College of American Pathologists
CAP Committees & Leadership CAP Calendar of Events Estore CAP Media Center CAP Foundation
 
About CAP    Career Center    Contact Us      
Search: Search
  [Advanced Search]  
 
CAP Home CAP Advocacy CAP Reference Resources and Publications CAP Education Programs CAP Accreditation and Laboratory Improvement CAP Members
CAP Home > CAP Reference Resources and Publications > Pathology Reporting > Formats and Terminology

  Formats and Terminology

 

 

 

Published September 1, 2005

Suggested Comments/Disclaimers

Cancer

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for stereotactic breast biopsis:
"Negative stereotactic biopsy results should not preclude additional tissue studies if results do not correlate with clinical impressions (intradepartmental staff consultation)."

Cytology

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for gynecologic Pap smears:
"The Pap smear is a screening test that aids in the detection of cervical cancer and cancer precursors. Both false positive and false negative results can occur. The test should be used at regular intervals, and positive results should be confirmed before definitive therapy."

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for colposcopic biopsies:
"Previous pap smear reviewed." 
"Pap smear performed elsewhere, not reviewed."
"Findings [do/do not] reflect changes seen in the previous pap smear (accession #)."

Nongynecological Cytology

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for negative FNABs:
"Hypocellularity may indicate that the specimen is unsatisfactory for interpretation."
"Technical considerations such as needle placement can cause a false negative or equivocal result."
"Negative NFAB results should not preclude tissue biopsy if FNAB results do not correlate with clinical impressions."

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for negative cytology:
"Non-diagnostic cytological results should not preclude tissue biopsy if they do not correlate with clinical impressions."

Ronald L. Sirota, MD, FCAP, suggests this language as a standard comment/disclaimer for positive cytology:
"When possible, cytology findings should be confirmed with histological studies or frozen section before undertaking definitive therapy."

 

 

Related Links

 

 

 

   
 
 © 2014 College of American Pathologists. All rights reserved. | Terms and Conditions | CAP ConnectFollow Us on FacebookFollow Us on LinkedInFollow Us on TwitterFollow Us on YouTubeFollow Us on FlickrSubscribe to a CAP RSS Feed