Pathology Report Template

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Pathologist Note

Patient Identification:
[Patient name, age, gender, medical record number if applicable]

Specimen Information:
(hyphenated list)
- [Specimen type] (e.g., tissue, fluid, cytology)
- [Anatomic site of origin]
- [Date and time of collection]
- [Clinical history or indication for specimen]

Gross Description:
(Paragraph format)
[Describe specimen appearance, size, weight, color, consistency, and any notable features. Include measurements in metric units. Note any orientation markers or special handling.]

Microscopic Description:
(Paragraph format)
[Describe histologic findings, including cell types, architecture, presence of inflammation, necrosis, atypia, mitotic figures, and any other relevant features. Specify location and extent of findings.]

Ancillary Studies:
(hyphenated list)
- [Immunohistochemistry results]
- [Special stains]
- [Molecular studies]
- [Other relevant tests]

Diagnosis:
[Concise summary of pathologic diagnosis, using standard medical terminology. Include grade, stage, margins, and other relevant prognostic information.]

Comment:
[Additional interpretive comments, correlation with clinical findings, recommendations for further studies if needed.]

Distribution:
(hyphenated list)
- [Referring physician]
- [Other relevant providers]
- [Medical record]