Reporting guidelines for clinical laboratory reports in surgical pathology.
BACKGROUND
The surgical pathology report (SPR) is an essential part of patient care because it documents the pathologic findings in tissues removed from patients for diagnostic or therapeutic reasons. Despite the importance of the SPR, exhaustive guidelines outlining the various elements of the SPR have not, to our knowledge, been published.


OBJECTIVE
To outline recommendations delineating the required, preferred, and optional elements that should be included in the SPR. These guidelines, if implemented, will bring uniformity to the reporting of surgical pathology specimens.


METHODS
The Surgical Pathology Resource Committee of the College of American Pathologists compiled and prioritized the elements that have been included in various institutional SPRs. Additional data sources include the College of American Pathologists Laboratory Accreditation Program checklists and the recommendations of the Association of Directors of Anatomic and Surgical Pathology. Each element was assigned a priority of required, preferred, or optional. These priorities were discussed and consensus was reached. This report does not address issues of formatting or style substantively.


CONCLUSIONS
These recommendations afford a framework for the creation of an SPR containing all of the components that are required or optimal for patient care.
Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachussetts 02215, USA. jgoldsmi@bidmc.harvard.edu
Jeffrey D
JD
Goldsmith
Gene P
GP
Siegal
Saul
S
Suster
Thomas M
TM
Wheeler
Richard W
RW
Brown
D000068:Accreditation; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards*; D010338:Pathology, Clinical / Q000592:standards*; D010340:Pathology, Surgical / Q000592:standards*; D010346:Patient Care Management / Q000592:standards; D010348:Patient Care Team; D012107:Research Design; D012955:Societies, Medical; D014481:United States