A surgical pathology report records what the laboratory found in tissue taken from a patient: what arrived, what it looked like, what the microscope showed, and the diagnosis. Copy the free template, see a breast biopsy and a colon polyp example, and learn what each section of a report means.
Blank pathology report template
FreeSURGICAL PATHOLOGY REPORT Patient: [Full name, date of birth, sex] Record number: [Medical record number] Accession number: [Laboratory case number] Collected: [Date, time, and where] Received: [Date and time] Reported: [Date and time of sign-out] Report status: [Final, preliminary, addended, or amended] Requesting clinician: [Name, specialty, and phone] Copies to: [Other clinicians who should receive the report, or none] CLINICAL INFORMATION History: [Relevant diagnoses and treatment, such as chemotherapy or radiation] Prior pathology: [Earlier biopsies or resections, with case numbers and diagnoses, or none] Imaging and procedure findings: [What imaging or the procedure showed, such as a BI-RADS category or the size of a polyp] Procedure: [Biopsy, excision, resection, or polypectomy, and the technique] Clinical question: [What the requesting clinician needs to know] SPECIMENS RECEIVED Part A: [Site, laterality, and procedure, as labeled on the container] Part B: [Site, laterality, and procedure, or no further parts] Identification: [Two identifiers on each container match the requisition, or the discrepancy and how it was resolved] Fixation: [Fixative used, and any tissue sent fresh or frozen for other tests] Time to fixation: [Time removed, time placed in formalin, and total time in formalin, when biomarker testing is likely] INTRAOPERATIVE CONSULTATION Frozen section or touch preparation: [Part, diagnosis given, time, and the surgeon who was told, or none performed] GROSS DESCRIPTION Received: [Number of pieces or the intact specimen, and the label on the container] Size and weight: [Three dimensions in cm, and weight in grams for resections] Orientation: [Sutures, clips, or markers, and what the surgeon says they mark] Inking: [Ink color for each margin] Description: [Each lesion: size, color, consistency, and distance to each margin] Lymph nodes: [Number found and how they were submitted, or none] Sections submitted: [Entirely or representatively submitted, and the number of cassettes] Cassette key: [What each cassette holds, such as A1, lesion with deep margin] Grossed by: [Name, role, and date] MICROSCOPIC DESCRIPTION Findings: [Features that support the diagnosis or explain a difficult case, or not included per laboratory practice] FINAL DIAGNOSIS Part A: [Site, laterality, procedure: main diagnosis first, then grade, margins, and other findings that change care] Part B: [Site, laterality, procedure: diagnosis] Pending: [Tests still in progress, to follow in an addendum, or none] SYNOPTIC CANCER REPORT Protocol: [CAP cancer protocol or ICCR dataset used, and its version] Procedure and site: [Procedure, tumor site, and laterality] Tumor: [Histologic type, grade with the system named, size, and focality] Extent: [Depth of invasion, or spread into nearby structures] Margins: [Involved or clear; distance to the closest margin, and which one] Lymphovascular invasion: [Present, not identified, or cannot be determined] Lymph nodes: [Number examined, number with metastasis, and size of the largest deposit] Treatment effect: [Response to therapy given before surgery, or not applicable] Pathologic stage: [pTNM, with the staging edition used] ANCILLARY STUDIES Immunohistochemistry and special stains: [Stains, block tested, results, and controls] Biomarkers: [ER, PR, HER2, Ki-67, mismatch repair proteins, or others: result, scoring method, and guideline] Molecular and other tests: [Test, laboratory, and result, or pending] COMMENT Interpretation: [How the findings fit the imaging and clinical picture, limits of the sample, and further testing advised] Second review: [Second pathologist or consultant who reviewed the case, and whether they agree, or none] COMMUNICATION Critical or unexpected result: [Yes or no, and why] Called to: [Name and role, date and time, who called, and read back confirmed] ADDENDA AND AMENDMENTS Addendum: [Date, what was added, and whether it changes the diagnosis] Amendment: [Date, what changed and why, original wording kept, and who was told] SIGN-OUT Pathologist: [Name, credentials, electronic signature, date and time] Attestation: [Your laboratory's statement that you examined the slides, and any residents or fellows involved]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Ultrasound-guided biopsy at a breast imaging center, reported by a hospital laboratory
Grace Whitfield, born March 14, 1971, female. Record number 3304817. Accession S26-21907. Collected November 3, 2026, at 10:36, at the breast imaging center. Received November 3 at 14:05. Reported November 5 at 15:40; addendum November 7. Requesting clinician: Dr. Nadia Petrov, breast radiologist, who did the biopsy. Copies to: Dr. Samuel Ortiz, family physician.
55-year-old woman with a right breast lump she noticed 3 weeks ago. Ultrasound: 1.6 cm irregular, hypoechoic mass with angular margins at 10 o’clock, 4 cm from the nipple; BI-RADS 5. Axillary ultrasound normal. No prior breast biopsy or cancer. Procedure: ultrasound-guided core needle biopsy, 14-gauge, 4 cores; marker clip placed. Question: is it cancer, and if so, the type, grade, and biomarkers for treatment planning.
Part A, right breast, 10 o’clock, core biopsy. Container labeled with name and date of birth, matching the requisition. Each core went into 10% neutral buffered formalin as it was taken, from 10:24 to 10:36, so time to fixation was under 2 minutes. 22 hours in formalin before processing, within the 6 to 72 hours that biomarker testing needs. Gross: four tan-white cores, 1.1 to 1.7 cm long and 0.1 cm in diameter, entirely submitted. Cassette key: A1, two cores; A2, two cores. Grossed by J. Alvarez, pathologists’ assistant, November 3.
Part A, right breast, 10 o’clock, ultrasound-guided core needle biopsy: Invasive breast carcinoma of no special type, also called invasive ductal carcinoma. Nottingham grade 2 of 3. Carcinoma in 4 of 4 cores; longest length in one core, 1.3 cm. Ductal carcinoma in situ not identified. Lymphovascular invasion not identified. ER, PR, HER2, and Ki-67 to follow in an addendum.
Elements from the CAP protocol for breast biopsies with invasive carcinoma. Procedure: ultrasound-guided core needle biopsy. Site: right breast, 10 o’clock. Histologic type: invasive carcinoma of no special type. Nottingham score 6: tubule formation 3, nuclear pleomorphism 2, mitotic count 1, so grade 2. Ductal carcinoma in situ: not identified. Lymphovascular invasion: not identified. Microcalcifications: not identified. Stage: not assigned on a biopsy.
The findings agree with the BI-RADS 5 imaging. Reviewed by a second pathologist, Dr. Ravi Menon, who agrees. New diagnosis of cancer: Dr. Helen Cho called Dr. Petrov on November 5 at 15:52, and Dr. Petrov read the diagnosis back. Dr. Petrov will tell the patient and refer her to the breast surgery clinic.
November 7, 2026, 14:20. Tested on block A1; external and internal controls stained as expected. Scored under the ASCO/CAP guidelines. ER: positive, 95% of tumor nuclei, strong. PR: positive, 60%, moderate to strong. HER2 by immunohistochemistry: score 1+, faint, incomplete membrane staining in about 40% of tumor cells. That is HER2-negative, and in the HER2-low group, which can matter for treatment if the cancer spreads. Ki-67: 15% of tumor nuclei. Diagnosis unchanged. Sent to Dr. Petrov, Dr. Ortiz, and the breast surgery clinic.
Helen Cho, MD, anatomic pathologist. Report electronically signed November 5, 2026, at 15:40. Addendum signed November 7 at 14:20.
Screening colonoscopy in an endoscopy unit, routine report from a community laboratory
Robert Haines, born July 22, 1964, male. Record number 5521096. Accession S26-22340. Collected November 4, 2026, at 09:15, in the endoscopy unit. Received November 4 at 13:30. Reported November 6 at 11:05; amended November 9. Requesting clinician: Dr. Priya Raman, gastroenterologist. Copies to: Dr. Lena Brooks, family physician.
62-year-old man, first colonoscopy, after a positive fecal immunochemical test. Two polyps. Part A: 15 mm pedunculated polyp in the sigmoid colon at 30 cm, corrected from descending colon in the amendment; removed whole by hot snare. Part B: 4 mm sessile polyp in the rectum, removed by cold snare. Question: polyp type, dysplasia, and whether part A was fully removed.
Two containers in formalin, each labeled with name and date of birth, matching the requisition. Part A, labeled “descending colon polyp”: one polyp, 1.5 × 1.2 × 1.0 cm, with a stalk 0.7 cm long and 0.4 cm across. Cauterized stalk margin inked black. Head lobulated, red-tan. Bisected through the stalk and entirely submitted in A1. Part B, labeled “rectal polyp”: one tan fragment, 0.4 cm, entirely submitted in B1. Three levels cut on each block. Grossed by M. Torres, pathologists’ assistant, November 4.
Part A: tubular glands throughout the head, lined by crowded, elongated nuclei that keep their polarity, as in low-grade dysplasia. No high-grade dysplasia, and no adenoma in the stalk. Nearest adenoma 3 mm from the inked margin. Part B: serrated crypts in the upper half of the mucosa, with normal crypt bases; no dysplasia.
A. Colon, sigmoid at 30 cm, hot snare polypectomy: Tubular adenoma with low-grade dysplasia, 1.5 cm. No high-grade dysplasia or invasive carcinoma. Cauterized stalk margin clear, by 3 mm. B. Rectum, cold snare polypectomy: Hyperplastic polyp. No dysplasia.
Synoptic report: not needed, as there is no carcinoma. Ancillary studies: none; mismatch repair testing is done on colorectal carcinomas, not adenomas. Comment: part A measures 1.5 cm in the laboratory, matching the endoscopic size of 15 mm. The surveillance interval is left to the endoscopist, who has the polyp count, the bowel preparation, and how completely each polyp was removed. Critical or unexpected result: none; routine release, no call.
November 9, 2026, 09:40. Part A site changed from descending colon to sigmoid colon at 30 cm. Dr. Raman called: the requisition and container named the wrong segment, and her procedure report and photos show the sigmoid colon. Diagnosis unchanged. The original report stays in the record, marked as replaced; the amended report went to Dr. Raman and Dr. Brooks.
Daniel Kowalski, MD, pathologist. Report electronically signed November 6, 2026, at 11:05. Amendment signed November 9 at 09:40.
Why the tissue was taken and what the clinician wants to know. For a patient, it’s the short history the clinician sent with the sample.
Avoid: Signing out with a blank history. Prior cancer, chemotherapy, or radiation changes how you read the slides, so call for it.
What arrived, how it was labeled, and how it was preserved. Tissue left too long before formalin, or in it too briefly, can give false biomarker results.
Avoid: Leaving out fixation times on breast specimens. ASCO/CAP guidelines ask for 1 hour or less before formalin and 6 to 72 hours in it for ER, PR, and HER2 testing.
What the tissue looked like to the naked eye: its size, weight, and color, and how it was cut up. It lets any pathologist trace a slide back to the exact spot it came from.
Avoid: A cassette key that says only “representative sections.” Name what each cassette holds, so the lesion and margins can be found on a slide.
What the pathologist saw under the microscope. Many laboratories leave it out of routine cases, because the diagnosis and synoptic report carry the findings.
Avoid: Repeating the diagnosis in longer words. Use it to explain your reasoning, or leave it out.
The answer. For each part: the site, the procedure, and what the tissue shows. It’s the section to read first, whether you’re the clinician or the patient.
Avoid: Burying the diagnosis in the comment or after a long description. Put the main point on the first line of each part.
A structured list of the cancer details that staging and treatment depend on. The elements come from the CAP cancer protocols or the ICCR datasets; write the answers in your own report.
Avoid: Leaving an element blank. Write “cannot be determined” and why, so the reader knows it was looked at.
Tests beyond routine slides: special stains, immunohistochemistry, biomarkers, and molecular tests. Results such as ER, PR, HER2, Ki-67, and mismatch repair proteins guide treatment.
Avoid: Reporting HER2 as “negative” with no score. A score of 1+, or 2+ with a negative ISH test, is called HER2-low and can open other treatment options.
What the findings mean together, and a record of any result that couldn’t wait for the routine report. Many laboratories keep a list of critical diagnoses, such as an unexpected cancer, that need a call.
Avoid: “Clinician notified.” Write who you spoke to, when, and that they read the result back.
Changes after sign-out. An addendum adds information, such as biomarker results, without changing the diagnosis. An amendment changes the report: a corrected diagnosis, site, or patient detail.
Avoid: Editing a signed report without a trace. Issue an amendment, mark what changed, and call the clinician if care could change.
Compare the laterality and site on the container, the requisition, and the procedure note at grossing. A left–right error carried into the diagnosis can send a patient to surgery on the wrong side.
ER or HER2 can stain falsely negative in tissue that waited hours before formalin. Record fixation times, check the internal controls, and say in the comment when a result may not be reliable.
For adenomas, size, number, and grade of dysplasia set the surveillance interval. Give the size you measured, or say the polyp came in pieces and the endoscopic size should be used.
“Moderately differentiated” on its own leaves the reader guessing. Name the system and the score, such as Nottingham grade 2 of 3.
If biomarkers or molecular tests are still running, say so in the diagnosis and issue an addendum when they finish. Otherwise treatment may be planned on an incomplete report.
Vero Scribe writes the pathology report in your template from your dictation, at the grossing bench or at the microscope. You review and edit every section, then copy it into your laboratory system or export it to Word or PDF. Vero works in 60+ languages.
Start with the final diagnosis: it names each sample, where it came from, and what it showed. The gross description is what the tissue looked like before it went under the microscope, and the microscopic description is what the pathologist saw there. For a cancer, the synoptic report lists the details treatment depends on, such as grade, size, margins, and lymph nodes. Ask the clinician who ordered the test to go through it with you.
Patient and specimen identifiers, the clinical history and question, what was received and how it was fixed, a gross description with a cassette key, the final diagnosis, a synoptic report for cancers, ancillary test results, any comment, a record of calls about critical results, and the pathologist’s signature. Addenda and amendments follow when results or corrections come later.
A structured list of the cancer details that staging and treatment depend on, such as histologic type, grade, size, margins, lymph nodes, and stage. The elements come from the College of American Pathologists cancer protocols or the International Collaboration on Cancer Reporting datasets. It sits alongside the diagnosis; it doesn’t replace it.
The margin is the cut edge of the tissue the surgeon removed. The laboratory paints it with ink so it shows under the microscope. A clear, or negative, margin usually means no tumor touches the ink, and the report often gives the distance to the closest margin. A positive margin means tumor reaches the edge, and more treatment may be needed.
An addendum adds information after sign-out, such as biomarker or molecular results, and leaves the diagnosis as it was. An amended report changes something already reported, such as the diagnosis, the site, or a patient detail. It keeps the original wording in the record, says what changed and why, and the clinician is told when care could change.
Yes. Copy it, or download it as a Word or text file. No account needed.
Gross and microscopic findings, drafted from your dictation in your report format.
Notes for the oncology visits where your report guides treatment.
Procedure and visit notes for the endoscopists who read your polyp reports.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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