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. He or she writes up a report for the healthcare provider who has either ordered the report or done the procedure. Pathology reports are used by your provider to figure out a diagnosis or treatment plan for a specific health condition or disease.
In most cases, a pathology report has this information:
Your name and your personal identifiers. These include date of birth, patient ID number, medical record 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 health history and current 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. Your healthcare 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
By law, you are entitled to a copy of your medical record. You can contact your healthcare provider to help you get a copy of your pathology report. 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 any pathology reports are very important to keep. Your diagnosis and treatment are often based on them. Also, understanding the report will help you and your healthcare provider (and any future providers) better understand your condition.