Surgical Pathology Report (Biopsy/Excision)

[Laboratory Name] | [Address] | [Phone] [ / Fax] | [Email] | [CLIA/License #]

Report Status: [Final / Preliminary / Amended / Addendum] (If not Final, state reason) | Accession Number: [Accession #]

Patient Name: [Patient full name] | MRN: [MRN] | DOB: [DOB] | Sex: [Sex]

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

Ordering Clinician: [Clinician name, credentials, contact]

Clinical Information

[Brief clinical history and indication as provided on requisition, including relevant endoscopic findings, imaging impressions, prior treatments, and pertinent laboratory results. If prior pathology was reviewed for comparison, include accession number, site, and date.] (If no clinical history was provided, state exactly: "Clinical history: Not provided.")

Specimen(s) Submitted

(List each specimen part exactly as designated. Maintain consistent part labels across all subsequent sections. If site or laterality is not provided, state "Site not specified." Document any labeling discrepancies or specimen condition issues with resolution, including who was contacted.)

• A. [Site and laterality as labeled] — [Procedure type: biopsy / excision / curettage / other] [Container count if multiple]
• B. [Site and laterality as labeled] — [Procedure type] [Container count if multiple]
• (Add additional parts as needed.)

Gross Description

(Provide a separate narrative for each part. For excisions, include orientation, inking scheme with color-to-orientation mapping, and lesion-to-margin distances when assessable. End each part with block/cassette summary. If tissue was sent for ancillary studies, document what was sent and where.)

Part A

[Fixation status: received in formalin / received fresh]. [Number and type of fragments/pieces] measuring [dimensions or size range], aggregate [size/weight if appropriate]. [For excisions: orientation (sutures/clips), inking scheme with color-to-margin mapping, lesion location and appearance, distance to margins if grossly assessable]. [Entirely submitted / Representative sections submitted]. Blocks: [Block summary, e.g., "Entirely submitted in A1" or "A1–A2 lesion with margins; A3–A4 peripheral margins"].

Part B

[Fixation status]. [Number and type of fragments/pieces], measuring [dimensions/size range]. [Excision details if applicable: orientation, inking scheme, lesion description, margin distances]. [Submission approach]. Blocks: [Block summary].

(Add additional parts as needed.)

Outside Consultation Material

(Include only when reviewing outside material with no gross examination performed.)

[Outside laboratory name], accession [#] dated [date]. Received: [number and type of slides/blocks], [stains present]. [Note any missing materials or quality issues.]

Microscopic Description

(Include only when it adds interpretive value beyond the diagnosis—e.g., complex inflammatory patterns, borderline lesions, or active differential diagnoses. Omit for routine cases.)

Part A

[Salient microscopic findings supporting interpretation.]

Part B

[Salient microscopic findings.]

(Add additional parts as needed.)

Final Diagnosis

(Report one diagnosis per specimen part. Use standardized terminology. For uncertainty, use graded language: "Consistent with...," "Favor...," "Suspicious for...," or "Indeterminate due to limited tissue." For excisions, always include margin status.)

• A. [Site], [Procedure] — [Diagnosis].

  • [Grade/activity; organisms with method; margin status (involved vs. clear, specifying which margins if involved, closest distance if clear); depth of invasion or key measurements] (Include only applicable elements as subordinate lines.)

• B. [Site], [Procedure] — [Diagnosis].

  • [Subordinate elements as applicable.]
• (Add additional parts as needed.)

Synoptic Report

(Include only when malignancy requiring structured cancer protocol reporting is diagnosed.)

• [Required Element]: [Response]
• [Required Element]: [Response]
• (Additional required/optional elements as applicable.)

Comment

(Include when clinicopathologic correlation is recommended, differential diagnosis remains open, unexpected findings require documentation, or prior pathology materially influenced interpretation. If clinician was contacted, document: name, date/time, method, and information communicated. Omit if not needed.)

[Comment text.]

Ancillary Studies

(Include only when special stains, immunohistochemistry, ISH, or molecular studies were performed.)

• [Marker/stain name]: [Result with pattern/intensity]; block [#]. [Interpretive statement if needed.] [Reference laboratory if applicable.]
• (Add additional studies as needed.)

Addendum

(Use for supplementary information after sign-out that does not change the original diagnosis. Omit if not applicable.)

Date: [Addendum date] | Author: [Name, credentials]

[New information and any refinement to interpretation.]

Amended Report

(Use when correcting finalized diagnosis or material elements. Omit if not applicable.)

Date: [Amendment date] | Author: [Name, credentials]

Amendment: [Old value] → [New value]; [Reason]. [Notification documentation per institutional policy.]

Electronically signed by: [Pathologist name, credentials] | Date: [Signature date/time]

Gross examination by: [Name, credentials] (Include only if different from signing pathologist.)