What is a pathology report?

A pathology report is a medical report about a piece of tissue, blood, or body organ that has been removed from your body. The specimen is analyzed by a medical doctor known as a pathologist. They write a report for the doctor who has either ordered the report or done the procedure. The report helps your doctor make a diagnosis or treatment plan for a health condition or disease.

The parts of a pathology report

In most cases, a pathology report includes:

• Your name and personal identifiers. These include date of birth, patient ID number, or medical record number.

• A case number. This identifies your specimen.

• The date and type of procedure by which the specimen was taken. For instance, it could be a blood sample, surgery, or biopsy.

• Your health history and current diagnosis.

• A general or gross (as seen by the naked eye) description of the specimen.

• A detailed description of what the pathologist sees during microscopic exam of the specimen.

• The final diagnosis. Your doctor relies on the final diagnosis to help choose the best treatment choices.

• The name and signature of the pathologist, as well as the name and address of the pathology lab.

Getting a copy of your pathology report

By law, you are entitled to a copy of your medical record. You can contact your doctor to help you get a copy of your pathology report. Or the report will appear automatically in your online patient information portal. The report may include a link to a website where you can find general information about your diagnosis. Procedures for getting medical records vary from state to state, and from facility to facility. You may have to pay a fee for your report. Copies of these reports may be important to keep. Your diagnosis and treatment are often based on them. Also, understanding the report will help you and your doctor (and any future doctors) better understand your condition.