There are several steps required to correctly document a gross description for a pathology report:
1. Describe how the specimen is received and labeled.
- Document the specimen's state upon receiving it (e.g., fresh, formalin, or other fixatives)
- Dictate the specimen identification on a requisition form and a container label
- Include at least 2 identifiers, such as the patient’s name, medical record number, date of birth, tissue type, or anatomical site
2. Identify anatomical structures and orientation designations present in the specimen.
- Identify and name organ or tissue type
- Include the name of the procedure, if applicable (e.g., tonsillectomy)
- Evaluate the specimen's integrity (e.g., intact, fragmented, ruptured) and document it, if necessary
- Indicate surgical orientation marks (e.g., short suture=superior margin, long suture=lateral margin)
3. Measure the specimen and its components in metric units.
- Measure the organ or tissue fragment in metric units (e.g., centimeters, grams) in 3 dimensions, from largest to smallest
- Measure liquid material volumes in milliliters or liters
- Measure fragmented specimens in centimeters from smallest to largest and in aggregated size
4. Describe, measure, and analyze the main pathological findings of the specimen.
- Measure any lesions and their distances to the surgical resection margins in metric units
- Document shape (e.g., round, ovoid, spherical, ellipse-shaped, cystic, multiloculated, linear whorled)
- Document color (e.g., pink-tan, red, green-yellow, brown, black)
- Document consistency (e.g., soft, firm, friable, rubbery, liquid, structure-less)
- Document odor (e.g., foul smell)
- Gross only specimens and mention inscriptions on medical devices
5. Identify and describe any secondary pathology or anatomic structures.
- Document any incidental polyps, second smaller lesion, diverticula, lymph nodes, etc.
6. Indicate ink code for resection margins or particular structure or lesion (e.g., perforation) of the specimen where you have applied tissue marking dyes.
- Use any color for unoriented and oriented specimens depending on the type of the specimen. Below is a recommended mnemonic for 6 color code schemes for oriented resections' specimens:
- Blue for superior margin (blue - “sky”)
- Green for inferior margin (green - “grass”)
- Red for medial margin (red - “mad”)
- Yellow for lateral (lateral - letter “L”)
- Black for posterior or deep (deep and away from the light)
- Orange for anterior (by default)
7. Document special studies or procedures.
- Document any and all frozen sections, digital gross photographs, radiographs, cytology preparations, studies by microbiology, flow cytometry and cytogenetics, electron microscopy, molecular studies, decalcification, estimated cold ischemic time, time in fixative, and tissues sent to the biorepository.
8. Describe tissue disposition.
- State if the specimen is entirely or representatively submitted
- Describe how margins are submitted (on face or on edge)
- Record cassettes summaries and add a numerical or alphabetical label, depending on the laboratory designation system
