SURGICAL 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]