Pathology Results Communication (Endoscopy)

Patient Message

Subject: [Portal message subject line] (Use a neutral subject such as "Results from your recent endoscopy"; avoid alarming terms like "abnormal" or "cancer.")

Patient Name: [Patient name]

Procedure: [colonoscopy / EGD / flexible sigmoidoscopy] on [Procedure date]

Date of Message: [Date sent]

Sending Clinician: [Name, credentials, clinic, callback number]

[Greeting and introduction] (State that this message shares pathology results from the recent procedure. Define pathology as tissue examined under a microscope. Note that the full pathology report may appear in the portal and that this message explains the findings in plain language.)

Summary

[Bottom-line summary] (2–4 sentences covering the overall result category, the primary next step, and whether follow-up is routine or time-sensitive. Use plain language; define any technical terms immediately.)

Results

• [Specimen 1: anatomic location, action, and finding] (State location, whether biopsy or polyp removal was performed, and a one-sentence plain-language explanation. Define pathology terms immediately: "benign (not cancer)," "adenoma (a precancerous polyp removed to lower your cancer risk)," "hyperplastic polyp (a common non-precancerous growth)," "dysplasia (abnormal cells that are not cancer)," "H. pylori (a stomach bacteria that can be treated).")
• [Specimen 2: anatomic location, action, and finding] (Same format.)
• (Add additional specimens as needed.)

What This Means

[Interpretation of findings] (Include only if additional context beyond the Summary would help. In 1–2 short paragraphs, connect findings to symptoms if relevant, provide reassurance without overstating certainty, and include condition-specific context—e.g., removing adenomas lowers colon cancer risk; H. pylori is treatable with antibiotics. Omit this section if the Summary is sufficient.)

Next Steps

(Include only applicable subsections. Use absolute dates and pair intervals with approximate due years. Do not infer surveillance intervals without documented rationale; if key details are missing, state what is pending.)

Surveillance

• [Recommended procedure and interval] (State procedure name and timing window with approximate due year, e.g., "Repeat colonoscopy in 7–10 years, around 2033–2036.")
• [Rationale] (Brief explanation based on pathology and procedural findings.)
• [Scheduling plan] (State whether clinic will contact patient or patient should call; include timeframe.)
• [Pending information] (If interval depends on additional details, specify what is pending and when update will be provided. Include only if applicable.)

Medications

• [Medication name, dose, frequency, duration, and key instructions] (List any started, stopped, or continued medications.)
• [Monitoring requirements] (Any required labs, tests, or follow-up. Include only if applicable.)

Referrals

• [Specialty, reason, expected timing] (Include what to do if not contacted within specified timeframe.)

Watch for These Symptoms

• Call us if: [Symptom list] (Post-procedure warnings such as mild bleeding, fever, or persistent pain.)
• Seek emergency care if: [Symptom list] (Red flags such as heavy bleeding, severe abdominal pain, vomiting blood, black stools, or signs of infection.)

Contact and Closing

[Clinic phone number and hours] (Include after-hours instructions if applicable. Note that portal messages are reviewed during business hours and are not for emergencies.)

[Clinician signature] (Name, credentials, clinic.)

[Invitation to reply or schedule] (Invite questions via portal or offer to arrange a visit.)

Communication Log (Internal)

(This section documents closed-loop communication for the medical record and should not appear in patient-facing content.)

Result Review

• Pathology accession number: [Accession number]
• Date finalized: [Date]
• Date reviewed: [Date]
• Responsible clinician: [Name]
• Procedure: [Type, date, endoscopist]

Notification Recipients

• Patient: [Notification method] (Portal message / phone / letter / in-person.)
• Referring clinician/PCP: [Name and method] (Include only if notified.)
• Other services: [Service and method] (Include only if applicable.)

Contact Attempts

• [Date/time, method, outcome, brief content summary] (Note interpreter use with language and ID if applicable. For voicemails, confirm sensitive details were not disclosed unless patient authorized.)
• [Additional attempts as needed]

Closed-Loop Status

• Receipt confirmed: [yes / no] — [Method of confirmation] (Phone confirmation, portal read receipt, certified mail delivery, or in-person discussion.)
• Escalation steps: [Actions taken] (Document if receipt not confirmed within policy timeframe. Include only if applicable.)

High-Risk Results

(Include this section only for malignancy, high-grade dysplasia, or other urgent findings.)

• Phone-first communication: [Date/time and outcome of call or attempts]
• Referral placed: [Specialty, urgency level, scheduling status]
• Portal release: [Released / delayed] (If delayed, document patient-specific justification.)