Surgical pathology reports with a portable microcomputer

A microcomputer reporting system for gross and microscopic surgical pathology is simple and inexpensive, reduces the need for clerical personnel, and saves the pathologist's time in the preparation of reports. Gross descriptions are performatted. A dictionary of microscopic diagnoses is constructed and stored on disks. The diagnosis to be used for a case is selected by a pathologist by number. It is called to a video screen from disk storage by entering the number on the microcomputer keyboard. The diagnosis is edited or expanded for an individual patient while it is on the screen and is printed after changes are made. Each diagnosis contains preentered classification, coding, and filing information, as well as format, medical terminology, and spelling. The system has rapid retrieval and search capability and may be used for patients awaiting frozen-section diagnosis. The system requires fewer clerical personnel in surgical pathology than with free-form reporting.