Pathology Results Disclosure and Follow-Up Note

Date/Time: [Date and time of documentation]

Author/Service: [Author name, credentials, and service/department]

Encounter Type: [phone call / in-person / video / portal message / letter / results review—no patient contact]

Pathology Results Reviewed

(Create one entry per specimen reviewed. For outside records, note source and whether filed in chart. If required elements are unavailable, state explicitly, e.g., "Accession number not available in scanned copy.")

• Specimen: [Procedure type, anatomic site with laterality, date obtained]
• Accession/case number: [Accession or case number]
• Report finalized: [Final report date; include addendum dates if applicable]

(Repeat for additional specimens as needed.)

Interpretation

[Plain-language summary stating benign, malignant, premalignant, or nondiagnostic status and specific diagnosis] (1–3 sentences. Patient-facing language such as "This is not cancer" is acceptable if clearly supported by the report.)

Management-driving elements: [Margins, grade, invasion features, tumor size, ancillary study results—include only elements explicitly documented in the pathology report that affect the plan] (Do not infer margins, grade, or stage if not reported. Note any limitations or clinical-pathologic discordance.)

Patient Communication

(Document closed-loop communication. Use the appropriate section below.)

Contact Made

• Contact: [Date/time, method, and who was reached—patient or surrogate with relationship] (Confirm permission for disclosure if surrogate)
• Information disclosed: [Summary using terminology consistent with pathology report]
• Patient response: [Understanding demonstrated, key questions asked and answers given]
• Agreed plan: [Plan discussed and accepted] (If declined, document refusal and counseling provided)

Unable to Reach

• Outreach attempts: [Date/time, method, and result for each attempt]
• Voicemail: [Message left / no voicemail] (If left, note content limited per HIPAA)
• Escalation: [Portal message / letter / alternate contact / PCP notification with dates]
• Ongoing plan: [Planned outreach and timeframe to close communication loop]

Assessment & Plan

Assessment: [Active problem statement using responsibility-focused language, e.g., "Basal cell carcinoma—needs definitive treatment"] (Note relevant comorbidities affecting plan. Include staging-relevant elements from pathology only if documented; do not assign definitive stage prematurely.)

Plan:

• Treatment/Reassurance: [Recommended intervention or reassurance as appropriate]
• Referrals: [Specialty, reason, and urgency] (Omit if none)
• Orders: [Labs, imaging, or procedures placed] (Omit if none)
• Surveillance: [Interval and basis] (For benign findings; omit if not applicable)
• Follow-up: [Timeframe and who is responsible for scheduling]
• Pending items: [Add-on studies, second opinions—expected timeframe and re-contact plan] (Omit if none)

(Omit elements not applicable. State explicitly if clinically significant information is missing and why it matters.)