Abstract
Information necessary for optimal patient management should be included in the pathology report for such report to be considered complete. This is an essential component of the postanalytic phase of a pathology test. The importance of a complete pathology report cannot be overemphasized as governmental and nongovernmental agencies are interested in pathology reports including the American College of Surgeons (ACS), Commission on Cancer (CoC) for cancer center accreditation, and governmental agencies, such as the Center for Medicare and Medicaid Services (CMS) for incentive payment. The use of cancer protocols as determined by the College of American Pathologists (CAP) for reporting of cancer resection specimens is in fact a laboratory accreditation requirement.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Associated of Directors of Anatomic and Surgical Pathology. Standardization of the surgical pathology report. Am J Surg Pathol. 1992;16:84–6.
Kempson RL. Checklists for surgical pathology reports. An important step forward. Am J Clin Pathol. 1993;100(3):196–7.
Recommendations for the reporting of breast carcinoma. Association of Directors of Anatomic and Surgical Pathology. Am J Clin Pathol. 1995;104(6):614–9.
Recommendations for the reporting of urinary bladder specimens containing bladder neoplasms. Association of Directors of Anatomic and Surgical Pathology. Pathol Int. 1996;46(11):901–3.
Recommendations for the reporting of resected large intestinal carcinomas. Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 1996;27(1):5–8.
Association of Directors of Anatomic and Surgical Pathology. Recommendations for the reporting of larynx specimens containing laryngeal neoplasms. Virchows Arch. 1997;431(3):155–7.
Zarbo RJ. Interinstitutional assessment of colorectal carcinoma surgical pathology report adequacy. A College of American Pathologists Q-Probes study of practice patterns from 532 laboratories and 15,940 reports. Arch Pathol Lab Med. 1992;116(11):1113–9.
Idowu MO, Bekeris LG, Raab S, Ruby SG, Nakhleh RE. Adequacy of surgical pathology reporting of cancer: a College of American Pathologists Q-Probes study of 86 institutions. Arch Pathol Lab Med. 2010;134(7):969–74.
American College of Surgeons: Statement on Principles. https://www.facs.org/about-acs/statements/stonprin. Accessed 7 July 2018.
Cancer Program Standards: Ensuring Patient-Centered Care 2016 Edition. https://www.facs.org/~/media/files/quality%20programs/cancer/coc/2016%20coc%20standards%20manual_interactive%20pdf.ashx. Accessed 22 July 2018.
2016 Pathology Preferred Specialty Measure Set. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/downloads/Pathology_Specialty_Measure_Set.pdf?agree=yes&next=Accept?agree=yes&next=Accept. Accessed 22 July 2018.
Centers for Medicare & Medicaid Services – Physician Quality Reporting System. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html. Accessed 22 July 2018.
Quality Payment Program Overview. https://qpp.cms.gov/about/qpp-overview. Accessed 2 July 2018.
Quality Payment Program – Explore Measures. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018&specialtyMeasureSet=Pathology. Accessed 26 July 2018.
CAP Cancer Protocols. http://www.cap.org/web/oracle/webcenter/portalapp/pagehierarchy/cancer_protocol_templates.jspx?_afrLoop=18474224026548#!%40%40%3F_afrLoop%3D18474224026548%26_adf.ctrl-state%3Drxuhiu0p4_4. Accessed 17 Aug 2018.
CAP. Laboratory Accreditation Program. http://www.cap.org/web/home/lab/accreditation/laboratory-accreditation-program?_afrLoop=18857642812833#!%40%40%3F_afrLoop%3D18857642812833%26_adf.ctrl-state%3Drxuhiu0p4_17. Accessed 17 Aug 2018.
CAP. Defintion of Synoptic Reporting. http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/Synoptic_Report_DefinitionAndExamples_v4.0.pdf. Accessed 18 Aug 2018.
Nakhleh RE. What is quality in surgical pathology? J Clin Pathol. 2006;59(7):669–72.
Renshaw MA, Renshaw SA, Mena-Allauca M, et al. Performance of a web-based method for generating synoptic reports. J Pathol Inform. 2017;8:13.
Kakar S, Pawlik TM, Allen PJ, VJ N. Exocrine pancreas. In: Amin MB, Edge SB, Greene FL, et al., editors. AJCC cancer staging manual. 8th ed. New York: Springer International Publishing; 2017.
Srigley JR, McGowan T, Maclean A, et al. Standardized synoptic cancer pathology reporting: a population-based approach. J Surg Oncol. 2009;99(8):517–24.
Messenger DE, McLeod RS, Kirsch R. What impact has the introduction of a synoptic report for rectal cancer had on reporting outcomes for specialist gastrointestinal and non-gastrointestinal pathologists? Arch Pathol Lab Med. 2011;135(11):1471–5.
Ellis DW, Srigley J. Does standardised structured reporting contribute to quality in diagnostic pathology? The importance of evidence-based datasets. Virchows Arch. 2016;468(1):51–9.
Sluijter CE, van Lonkhuijzen LR, van Slooten HJ, Nagtegaal ID, Overbeek LI. The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review. Virchows Arch. 2016;468(6):639–49.
Renshaw AA, Mena-Allauca M, Gould EW, Sirintrapun SJ. Synoptic reporting: evidence based review and future directions. JCO Clin Cancer Inform. 2018;2:1–9.
Onerheim R, Racette P, Jacques A, Gagnon R. Improving the quality of surgical pathology reports for breast cancer: a centralized audit with feedback. Arch Pathol Lab Med. 2008;132(9):1428–31.
Imperato PJ, Waisman J, Wallen M, Llewellyn CC, Pryor V. Breast cancer pathology practices among Medicare patients undergoing unilateral extended simple mastectomy. J Womens Health Gend Based Med. 2002;11(6):537–47.
Leong AS. Synoptic/checklist reporting of breast biopsies: has the time come? Breast J. 2001;7(4):271–4.
Chang A, Gibson IW, Cohen AH, et al. A position paper on standardizing the nonneoplastic kidney biopsy report. Hum Pathol. 2012;43(8):1192–6.
Valenstein PN. Formatting pathology reports: applying four design principles to improve communication and patient safety. Arch Pathol Lab Med. 2008;132(1):84–94.
Renshaw AA, Gould EW. Comparison of accuracy and speed of information identification by nonpathologists in synoptic reports with different formats. Arch Pathol Lab Med. 2017;141(3):418–22.
Strickland-Marmol LB, Muro-Cacho CA, Barnett SD, Banas MR, Foulis PR. College of American Pathologists Cancer Protocols: optimizing format for accuracy and efficiency. Arch Pathol Lab Med. 2016;140(6):578–87.
Renshaw SA, Mena-Allauca M, Touriz M, Renshaw A, Gould EW. The impact of template format on the completeness of surgical pathology reports. Arch Pathol Lab Med. 2014;138(1):121–4.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Mayo Foundation for Medical Education and Research
About this chapter
Cite this chapter
Hatfield, B.S., Idowu, M.O. (2019). The Complete Surgical Pathology Report. In: Nakhleh, R., Volmar, K. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-18464-3_11
Download citation
DOI: https://doi.org/10.1007/978-3-030-18464-3_11
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-18463-6
Online ISBN: 978-3-030-18464-3
eBook Packages: MedicineMedicine (R0)