Context.—Gynecologic cytology terminology and report
formatting have been nationally standardized since the implementation
of The Bethesda System of 1988, but standard
reporting for nongynecologic cytology has never been
formally addressed on the same scale.
Objectives.—To promote patient safety through uniform
reporting in nongynecologic cytology (including fine-needle
aspiration cytology) and to improve communication between
laboratories and health care providers.
Data Sources.—Sources include the College of American
Pathologists Cytopathology Resource Committee; the College
of American Pathologists Council on Scientific Affairs
Ad Hoc Committee on Pathology Report Standardization;
the College of American Pathologists Laboratory Accreditation
Program inspection checklists; the Joint Commission
for Accreditation of Healthcare Organizations; and the
Clinical Laboratory Improvement Amendments of 1988.
Conclusions.—We describe the major elements of quality
nongynecologic cytology reporting and discuss areas of
controversy in cytology reporting. Standardized nongynecologic
specimen reporting will expand the concept of
common report elements already widely implemented in
gynecologic cytology reporting. The intent is to improve
communication with the health care team while remaining
in compliance with federal mandates and accreditation
guidelines.
(Arch Pathol Lab Med. 2009;133:1743–1756)

The primary ‘‘product’’ of pathologists is the interpretive
report. The pathology report is the result of a
medical consultation with the pathologist to examine the
patient (in the form of his or her tissue) and provide an
opinion regarding the presence or absence of a diseased
state. These consultations, especially in cytopathology, often
require a comprehensive evaluation of the circumstances
surrounding the patient’s complaint, including review
of his or her clinical laboratory test results, imaging
studies, clinical symptoms, and personal or family medical
history. Pathology reports represent a pivotal point in
clinical care; they influence decisions to treat or not to treat
as well as direct therapy decisions. As such, pathology
reports are a primary target for quality improvement efforts
in anatomic pathology. Cancer checklists for reporting
the results of pathologic examination are already widely implemented by most pathology practices as a
means of ensuring the inclusion of critical data elements
into the pathology report. In keeping with its long tradition
of leadership in promoting ‘‘best practices’’ in pathology
reporting and terminology, the College of American
Pathologists (CAP) has initiated efforts to provide
standardized reporting protocols for tissue specimens other
than cancer in addition to those already established for
most conventional tumors.
During the past 20 years, there has been considerable
interest in and effort toward improving pathology reporting
through the use of report protocols, synoptic reports,
electronic or paper templates, worksheets, and checklists.
1–3 Protocols are outlines for the formatting of an entire
document to guide one’s practice. Synoptic reports are
summarized, streamlined versions of case findings determined
to be significant based on potential clinical relevancy.
4 Templates are preformatted outlines for tabular
data.5 Tumor worksheets or checklists are shortened versions
of the key elements that should be included in a
report and are to be used as a prompt or reminder to
include specific data, and they may be applied to one portion
or several portions of a report. The effort toward standardized
formatting serves many functions: it ensures that
vital staging, grading, and prognostic information is included
in the report; it reminds pathologists to report specific
elements; it enhances data extraction for billing personnel
and tumor registries; it supports research efforts
by prospectively reporting potentially critical information;
it promotes computer data capture; and it facilitates retrieval
of information by the reader. It is only recently that
attention has been focused on the ‘‘granularity’’ (or number
of small, labeled segments of data) of report formatting and its influence on reader comprehension and retention.
Searching for information in diagnostic narratives in
the form of free text is often tedious to the reader. Tange
et al6 reported that subdividing information into ‘‘labeled
segments’’ enhances retrieval of important information in
medical records, but too much subdivision reduces the
speed of retrieval. There is a considerable volume of literature
on sentence structure and formatting as they relate
to human cognition and comprehension that is beyond the
scope of this article. However, the major findings can be
concisely summarized through the following observations
from the Agency for Healthcare Research and Quality: (1)
People do not remember much; (2) lots of data does not
translate into better decisions; (3) people prefer information
they can easily evaluate; and (4) hierarchies help people
understand and remember information.7 Despite pathologists’
best intentions, changes in report formatting,
including attempts to streamline reports, may actually decrease
comprehension.8 This may be related to the degree
of familiarity an individual has with a particular format
and emphasizes the need to engage clients in overall report
design.
A pathology report is the only documentation of what
a pathologist does and thinks; it is a pathologist’s note in
the patient’s record. It should reflect the logical sequence
of events that resulted in the final assessment of that patient.
Nongynecologic cytopathology is ideally suited to
standardization because a model currently exists—that of
The Bethesda System for Reporting Cervical Cytology.9
Many concepts from the gynecologic system of reporting
Papanicolaou test results are incorporated into the currently
proposed nongynecologic cytology protocol. The
protocol mirrors standards already established by tumor
protocol subcommittees and follows requirements of the
Clinical Laboratory Improvement Amendments of 1988
(CLIA),10 the Joint Commission on Accreditation of
Healthcare Organizations, and the CAP Commission on
Laboratory Accreditation’s Laboratory Accreditation Program
(LAP)11 checklists. For convenience, this protocol includes
the CAP LAP numbers identifying the specific professional
standards in the 2007 inspection checklist.
This protocol (Table 1) is not intended to be used for
litigation or to enforce rigid adherence to one report design.
Although standardized reporting enhances efforts to
ensure appropriate reimbursement, this protocol should
not be required for reimbursement. This effort is intended
to act as a guide with which to ensure that critical information
is entered into a cytopathology report. Because of
computer reporting constraints or difficulty in obtaining
accurate information from submitting providers, certain
elements, although desirable, may not be feasible to include
in a report. However, this protocol offers an idealized
model for the reporting of nongynecologic cytology
specimens and is a worthwhile addition to quality improvement
efforts.
DATA SOURCES
The CAP Cytopathology Resource Committee, in conjunction
with the CAP Council on Scientific Affairs Ad
Hoc Committee on Pathology Report Standardization, reviewed
existing regulatory requirements for the reporting
of pathology specimens and drafted a list of required, desirable,
and optional report elements. This document was
delegated to a Cytopathology Resource Committee task
force for further modification. The task force reviewed available recommendations from other sources12–15 and solicited
cytopathologists’ expert opinions on practice variation
and feasibility of implementation. Where regulations,
guidelines, and standards showed slightly different
requirements, the most stringent were applied. The final
recommendation for the protocol by the Cytopathology
Resource Committee was reviewed and approved by the
CAP Council on Scientific Affairs.
太长了，还有很多规范化的表格模式粘贴不上。就不复制了