In training and practice, you’ll see a lot of reporting styles. While there is no objective single correct way, there are definitely ways that are hard to read and confusing that should be avoided.
When writing a report, I think that we need to remember that clinicians are very busy. The reader of your report may be in a rush and not be reading very carefully. Do everyone a favor and make the report easy for them to read. Be very clear, concise, and helpful.
To quote Dr. Juan Rosai, “It should be accurate, prompt, and brief.”
To do this, I try to do the following:
- Keep it short and sweet.
- Consider/address the clinical question, if possible.
- Use common, consensus wording and formatting.
- Be helpful: If the findings aren’t diagnostic of a single thing, at least give an interpretation or differential or suggest next investigative steps.
Keep it short and sweet.
Avoid unnecessary words that clutter a report as chaff that the clinician has to mentally separate out.
If there are random colon biopsies for “rule out microscopic colitis,”
Do NOT say:
– Benign colonic mucosa with no significant histopathologic abnormality
– No increased intraepithelial lymphocytes
– No crytptitis or crypt abscesses
Instead, I would say simply:
– No significant abnormality
You’ll note that I tend to not give “pertinent negatives” in the diagnostic line. To me, listing absent findings on the diagnostic line seems like a confusing slippery slope that could lead to a virtually unending cluttered list of increasingly irrelevant possible (but not present) diagnoses. Instead, if I don’t specifically list it as present, it is to be assumed that it isn’t there.
There are, of course, noteworthy exceptions that I may mention. For example, if a biopsy is intended to be of a lung mass but looks like normal lung, I might have as the diagnostic line “Alveolated lung parenchyma with no significant abnormality” and in a comment reinforce that “there are no histologic findings to explain the clinical impression of a lung mass.” Likewise, I try to mention in an IBD comment that I don’t see any viral inclusions or dysplasia or in a transplant liver biopsy that there is no evidence of rejection.
I don’t list the type of tissue if they clearly stated it and my observations agree with there description. If they tell me that it’s colon, then I don’t add anything by telling them it is colon–just tell them what’s wrong with it (if anything). I make an exception to this if the tissue differs from what it was submitted as. For example, if they submit something as lung and it’s heart tissue, then that needs to be documented (as does your phone call letting them know! 😉 )
Don’t include descriptive words that have no implications for patient care. They are quite literally meaningless and just add clutter that has to be sorted out.
For example, instead of saying:
– Invasive keratinizing squamous cell carcinoma, with ulceration, acute inflammation, and debris
Just say:
– Invasive squamous cell carcinoma
It’s unnecessary and confusing to include immunohistochemical stains, levels, etc… in your topline diagnosis. Mentally, incorporate them into your diagnosis, and document them for billing purposes inconspicuously lower down in the report.
For example, instead of saying:
– Metastatic lung adenocarcinoma, confirmed by TTF1 and Napsin-A immunohistochemical stains
– Deeper levels examined
Just say:
– Metastatic lung adenocarcinoma
(and then document anything necessary, like stains, in a comment or microscopic descriptions).
Consider/address the clinical question.
Always ask yourself: “Why did they do this biopsy?” “What are they concerned about?”
This requires some clinical knowledge and experience.
If you have a mediastinal lymph node from someone with known lung cancer, it can be assumed that they’re likely staging the patient and/or trying to explain lymphadenopathy. Consider possible reasons for lymphadenopathy (e.g., metastatic carcinoma, granulomatous disease, lymphoma, reactive lymphoid hyperplasia) and address those in your report somewhere.
If someone has a breast or lung mass, be sure to focus on findings that could be “tumefactive” in your report.
Use common, consensus wording and formatting.
Stick to the lingua franca for each type of specimen.
For tumors, use the WHO “Blue book” systems for naming tumors. For inflammatory lesions, stick to the common subspecialty literature and texts. For cytology, use the established systems for each specimen type.
Using standardized wording keeps us all speaking the same language and understandable. This requires keeping abreast of the evolution of the field and potentially subspecialty training.
In regards to formatting, my main point is to not be an outlier. Use whatever is common in your area, group, and institution, that your clinicians are familiar with. You don’t want to make the clinician work to figure out your own “unique” format. The format should blend into the background, allowing the diagnostic findings to take center stage.
Be helpful: If the findings aren’t diagnostic of a single thing, at least give an interpretation or differential or suggest next investigative steps.
While not every pattern of histologic findings has a single associated clinical diagnosis, I think it is very lame to just stop at a descriptive diagnosis when we can reasonably say more. As the pathologist, you undoubtedly know more about the possible associated clinical diagnoses than the clinician. Do them a favor and tell them what could look like this. Add value!
If you think it would be helpful, you can suggest additional studies (e.g., serum markers, additional sampling, genetic testing, etc…) that could aid in the diagnostic process.
To quote Dr. Richard Reed, “A competent [pathologist] is not simply a storage site for microscopic verbiage. It is not enough to be able to recite by rote the microscopic findings once the clinical diagnosis is established. The ability to offer clinical differential diagnoses from the interpretation of microscopic findings is the mark of the mature [surgical] pathologist… and is the art of pathology.”
For example, instead of merely saying for every colon biopsy from a patient:
– Cryptitis, Crypt abscess formation, basal lymphoplasmacytosis, and architectural distortion
Say:
– Chronic active colitis (see comment)
COMMENT: The histologic sections show an active colitis with cryptitis and crypt abscess formation. There are also features of chronicity including crypt architectural distortion and a basal lymphoplasmacytosis. No granulomas or viral cytopathic effect are identified. There is no evidence of dysplasia.
These findings are compatible with the patient’s reported history of inflammatory bowel disease. However, other etiologies, including medication-effect (particularly NSAIDs) and an infection, should be excluded clinically. Clinical and endoscopic correlation is recommended.
Admittedly, not all cases are amenable to super short reports. Some cases are complicated and require a discussion, but save that for the cases that really need them.
And, finally, always be sure to proofread your report, at least once. I often read my reports out loud before clicking the final button. Typographical errors can sometimes significantly change the meaning of a report in additional to casting it into doubt.