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Reporting guidelines for clinical laboratory reports in surgical pathology
Jeffrey D Goldsmith1, Gene P Siegal, Saul Suster
1Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachussetts 02215, USA. jgoldsmi@bidmc.harvard.edu
Standardized surgical pathology reports (SPRs) are crucial for patient care. This study outlines recommendations for required, preferred, and optional elements to ensure consistent reporting of pathology findings.
Area of Science:
- Pathology
- Medical Reporting
- Healthcare Standards
Background:
- Surgical pathology reports (SPRs) document critical patient tissue findings.
- Existing guidelines for SPR content are not exhaustive, leading to variability.
Framework:
- Developed recommendations for required, preferred, and optional SPR elements.
- Prioritized elements based on institutional reports and professional guidelines.
Implementation:
- The College of American Pathologists compiled and prioritized SPR elements.
- Consensus was reached on element priorities after discussion.
Implications:
- Provides a framework for creating comprehensive SPRs.
- Aims to standardize surgical pathology reporting for improved patient care.
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