Bone Marrow Biopsy Results Review Note

Date/Time of Encounter: [Date and time]

Patient: [Patient full name]

Provider: [Provider name, credentials]

Encounter Type: [in-person / video / telephone]

Specimen Date and Site: [Collection date; anatomic site]

Accession/Case Number: [Accession/case number] (If outside pathology and accession unavailable, state: "Outside report pending; diagnosis to be confirmed.")

Outside Pathology/Referring Institution: [Referring institution] (Include only if outside pathology was reviewed.)

Chief Concern

[Patient-facing reason for visit] (State as: Review bone marrow biopsy results performed for [indication]; discuss diagnosis and next steps.)

Interval History

[Concise narrative impacting interpretation and urgency] (Include: indication for biopsy and key pre-biopsy findings; post-procedure course if relevant; current symptoms influencing urgency or therapy selection; pertinent therapy context including prior treatments, transfusions, or growth factors. Omit unrelated historical details. If post-procedure symptoms were not assessed, state explicitly.)

Objective

Vitals/Performance Status: [Vitals; ECOG performance status] (Include ECOG if malignancy diagnosed or suspected. For telephone/video visits, state "No vitals obtained.")

Exam: [Focused exam findings] (Include only if performed: general appearance, skin findings, lymphadenopathy, hepatosplenomegaly, neurologic findings if hyperviscosity concern. If not examined, state "Exam deferred.")

Labs Reviewed: [CBC with differential, chemistries, disease-specific markers as relevant, with dates] (Label results as new vs baseline. For missing labs, distinguish "not resulted" from "not ordered.")

Bone Marrow Pathology Findings

[Final diagnosis / Working diagnosis]: [Concise diagnosis statement] (State if definitive, provisional pending ancillary studies, or indeterminate.)

• Specimen adequacy: [Aspirate/core quality; limitations] (Note hemodilution, dry tap, or crush artifact; describe interpretive impact.)
• Cellularity: [Estimated cellularity (%) and age-adjusted context]
• Blasts: [Blast percentage and method] (Specify source: aspirate differential, flow cytometry, and/or IHC.)
• Dysplasia: [Lineages involved and degree] (Include only if present.)
• Fibrosis: [Fibrosis grade] (Include only if present or clinically relevant.)
• Immunophenotype: [Key flow cytometry/IHC findings] (Highlight aberrant or diagnostic patterns.)
• Cytogenetics/FISH: [Key abnormalities or normal karyotype]
• Molecular/NGS: [Pathogenic variants with clinical significance] (Note diagnostic, prognostic, or targetable relevance; label VUS separately.)
• Pending studies: [List pending tests and expected turnaround] (Include only if studies are pending.)

(Summarize clinically actionable elements; do not reproduce entire pathology report.)

Assessment

[Primary hematologic diagnosis or differential]

[Status statement with key supporting evidence and clinical implications] (State whether diagnosis is definitive, provisional, or indeterminate; integrate marrow findings with peripheral blood and clinical context.)

• Risk stratification: [Model used, key inputs, risk category] (Use disease-appropriate model: ELN for AML, IPSS-R/IPSS-M for MDS, R-ISS for myeloma, DIPSS for myelofibrosis. If incomplete, specify missing inputs.)

[Additional problems as applicable]

[Brief status, evidence, and implications for each]

Plan

• Immediate safety actions: [Admission, urgent therapy, transfusion as indicated]
• Additional workup: [Pending studies, repeat marrow, germline testing, staging imaging as needed]
• Treatment plan: [Regimen, intent, rationale, clinical trial consideration] (Include pre-treatment requirements if initiating therapy.)
• Supportive care: [Transfusion thresholds, infection prophylaxis, tumor lysis precautions as relevant]
• Referrals: [Transplant evaluation, tumor board, specialty consultations]
• Follow-up: [Timing, modality, plan for communicating pending results]
• Patient communication: [How results were communicated; who was present; discussion of diagnosis, prognosis, and options; patient understanding and preferences]
• Contingency planning: [If/then actions based on pending results] (Example: If cytogenetics show high-risk features → [action]; if favorable → [action].)
• Urgent notifications: [Who notified, when, actions taken] (Include only if critical results required urgent notification.)