29 October 2008

Types of transcribed reports

Medical transcriptionists type a variety of reports. One report type is the Pathology Operative Report.

This particular report type differs from a typical operative report, or "op note," in that during this procedure, a specimen is removed during the operation and sent for pathological examination. "The operative pathology report of the surgical specimen contains a description of the gross and microscopic examination of the surgical specimen."* The specimen might be a tumor or cancerous growth or any other portion of a diseased organ or tissue.

The pathology operative report details "which structures and organs of the body are involved by the tumor. It verifies the primary site of the cancer and describes the extent to which it has spread. Tumor size will usually be stated in the gross description of the surgical specimen. It is usually specified in centimeters."*

The pathology operative report will feature many of the same characteristics of a typical operative report, including the patient's name, date of the procedure, and preoperative and postoperative diagnosis. As noted above, it may also feature diagnoses relating to the pathological findings of the specimen. Finally, the body of the report will detail the surgical procedure performed and findings therein.


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