Cytopathology Report (Non-Gynecologic)

Patient: [Patient name or identifier]

MRN: [Medical record number]

DOB/Sex: [Date of birth and sex]

Accession Number: [Accession ID]

Ordering Provider: [Name and role]

Collection Date: [Date/time] Received Date: [Date/time] Report Date: [Date/time]

Report Status: [Final / Preliminary / Addendum / Amended] (If Amended, include amendment date and brief description of what changed and why.)

Specimen [Part Designation]

Source: [Anatomic site, laterality, specimen type, and collection procedure]

Clinical Information: [Indication, relevant malignancy history, pertinent imaging findings] (If not provided and this limits interpretation, state "Clinical history not provided.")

Specimen Description: [Volume/quantity received, appearance, fixative if relevant]

Preparations Examined: [Preparation types reviewed and stains used]

Adequacy: [Satisfactory for evaluation / Limited for evaluation / Unsatisfactory (non-diagnostic)] (If Limited or Unsatisfactory, state reason. If diagnostic malignant cells are present, classify as Satisfactory while documenting any limitations.)

Reporting System: [TIS for serous fluids / Paris System for urine / WHO System for lung / PSC System for pancreatobiliary / Institutional descriptive] (Select applicable system.)

Diagnosis: [Non-diagnostic / Negative for malignancy / Atypical / Suspicious for malignancy / Malignant] — [Descriptive diagnosis with key findings, tumor type/origin, or organism if applicable]

Microscopic Description: (Include only for atypical, suspicious, malignant, or infectious cases. Omit for straightforward negative cases.)

• [Key cell populations and cytomorphology]
• [Degree and quantity of atypia]
• [Background elements]

Ancillary Studies: (Include only if performed.)

• [Test name] — [Specimen component] — [Result] — [Interpretation] (Note any limitations. If pending, indicate addendum will follow.)

Comment: [Clinicopathologic correlation, differential diagnosis, suggested next steps, or limitations] (Include for atypical/suspicious/malignant cases or when clarifying interpretive limitations. Use non-prescriptive language for recommendations. Document prior pathology accession numbers if reviewed.)

Communication: [Recipient name/role, date/time, reason for communication] (Include only if urgent or significant unexpected findings were verbally communicated.)

Specimen [Next Part Designation]

(Repeat the Specimen block above for each additional part, maintaining parallel structure.)

Sign-out

Pathologist: [Name and credentials]

Sign-out Date: [Date/time]

Addendum

(Include only if applicable.)

Addendum Date: [Date/time]

Author: [Name and credentials]

Reference: [Specimen part and information being supplemented]

Addendum Content: [Results, interpretation, and any limitations] (If diagnosis is changed, explicitly state revised diagnosis and reason.)