Pathology - Result Entry (report/observation tabs with rich text editor)

Use the Pathology Result Entry form to author, review, and finalize anatomic pathology reports. The screen is organized to support multi‑part cases and observation‑driven reporting with a ribbon‑style word processor similar to MS Word.

Screen layout at a glance

• Orders grid (top)
  • Displays all orders loaded for result entry.
• Tests grid (middle)
  • Lists the pathology tests for the selected order (e.g., Surgical Pathology, Cytology, IHC panel).
• Observations workspace (bottom)
  • Each observation generates its own tab (e.g., Gross, Microscopic, Diagnosis, IHC/Ancillary, Synoptic/Protocols, Comment).
  • The Final Report is a compilation of all included observation tabs in the configured order.

Typical observations (examples; your configuration may vary):

• Gross Description
• Microscopic Description
• Final Diagnosis (per specimen/part)
• Synoptic/Structured Protocols (e.g., CAP checklists)
• Ancillary Studies (IHC, ISH, Molecular), with interpretation
• Comment/Addendum sections

Authoring with the rich text editor (ribbon UI)

The observation tabs use an advanced word processor with a familiar ribbon interface.

Key capabilities

• Styles and formatting: headings, fonts, bullet/number lists, alignment, page breaks
• Templates/snippets: insert test‑specific templates and standardized phrases (macros)
• Tables and images: embed tables (e.g., IHC result grids) and insert annotated images
• Spell check and find/replace
• Merge fields: auto‑populate patient, specimen, and case metadata
• Structured data entry: fields for synoptic elements (tumor size, margins, stage) as configured

Tips

• Use templates to standardize structure (e.g., “Skin Excision – Gross/Micro/Diagnosis”).
• Keep synoptic elements in structured fields for clean downstream reporting.
  

Workflow (step‑by‑step)

1. Load orders

• Results → Pathology Result Entry → Search → apply filters → Find → select orders → Done.

2. Select a test

• Highlight an order in the Orders grid, then select the pathology test in the Tests grid.

3. Author observations

• Open each observation tab (Gross, Microscopic, Diagnosis, Synoptic, etc.).
• Insert templates or snippets; complete free text and structured fields.
• Attach images or tables as needed.

4. Preview the compiled report

• Use Preview to see the final, compiled report exactly as recipients will.

5. Save 

Addendums and corrections (post‑release)

• Addendum
  • Append new information (e.g., late ancillary studies, clarifications) without changing prior findings.
  • Generates and distributes an Addendum version; prior content remains intact.
• Correction/Revision (Corrected Report)
  • Use when modifying previously released content (values, diagnoses, interpretations).
  • Requires a documented reason; produces a Corrected report and re‑distributes.

Best practices

• Use standardized templates and synoptic protocols to ensure completeness and consistency.
• Keep Diagnosis concise and specimen‑specific; use specimen labels/parts clearly (A, B, C…).
• Separate interpretation from methods; reserve Addenda for late‑arriving ancillary data.
• Preview before release to confirm tab order, headers/footers, pagination, and image placement.
• Avoid PHI in reusable templates; rely on merge fields for patient identifiers.
  

With observation tabs, rich text editing, and compiled reporting, Pathology Result Entry supports clear, standardized, and audit‑ready AP reports—while enabling addenda and corrections to maintain an accurate longitudinal record.