How To Write a Pathology Report

Many hospitals are required to give out a pathology report when diagnosing patients with their condition. It is generally a report that contains diagnosis with the very gross description about the parts of the body the doctor has examined. Pathology reports should be complete with all the necessary information the patient has to keep him aware and informed of what his diagnosis is and everything including the procedure done to him. If you work in a hospital, chances are your hospital has already a good spreadsheet for a pathology report. All you have to do is to fill in the blanks and the necessary information that the pathology report needs. If your hospital does not have a standardized spread sheet, you can use the program Microsoft Word to get this report done. In order to write a good pathology report, you should follow these tips:

  • The very first thing you should do is to write down all the information of the patient you have examined and are writing the report for. Write the full name including the middle name in case the patient’s name is common. It will distinguish each patient’s name from one another and it will be easier for the nurses and doctors to find and access your pathology report. Do not forget to indicate the requesting physician to make sure that your pathology report will reach the right people once you are done with it.
  • Carefully scan the pathology spread sheet and start from the very top working your way towards the end of the report. It is much better to be organized in writing your pathology report to avoid missing out any important items. If you are unorganized and skip from one item to another item, there will be a tendency you will get your report all mixed up and not to rule out the possibility of switching diagnosis which will have a big effect on your patient’s proper health and medication.
  • Type in a brief history of your patient’s condition followed by your diagnosis of the sickness. You should very well specify first the diagnosis in a simple sentence before proceeding in explaining why you have come to that conclusion. Be sure to always write down the description of the condition and what procedure you have done to cure the condition. Be very specific in your words and be very clear and concise and avoid writing very long sentences.
  • Do not forget to affix your signature and your full details on the spaces provided for the pathologist. Your details are essential to the doctors who are going to use your report so they will have a track on where to ask questions if there are some things in the report that are not clear to them

Most of the time, some doctors can debate over a pathology report so it is important to be always available for some discussion. Always remember not to forget indicating the type of tests you have ran for the patient and the corresponding diagnosis. It would be an effective report if you are complete and clear in details.


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