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Pathology and Surgical Reports

Pathology and Surgical Reports

Date : 11-12-2003 - 06:24 AM - Readers : 16585

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I recently obtained copies of my pathology and surgical records, it was with much difficulty though. Any advice on getting these in a more timely manner and with less difficulty for future reference?

I am also having trouble deciphering the meaning of much of the terminology used in them. Are there sites to help with translating the medical terms?

Receiving copies of all medical records, pathology, surgical records is something we are entitled. There are laws in place to ensure we are to receive them in a timely manner and without delay.
Unfortunately, the medical facility holding these files can charge by the page which can sometimes add up.

Another option would be to request from your Doctor a copy of the report(s) they have. That does not guarantee you will receive them all.

The best option is to go in person to the medical records department of the facility in which your surgery was performed and request them. Also, should you want Doctors and/or Nurses notes, those need to be requested as they will generally only give you the actual surgery report, laboratory test results and pathology reports.

As for the terminology used, there are some excellent websites that provide definitions for many of the terms generally used. Here are some of the more commonly used ones along with information on the different sections of the report:

A typical laboratory report is divided into several sections:

The Diagnosis:

This usually appears with the body site, surgical procedure, and final diagnosis. Examples include biopsy, excision, and resection.

The Gross Description:

This describes the actual appearance of the tissue specimen as viewed by the pathologists. There is sometimes a where the Pathologists has dictated their summary of the tissue. They also include measurements and weights of organs that were sent for review.

The Microscopic Description:

This is the record of what was viewed under the microscope. The language becomes highly technical here generally.

Acute: Relatively serious and severe; having a brief course.

Adenocarcinoma: Malignant tumor arising in glandular epithelium.

Adenoma: Benign tumor arising in glandular epithelium.

Adhesion: Scar tissue joining two parts usually separate.

Atypia: A general term describing cells that vary in appearance from the normal cell.

Benign: Not malignant.

Cyst: Sac containing usually a fluid or semisolid material.

Differentiation: Describes the degree or extent that cancer cells resemble normal cells.

Dysplasia: Disorderly but non-cancerous growth.

Endometrium: The uterine lining; the cells that line the uterus.

Epithelium, Epithelial: A specialized lining cell of organs.

Fibroid: Term for uterine fibroleiomyoma.

Hemorrhage: Rupture of blood vessels leading to blood within tissue.

Hyperplasia: Increase in size of a part due to increase of number of units.

Lesion: Characteristic change in organism produced by disease.

Necrosis or Necrotic: Cell death.

Stroma: General term to describe the connective tissue supporting matrix.

Additional information and resources:

Terms medical dictionary A-Z List:
http://www.medterms.com/script/main/hp.asp

Information on commonly used terminology for pathology reports:
http://www.pathologyoutlines.com/

Information on cancer cells:
http://www.cancerhelp.org.uk/help/default.asp?page=96

PUBLIC LAW 104-191
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
OF 1996:
http://aspe.hhs.gov/admnsimp/pl104191.htm

If you receive care in a federal medical facility, you have a right to obtain your records under the Federal Privacy Act of 1974 (5 USC 552a).

There is web access at:
www.usdoj.gov/foia/privstat.htm

Most medical offices will want you to make your request in writing.

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