Pathology reports are used by your physician to determine a diagnosis or treatment plan for a specific health condition or disease. In a small percentage of cases, an inadequate sample is obtained, which means there is not enough blood, tissue, etc., to perform the necessary analysis. In those cases, a second sample must be obtained. It does not mean that an abnormal finding was present, it simply means a laboratory analysis was not performed because the sample size was too small.
In most cases, a pathology report contains the following information:
your name and your individual identifiers such as date of birth or age, patient ID number, or Social Security number
the accession number of the case (a number used to identify your specimen)
the date and type of the procedure by which the specimen was obtained (blood sample, surgery, biopsy)
your medical history and current clinical diagnosis
a gross (obvious) description of the specimen received in the laboratory, before the pathologist examines it
a description of what the pathologist sees upon examination of the specimen (this section may be brief or long, depending on the test performed and the type of tissue being examined)
the final diagnosis which is the "bottom line" of the testing process, although this section may appear at the top or bottom of the page; the patient's doctor relies on the final diagnosis to help in choosing the best treatment options for the patient
the name and signature of the pathologist, as well as the name and address of the laboratory
By law, you are entitled to a copy of your medical record. However, in most cases, a copying fee is charged by the medical centers and/or hospitals. Many physicians and clinics will provide you with a certain number of copies free of charge. Copies of any pathology reports are very important to keep, as your diagnosis and treatment are often based on them. Further, understanding the report will help you and your physician (and any future physicians) better understand your condition.
© 2013 Main Line Health