Cytopathology Report (Fine-Needle Aspiration)

Report type: Cytopathology Report – Fine-Needle Aspiration

Laboratory name and location: [Laboratory name and location]

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Sex: [Sex]

Accession/case number: [Accession/case number]

Ordering clinician: [Ordering clinician name and credentials]

Collection date/time: [Collection date and time]

Received date/time: [Received date and time]

Report date/time: [Report date and time]

Report status: [Preliminary / Final / Amended]

Pathologist: [Pathologist name and credentials]

Signature date: [Signature date]

(For any header field not provided, enter "Not provided on requisition" rather than leaving blank or inferring.)

Clinical Information

• [Indication for FNA (e.g., mass evaluation, staging, rule-out recurrence)]
• [Target lesion imaging context including location, size, and characteristics]
• [Pertinent oncologic or medical history]
• [Relevant prior pathology accession numbers]

(Include only information explicitly provided. If no clinical history is supplied, state: "Clinical history not provided.")

Specimen

(Repeat the following subsection for each specimen part. Do not combine multiple anatomic sites within one part. Use sequential part labels: Part A, Part B, Part C, etc.)

Part [A]

Diagnostic category: [Organ-specific system and category if applicable (e.g., "Bethesda System: Category VI – Malignant" for thyroid; "Milan System: Category IVB – Salivary Gland Neoplasm, Malignant" for salivary gland) OR general cytology category: Non-diagnostic / Negative (Benign) / Atypical / Neoplasm / Suspicious for Malignancy / Malignant]

Specific diagnosis: [Most specific diagnosis supported by findings; if limited, provide descriptive diagnosis with focused differential and state what limits further characterization]

Adequacy: [Satisfactory for evaluation / Satisfactory but limited by (specify) / Unsatisfactory (specify reason)] (If aspirate from a targeted lesion shows only benign/background elements, note potential non-representativeness of the imaged lesion.)

ROSE: [Personnel; preliminary adequacy assessment; triage decisions if applicable (e.g., cell block allocation, flow cytometry submission)] (Include only if ROSE was performed. Clearly label as preliminary, not the final diagnosis. Omit this field entirely if ROSE was not performed.)

Specimen source: [Specimen source as submitted verbatim] (If source is uncertain, document what is known from the container label and add: "Clinical correlation recommended.")

Procedure/guidance: [FNA; guidance method if provided: ultrasound / CT / EUS / palpation / other] (Do not infer if not stated.)

Preparations examined: [List applicable: direct smears (air-dried/Diff-Quik, alcohol-fixed/Papanicolaou), liquid-based preparation, cell block (prepared/not prepared), needle rinse] (Include only preparations actually submitted.)

Comment: [Correlation statements with imaging or clinical findings; diagnostic limitations; recommendations for additional workup (repeat FNA, core biopsy, excision); clarification of primary versus metastatic disease; material availability for ancillary testing] (Include only if needed; omit if not applicable.)

Part [B]

(Repeat the structure above for each additional specimen part.)

Ancillary Studies

(Include this section only if ancillary testing was performed, ordered, or is pending. Omit entirely if not applicable.)

• Test: [Test type and name (e.g., cell block IHC, flow cytometry, molecular, FISH, special stain)]

  Specimen/block: [Designation (e.g., Part A, Cell Block A1)]

  Clinical question: [Diagnostic question being addressed]

  Specimen suitability: [Adequate / Limited (specify) / Inadequate]

  Status: [Ordered / Pending / In progress / Completed]

  Result: [Summarized result] (Include only for completed studies.)

  Interpretation: [How result supports or refines cytology diagnosis; note limitations such as low tumor fraction or scant material]

  Date/Pathologist: [Completion date and responsible pathologist] (For completed studies.)

• (Repeat for each ancillary study.)

Addendum

(Include only for amended reports or when ancillary results return after initial sign-out. Maintain clear chronology; do not silently revise prior content. Omit section entirely if not applicable.)

• Addendum type: [Ancillary result / Interpretive revision / Corrected report]

  Description: [What was added, updated, or corrected; specify affected specimen part(s) and diagnosis if relevant]

  Date/time: [Addendum date and time]

  Author: [Pathologist name and credentials]

• (Repeat for each addendum entry.)