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 pathologist, who then writes up a report for the medical provider who has either ordered the report or performed the procedure. Pathology reports are used by your medical provider to determine a diagnosis or treatment plan for a specific health condition or disease.

Components of a pathology report

In most cases, a pathology report contains the following information:

• Your name and your individual identifiers. These include date of birth, patient ID number, or Social Security number.

• A case number. This is used to identify your specimen.

• The date and type of procedure by which the specimen was obtained (for instance, a blood sample, surgery, or biopsy)

• Your medical history and current clinical diagnosis

• A general description of the specimen received in the lab

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

• The final diagnosis, which is the "bottom line" of the testing process. Your medical provider 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 medical provider to help you get a copy of your pathology report. Procedures for obtaining medical records vary from state to state, and from facility to facility. You may have to pay a fee for your report. 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 medical provider (and any future medical providers) better understand your condition.