Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology (Cap Laboratory Improvement Programs) (Clinical Report)

Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology (Cap Laboratory Improvement Programs) (Clinical Report)

The surgical pathology report (SPR) is the final written product of the surgical pathology laboratory, and it contains critical information that drives patient care, especially in the oncologic setting. A variety of individuals, including physicians, nurses, statisticians, epidemiologists, support personnel, and patients, use the information contained in the SPR. Because of the variety of people who access the SPR and the importance of the information contained therein, the report must contain a minimal amount of standard content and must be presented in such a way as to efficiently and accurately convey its information. The College of American Pathologists (CAP) has developed guidelines for the content of SPRs. Similar guidelines were developed in the past by the Association of Directors of Anatomic and Surgical Pathology (see http://www.adasp.org/papers/position/Standardization.htm, last accessed March 14, 2008); additionally, various organizations have called for report standardization. (1) In this article, we have compiled an exhaustive list of elements to be included in the SPR. Some of these recommendations are contained in the CAP Laboratory Accreditation Program checklists (see http://www.cap.org, last accessed March 14, 2008). This article is meant to convey guiding principles regarding the elements that should be contained in the SPR. Additionally, this article serves to rank these elements by degree of importance.

Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology (Cap Laboratory Improvement Programs) (Clinical Report)

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