WRITING A PATHOLOGY REPORT

            The pathology report will compile the description of all gross anatomic changes, as well as results from the histology examination and other ancillary tests that were used to reach a final diagnosis. All the information available will be used to comment on the main findings and their relevance to the case. Occasionally no diagnosis will be possible based on the available data and that is part of the job.

            As it is the case with the postmortem examination technique, the pathology report formatting is highly dependable on the institution. Some reports are written in the present tense, other report gross changes in the past tense and histology findings in the present tense. That is not what it is important. The main goal of the report is to confirm that a specific animal was examined and to provide clear and sufficient scientific data for professionals to understand why a particular diagnosis was established. The report (together with photographs, selected tissue samples, glass or digital slides, and paraffin blocks) will remain as the only legal document capable to identify the examined animals and the changes observed during postmortem examination.

            It is a good practice to start the description by stating what type of animal is being examined (age, sex, breed, and species), along with its body condition and weight. Make sure all anatomic features or particularities (color, identifying tattoos, ear tags, or brands) are described for identification purpose. A detailed description of the external and then internal findings will follow. The description will be highly dependable on previous professional training, institution, and personal style. For example, some reports may have descriptions for each body compartment (thorax, abdomen, etc.); others may describe changes in each organ system in the order they were examined; others may have descriptions of most important findings first and in one single paragraph. The important thing is to follow a system and keep in mind all the features necessary for a complete gross description. You will learn different techniques and styles from different pathologists. Use those learning experiences to create your own style.




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