific test requested by the referring physician.
- Specimen Adequacy – Specific to cytology reports and measures if there is sufficient quantity & quality of specimen to render diagnosis.
- Cytologic Diagnosis – This is the heart of the Cytology report. It is where the Pathologist lists the diagnoses on the cells, after they have performed their examination.
- Diagnostic Comments – This section is optional and may not be on every report. If there is information that the Pathologist would like to convey to the physician, but it is not part of the diagnosis, this is where the Pathologist can list this information.