Pathology Consultation Report (Outside Slide Review)

Pathology Consultation Report (Outside Slide Review)

Patient Name: [Patient name]

MRN: [Medical record number]

DOB: [Date of birth]

Sex: [Sex]

Report Date: [Report date]

Report Status: [Final / Preliminary / Amended]

Consulting Laboratory: [Consulting laboratory name], CLIA# [CLIA number]

Consultation Accession #: [Consultation accession number]

Requesting Clinician: [Requesting clinician name and credentials]

Requesting Institution: [Requesting institution name]

Outside Accession #: [Outside institution accession number]

Date Material Received: [Date received]

(For all header fields: if information is not available, enter "Not provided" rather than leaving blank.)

Clinical Information

[Reason for consultation and pertinent clinical history as provided] (Limit to 2–4 sentences or a brief bulleted list. If no history provided, state: "Clinical history: Not provided.")

Materials Received and Reviewed

[One-line summary] (Format as: "Reviewed: [number] [slide types] from [Outside Institution], Case #[outside accession]; outside report dated [date]." If outside report not received, state "outside report not received.")

• Outside institution and case: [Outside institution name], Accession #[Outside accession number]
• Specimen/part mapping:
  • [Part A] = [Outside specimen/block designation]
  • [Part B] = [Outside specimen/block designation] (Add additional parts as needed)
• Slides received: [Number and type by category; indicate source] (e.g., "4 H&E, 2 special stains, 3 immunostains; all prepared at outside institution")
• Blocks received: [Block identifiers] (If none, state "None")
• Documentation reviewed: [List documents with dates] (e.g., "Outside pathology report (1/10/2026), operative note (1/8/2026)"; if not received, state explicitly)
• Specimen condition/adequacy: [Condition issues and impact on interpretation] (Include only if integrity issues present)

Outside Diagnosis

(Include only if an outside diagnosis was provided.)

Outside Institution: [Institution name] | Accession #: [Accession] | Report Date: [Date]

• Part A ([Outside designation]): [Verbatim outside diagnosis]
• Part B ([Outside designation]): [Verbatim outside diagnosis]
• (Add additional parts as needed; note any internal inconsistency without speculation)

Consultation Diagnosis

(Provide stand-alone diagnosis for each specimen/part. Do not state "same as outside." Include organ/site, procedure, and key qualifiers—grade, invasion, margins—when determinable. Use standardized terminology. If indeterminate, provide descriptive diagnosis with targeted differential and state what would resolve uncertainty. Reference Comment with "(see Comment)" when needed.)

• Part A: [Consultation diagnosis]
• Part B: [Consultation diagnosis]
• (Add additional parts as needed)

Microscopic Description

(Include only for complex cases, discrepant interpretations, significant limitations/artifact, or teaching contexts. Keep brief; do not duplicate the diagnosis. Omit section if not needed.)

[Focused morphologic description]

Ancillary Studies

(Include if immunohistochemistry, special stains, or molecular studies were reviewed or performed. Omit section if not applicable.)

Studies reviewed (performed at outside institution):

• [Marker/test]: [Result] — [Interpretive summary]

Studies performed at consulting laboratory:

• [Marker/test] on [Specimen/Block]: [Result] — [Interpretation]

Pending studies: [Pending tests] (Include only if applicable)

(If tissue is exhausted or insufficient for recommended tests, state explicitly.)

Comparison with Outside Diagnosis

(Include only if an outside diagnosis was provided.)

[Concordant with outside diagnosis / Discordant with outside diagnosis]

[If discordant: nature of discrepancy, brief restatement of consultant diagnosis, and clinical implications] (Focus on interpretive outcome; do not attribute error)

Comment

(Explain diagnostic reasoning and key findings. Address labeling ambiguity, sampling limitations, or artifact as applicable. Provide specific correlation guidance rather than generic "clinical correlation recommended." Clearly separate observed facts, interpretations, and recommendations.)

[Interpretive comment]

Recommendations

(Include only when actionable recommendations exist. Omit section if none.)

• [Recommendation: what + why]
• [Request for additional material if needed]

Communication

(Include only for urgent diagnoses, significant unexpected findings, or major discordance affecting management. Omit section if not applicable.)

Contacted: [Name and role] | Date/Time: [Date and time] | Method: [phone / secure message] | Summary: [Brief summary of communication]

Material Disposition

(Include when material return/retention is clinically relevant or requested. Omit section if tracked separately.)

• Slides: [Returned to / Retained by] [Institution]; [Date]
• Blocks: [Returned to / Retained by] [Institution]; [Date]
• Tissue consumed: [Details of blocks/levels consumed for ancillary testing, or "None"]

Signature

Pathologist: [Name, credentials, subspecialty]

Electronic Signature: [Signature]

Sign-out Date/Time: [Date and time]

Laboratory Contact: [Phone and/or email]