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Difference between revisions of "Pathology reports"
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→Onlinepathology formating recommendations
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==''Onlinepathology'' formating recommendations== | ==''Onlinepathology'' formating recommendations== | ||
===Diagnosis=== | |||
*The tissue type/site usually should be what the clinician submitted it as. | |||
**Lay terms are preferred in some circumstances (e.g. ''stomach'' instead of ''gastric''), as the patients often read their pathology reports. | |||
*The tissue type should be the first thing in the diagnostic line if it is not obvious from the diagnosis, e.g. ''gastric body-type mucosa''. | |||
*If several diagnoses are made, the most clinically important diagnosis should be listed first. | |||
*Each diagnostic line should end with a period or semicolon. | *Each diagnostic line should end with a period or semicolon. | ||
**Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref> | **Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref> | ||
**The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked. | **The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked. | ||
===Abbreviations=== | ====Abbreviations==== | ||
*Abbreviations should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | *Abbreviations should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | ||
**Patients often read their reports. Abbreviations muddle things. | **Patients often read their reports. Abbreviations muddle things. | ||
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Notes: | Notes: | ||
*One should ''not'' assume it is going to be read by the clinician. | *One should ''not'' assume it is going to be read by the clinician. | ||
**If it is essential to read | **If it is essential to read, a comment in the diagnosis section, that says ''see microscopic'', is advisable. | ||
*Immunostains should be reported as a comment in the ''diagnosis'' section. | *Immunostains should be reported as a comment in the ''diagnosis'' section. | ||
*Internal reviews/consults should likewise not be found here; they should be in a comment in the ''diagnosis'' section. | *Internal reviews/consults should likewise not be found here; they should be in a comment in the ''diagnosis'' section. | ||