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Path Lab
Reading Between the Lines in the Pathology Report
Julia Dahl
Publish Date: February 9, 2008

If you refer pathology specimens to more than one lab, the reports you receive back can vary from lab to lab and from pathologist to pathologist. To ensure that you're receiving all the information you need, here's an overview of the required and optional elements of the surgical pathology report.

Required elements
Required elements of the pathology report include:

  • Patient identifying information. At least two patient identifiers (such as name, date of birth, medical record number or gender) must be on all pathology reports. Report any errors to your lab and document their correction.
  • Submitting physician, facility and report distribution. The submitting physician and procedure facility must appear on each report to document the request for consultation. In addition to distributing the report to the submitting physician and facility, list all physicians and facilities to which the pathology report will be forwarded. If you opt to distribute pathology reports received from the path lab rather than entrusting the lab to do so, document report distribution within the medical record.
  • Clinical history. Any pathology specimen received without clinical history must be "rejected" pending receipt of the clinical history, according to Clinical Laboratory Improvement Amendments and the College of American Pathologists. Some may think that providing clinical history biases the pathologist at the time of tissue examination, but as consulting physicians, pathologists should be able to consider the histologic findings in the context of the patient's medical history. To support this, most surgical pathology requisitions have a dedicated space for including clinical history. Some labs have opted to offer Internet or database-accessible electronic order entry for pathology services, which may streamline the requisition process and reduce the time required for conveying clinical history. Alternatives to including the clinical history on a requisition (paper or electronic) include interfaces with procedure report writers and electronic medical records or the old-fashioned method of sending a copy of the patient's history and physical or procedure report (if available) with the specimen.
  • Specimen data. The site from which the biopsy material was procured should appear in the report's "gross examination" section, which also conveys how the tissue was received, in what type of fixative, how it's labeled and its characteristics. For more complicated cases, some path labs provide specimen photos or diagrams to facilitate review of the diagnosis. Reviewing the specimen information is useful in the uncommon instance of an unexpected diagnosis or concern for error, as the tissue characteristics may be an indicator of error. For example, a patient with a sessile polyp receives an "invasive carcinoma limited to the head of a pedunculated polyp" diagnosis. The specimen data may help determine where the error occurred. Current guidelines require that tissue be held for three weeks after completion of the pathology report, after which the tissue is destroyed.
  • Final diagnosis and comments. The final diagnosis should incorporate the tissue site and provide clinically relevant information, concisely communicated in a timely manner. Although not a required element of the report, pathologists often use the comment section as an extension of the final diagnosis. All pathology consultations are intended to be correlated to the complete clinical circumstance of each patient. You should question the diagnosis in the event that the rendered pathology diagnosis doesn't match the patient's clinical presentation. If the diagnosis is in doubt, send the case out — with clinical history, of course.
  • Laboratory information. Each path report must contain the lab's name, address, phone number and CLIA certification identifier, as well as the name of the lab's medical director. If any part of the tissue evaluation is performed at a location other than the lab, then the path report must contain the address where the evaluation took place. Busy labs may farm out patient cases to alternate facilities. This may hinder your ability to form close working relationships with the pathologists serving your facility.

Optional elements
With the increase in competition in the outpatient surgical pathology marketplace, some labs now offer enhanced reporting features as well as report distribution interfaces. These features are non-essential in terms of compliance with accreditation or lab certification, but they may be of value to your facility, your physicians and your patients. Optional elements that may be included in pathology reports include:

  • Microscopic description and/or photomicrographs. The microscopic description provides a narrative description of the tissue characteristics under the microscope. This portion of the report has more usefulness for conveying findings between pathologists than to provide a clearer picture of the case for the submitting physician or facility. For this reason (and to reduce transcription costs), many labs have eliminated the microscopic description portion from their reports. In lieu of the microscopic description, some labs offer photomicrographs to document the histologic findings. As you can see in the examples above, photomicrographs can provide a view of the case that simulates the rapidly declining practice of "looking at the case with the pathologist" across the microscope. Some labs provide a stock image of a pathology condition, rather than documenting the particular patient's case. Another use of photomicrographs is to guide discussions with patients. It's important to keep in mind that the final diagnosis is rendered by evaluating all of the tissue on the slides; a single photomicrograph may represent less than 1 percent of the examined tissue.
  • Enhanced reporting features. Other enhanced reporting features include diagrammatic representations of the tissue and the disease classification of the tissue findings: benign, inflammatory, dysplasia or malignant. While these diagrams may serve as visual aids, it's essential to determine a patient's treatment (particularly definitive treatment for malignancy) on the final diagnosis. As we enter the age of molecular diagnostics, surgical pathology reports may also include a summary of ancillary study findings, such as results of microsatellite instability tests, PCR (polymerase chain reaction) analysis and genomic drug sensitivity testing. If the ancillary test is reported separately, it should be connected to the original case with an addendum report to document what tissue the ancillary test was performed on, as well as the final disposition of the tissue.
  • Quality assurance reports. Within the body of the surgical pathology report, any quality assurance activity or variance that may impact the final diagnosis may be recorded. For example, the comment "this case has been reviewed in intradepartmental consultation" is a quality assurance activity. As quality assurance programs within each laboratory are generally peer review activities, most labs opt to not include quality assurance data on individual reports. Some labs provide quality assurance reports to facilities on a quarterly or annual basis. A helpful hint: These reports can be very useful in accreditation documentation.
  • References. It's unusual for references to occur in surgical pathology reports, although they're more common for consulting pathology reports, in which the case was referred for extra-departmental (expert) consultation.
  • CPT and ICD-9 codes. When tissue is procured during a surgical procedure, the final billing codes (ICD-9) rely on the final pathology diagnosis, rather than the clinical impression. Additionally, patients may be concerned about the total procedure cost, including the cost of pathology services. Some labs report both CPT and ICD-9 codes routinely within the path report. Reviewing the path report for relevant codes may reduce significant coding time for facility personnel.

Common Phrases and Terms Within the Pathology Report

Term

What it Really Means

"Clinical correlation required"

Indicates that the clinician must correlate the conveyed information in the context of all available clinical history. This phrase is often used in a "protective" manner, to return accountability for the final diagnosis to the submitting physician, rather than the pathologist.

"Compatible with"

Frequently used in the context of a descriptive diagnosis and may appear within the diagnostic line or within a comment. The phrase indicates that the findings are likely to represent the diagnosis issued. However, there is a degree of diagnostic uncertainty (around 20 percent) due to overlap of histologic features with other disease entities.

"Consistent with"

Frequently used in the context of a descriptive diagnosis and may appear within the diagnostic line or within a comment. The phrase indicates that the pathologist interprets the findings to be "nearly equivalent to" the diagnosis. However, there is a degree of diagnostic uncertainty (around 5 to 10 percent) due to overlap of histologic features with other disease entities.

"Suggestive of"

Frequently used in the context of a descriptive diagnosis and may appear within the diagnostic line or within a comment. The phrase indicates that the pathologist interprets the findings to be "within the ballpark of" the diagnosis; however, there is a significant overlap of histologic features between diseases. The degree of diagnostic uncertainty is higher.

"Concerning for"

May be used with either categorical diagnoses or descriptive diagnoses and is usually on the diagnostic line but may be within a comment. The phrase indicates that the pathologist has a high degree of suspicion for a finding that will generally result in a significant treatment differential for the patient. However, there are insufficient findings to render the suspected diagnosis. Synonyms: "worrisome for" or "suspicious for."

— Julia Dahl, MD

To your satisfaction
Each facility's needs, from a diagnostic surgical pathology perspective, are unique. At the very basic level, the pathology services should support the facility's accreditation requirements and your physicians' diagnostic needs. Once that's been achieved, consider if additional services would benefit your facility's accuracy and workflow, as well as your patients' satisfaction.

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