Dermatopathology Diagnostic Language, Pathology Reports and Database

Over the past two years we have revised our diagnostic language with emphasis on consolidation of multiple terms for the same entity into concise, single terms that are universally accepted and understood. Where there are two frequently used terms for the same entity, we have chosen the most universally accepted term as our main term and enclosed the synonym in parenthesis. We have also revised our basic microscopic descriptions to contain only the diagnostic elements that are found in all examples of a specific entity and we believe these reflect the minimal microscopic criteria for that disease. Each diagnosis is linked to an internal searchable code and to ICD9 and ICD10 codes. This revision of our diagnostic terms and microscopic description database was achieved by the consensus efforts of all of our dermatopathologists who have trained and had experience at multiple different institutions. Our database is not static and is constantly being revised as new information is published and accepted.

We have standardized the format of our reports with the diagnosis line including only the diagnosis and margin information, if appropriate. In the comment section, we put the most important information first. Microscopic descriptions may or may not be included based upon the degree
of certainty of the diagnosis or the preferences of the submitting clinician. Instead of a separate microscopic description section, we incorporate the microscopic description into the comment section. The reason for putting the microscopic description into the comment section is that it allows for a concise discussion of the features observed in the case in relation to the diagnosis.

The advantages of this standardization include similar diagnostic language and report format from all of our dermatopathologists. Since all of our reports are generated and stored on a single computer platform, we have a national database of dermatologic disease that can be used for epidemiologic studies and improvement of health caredelivery.

– Evan Farmer, MD; Renata Joffe, MD