A 2016 Practice Survey by the College of American Pathologists documented that 71 percent of pathologists practice in nonacademic (48 percent) and academic (23 percent) hospitals and medical centers. In general, these institutions use the pathology report format present in their electronic health records (EHRs). When possible, pathologists are encouraged to work with the hospital administration, medical staff, and EHR vendor to incorporate the guidelines below into the EHR report format.
Medical malpractice claims can be won or lost based on the quality and content of the medical record. When making a diagnosis in the pathology report, it is important for pathologists to record details about their decision-making process. Because claims are often filed years after an adverse event occurred, having a detailed report can help the pathologist remember the case specifics.
These guidelines are designed to help you accurately document your reports:
- Issue synoptic reports. They make the pathology report clinically relevant, ensure that important diagnostic criteria are considered, and provide essential therapeutic and prognostic information.1
- Provide a detailed microscopic description for difficult or unusual cases. In a separate “comment,” document how you arrived at the diagnosis.
- Enter the clinical information provided into the clinical diagnosis or pre-op diagnosis section of the report. If it cannot be obtained, document “no clinical information provided.” Collaborate with ordering clinicians to ensure they provide pertinent clinical information with specimens to aid in your diagnostic process.
- Make a definitive diagnosis. If you are unable to do so, seek consultation. Do not make descriptive diagnoses, e.g., “spindle cell tumor, probably benign.”
- Discuss the differential diagnostic considerations in the report. This may result in the clinician’s providing important additional clinical information that is unknown to the pathologist.
- Document recommendations made for follow-up studies, diagnostic procedures, and treatment in the report—preferably in a comment; e.g., “The lesion extends to the margins, and conservative re-excision is recommended.”
- Explicitly identify any diagnosis that is awaiting the results of immunohistochemical stains, second opinions, consultations, etc., as a provisional diagnosis. State that a definitive, or final, diagnosis will follow when studies are complete or a consultation has been received.
- Develop and follow policies for effectively communicating urgent diagnoses and unexpected diagnoses. These communications should be documented in the original pathology report, as an addendum, and in the EHR when appropriate.2
- Always issue a Supplemental Report whenever you receive important new information subsequent to the release of the initial report.
- Document intradepartmental second opinions on malignant, suspicious, and atypical diagnoses and on diagnostic problems and rare or unusual lesions (soft tissue tumors, bone tumors, etc.).
- Document your intention to seek an outside expert second opinion in order to arrive at a definitive diagnosis.
- Always issue a written report for “curbside” consultations. Otherwise, the only record of your conversational diagnosis is the clinician’s brief note in the medical record. (For more on this topic, see our article “Curbside Consultations: Patient Safety and Legal Risks.”)
- Review the report before its release to detect any transcription or documentation errors.
For additional information, see our article, “Requests for Pathology Specimens: Medical and Legal Guidelines” or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.