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How To Write A Lab Report | Step-by-Step Guide & Examples

Published on May 20, 2021 by Pritha Bhandari . Revised on July 23, 2023.

A lab report conveys the aim, methods, results, and conclusions of a scientific experiment. The main purpose of a lab report is to demonstrate your understanding of the scientific method by performing and evaluating a hands-on lab experiment. This type of assignment is usually shorter than a research paper .

Lab reports are commonly used in science, technology, engineering, and mathematics (STEM) fields. This article focuses on how to structure and write a lab report.

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Table of contents

Structuring a lab report, introduction, other interesting articles, frequently asked questions about lab reports.

The sections of a lab report can vary between scientific fields and course requirements, but they usually contain the purpose, methods, and findings of a lab experiment .

Each section of a lab report has its own purpose.

  • Title: expresses the topic of your study
  • Abstract : summarizes your research aims, methods, results, and conclusions
  • Introduction: establishes the context needed to understand the topic
  • Method: describes the materials and procedures used in the experiment
  • Results: reports all descriptive and inferential statistical analyses
  • Discussion: interprets and evaluates results and identifies limitations
  • Conclusion: sums up the main findings of your experiment
  • References: list of all sources cited using a specific style (e.g. APA )
  • Appendices : contains lengthy materials, procedures, tables or figures

Although most lab reports contain these sections, some sections can be omitted or combined with others. For example, some lab reports contain a brief section on research aims instead of an introduction, and a separate conclusion is not always required.

If you’re not sure, it’s best to check your lab report requirements with your instructor.

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Your title provides the first impression of your lab report – effective titles communicate the topic and/or the findings of your study in specific terms.

Create a title that directly conveys the main focus or purpose of your study. It doesn’t need to be creative or thought-provoking, but it should be informative.

  • The effects of varying nitrogen levels on tomato plant height.
  • Testing the universality of the McGurk effect.
  • Comparing the viscosity of common liquids found in kitchens.

An abstract condenses a lab report into a brief overview of about 150–300 words. It should provide readers with a compact version of the research aims, the methods and materials used, the main results, and the final conclusion.

Think of it as a way of giving readers a preview of your full lab report. Write the abstract last, in the past tense, after you’ve drafted all the other sections of your report, so you’ll be able to succinctly summarize each section.

To write a lab report abstract, use these guiding questions:

  • What is the wider context of your study?
  • What research question were you trying to answer?
  • How did you perform the experiment?
  • What did your results show?
  • How did you interpret your results?
  • What is the importance of your findings?

Nitrogen is a necessary nutrient for high quality plants. Tomatoes, one of the most consumed fruits worldwide, rely on nitrogen for healthy leaves and stems to grow fruit. This experiment tested whether nitrogen levels affected tomato plant height in a controlled setting. It was expected that higher levels of nitrogen fertilizer would yield taller tomato plants.

Levels of nitrogen fertilizer were varied between three groups of tomato plants. The control group did not receive any nitrogen fertilizer, while one experimental group received low levels of nitrogen fertilizer, and a second experimental group received high levels of nitrogen fertilizer. All plants were grown from seeds, and heights were measured 50 days into the experiment.

The effects of nitrogen levels on plant height were tested between groups using an ANOVA. The plants with the highest level of nitrogen fertilizer were the tallest, while the plants with low levels of nitrogen exceeded the control group plants in height. In line with expectations and previous findings, the effects of nitrogen levels on plant height were statistically significant. This study strengthens the importance of nitrogen for tomato plants.

Your lab report introduction should set the scene for your experiment. One way to write your introduction is with a funnel (an inverted triangle) structure:

  • Start with the broad, general research topic
  • Narrow your topic down your specific study focus
  • End with a clear research question

Begin by providing background information on your research topic and explaining why it’s important in a broad real-world or theoretical context. Describe relevant previous research on your topic and note how your study may confirm it or expand it, or fill a gap in the research field.

This lab experiment builds on previous research from Haque, Paul, and Sarker (2011), who demonstrated that tomato plant yield increased at higher levels of nitrogen. However, the present research focuses on plant height as a growth indicator and uses a lab-controlled setting instead.

Next, go into detail on the theoretical basis for your study and describe any directly relevant laws or equations that you’ll be using. State your main research aims and expectations by outlining your hypotheses .

Based on the importance of nitrogen for tomato plants, the primary hypothesis was that the plants with the high levels of nitrogen would grow the tallest. The secondary hypothesis was that plants with low levels of nitrogen would grow taller than plants with no nitrogen.

Your introduction doesn’t need to be long, but you may need to organize it into a few paragraphs or with subheadings such as “Research Context” or “Research Aims.”

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A lab report Method section details the steps you took to gather and analyze data. Give enough detail so that others can follow or evaluate your procedures. Write this section in the past tense. If you need to include any long lists of procedural steps or materials, place them in the Appendices section but refer to them in the text here.

You should describe your experimental design, your subjects, materials, and specific procedures used for data collection and analysis.

Experimental design

Briefly note whether your experiment is a within-subjects  or between-subjects design, and describe how your sample units were assigned to conditions if relevant.

A between-subjects design with three groups of tomato plants was used. The control group did not receive any nitrogen fertilizer. The first experimental group received a low level of nitrogen fertilizer, while the second experimental group received a high level of nitrogen fertilizer.

Describe human subjects in terms of demographic characteristics, and animal or plant subjects in terms of genetic background. Note the total number of subjects as well as the number of subjects per condition or per group. You should also state how you recruited subjects for your study.

List the equipment or materials you used to gather data and state the model names for any specialized equipment.

List of materials

35 Tomato seeds

15 plant pots (15 cm tall)

Light lamps (50,000 lux)

Nitrogen fertilizer

Measuring tape

Describe your experimental settings and conditions in detail. You can provide labelled diagrams or images of the exact set-up necessary for experimental equipment. State how extraneous variables were controlled through restriction or by fixing them at a certain level (e.g., keeping the lab at room temperature).

Light levels were fixed throughout the experiment, and the plants were exposed to 12 hours of light a day. Temperature was restricted to between 23 and 25℃. The pH and carbon levels of the soil were also held constant throughout the experiment as these variables could influence plant height. The plants were grown in rooms free of insects or other pests, and they were spaced out adequately.

Your experimental procedure should describe the exact steps you took to gather data in chronological order. You’ll need to provide enough information so that someone else can replicate your procedure, but you should also be concise. Place detailed information in the appendices where appropriate.

In a lab experiment, you’ll often closely follow a lab manual to gather data. Some instructors will allow you to simply reference the manual and state whether you changed any steps based on practical considerations. Other instructors may want you to rewrite the lab manual procedures as complete sentences in coherent paragraphs, while noting any changes to the steps that you applied in practice.

If you’re performing extensive data analysis, be sure to state your planned analysis methods as well. This includes the types of tests you’ll perform and any programs or software you’ll use for calculations (if relevant).

First, tomato seeds were sown in wooden flats containing soil about 2 cm below the surface. Each seed was kept 3-5 cm apart. The flats were covered to keep the soil moist until germination. The seedlings were removed and transplanted to pots 8 days later, with a maximum of 2 plants to a pot. Each pot was watered once a day to keep the soil moist.

The nitrogen fertilizer treatment was applied to the plant pots 12 days after transplantation. The control group received no treatment, while the first experimental group received a low concentration, and the second experimental group received a high concentration. There were 5 pots in each group, and each plant pot was labelled to indicate the group the plants belonged to.

50 days after the start of the experiment, plant height was measured for all plants. A measuring tape was used to record the length of the plant from ground level to the top of the tallest leaf.

In your results section, you should report the results of any statistical analysis procedures that you undertook. You should clearly state how the results of statistical tests support or refute your initial hypotheses.

The main results to report include:

  • any descriptive statistics
  • statistical test results
  • the significance of the test results
  • estimates of standard error or confidence intervals

The mean heights of the plants in the control group, low nitrogen group, and high nitrogen groups were 20.3, 25.1, and 29.6 cm respectively. A one-way ANOVA was applied to calculate the effect of nitrogen fertilizer level on plant height. The results demonstrated statistically significant ( p = .03) height differences between groups.

Next, post-hoc tests were performed to assess the primary and secondary hypotheses. In support of the primary hypothesis, the high nitrogen group plants were significantly taller than the low nitrogen group and the control group plants. Similarly, the results supported the secondary hypothesis: the low nitrogen plants were taller than the control group plants.

These results can be reported in the text or in tables and figures. Use text for highlighting a few key results, but present large sets of numbers in tables, or show relationships between variables with graphs.

You should also include sample calculations in the Results section for complex experiments. For each sample calculation, provide a brief description of what it does and use clear symbols. Present your raw data in the Appendices section and refer to it to highlight any outliers or trends.

The Discussion section will help demonstrate your understanding of the experimental process and your critical thinking skills.

In this section, you can:

  • Interpret your results
  • Compare your findings with your expectations
  • Identify any sources of experimental error
  • Explain any unexpected results
  • Suggest possible improvements for further studies

Interpreting your results involves clarifying how your results help you answer your main research question. Report whether your results support your hypotheses.

  • Did you measure what you sought out to measure?
  • Were your analysis procedures appropriate for this type of data?

Compare your findings with other research and explain any key differences in findings.

  • Are your results in line with those from previous studies or your classmates’ results? Why or why not?

An effective Discussion section will also highlight the strengths and limitations of a study.

  • Did you have high internal validity or reliability?
  • How did you establish these aspects of your study?

When describing limitations, use specific examples. For example, if random error contributed substantially to the measurements in your study, state the particular sources of error (e.g., imprecise apparatus) and explain ways to improve them.

The results support the hypothesis that nitrogen levels affect plant height, with increasing levels producing taller plants. These statistically significant results are taken together with previous research to support the importance of nitrogen as a nutrient for tomato plant growth.

However, unlike previous studies, this study focused on plant height as an indicator of plant growth in the present experiment. Importantly, plant height may not always reflect plant health or fruit yield, so measuring other indicators would have strengthened the study findings.

Another limitation of the study is the plant height measurement technique, as the measuring tape was not suitable for plants with extreme curvature. Future studies may focus on measuring plant height in different ways.

The main strengths of this study were the controls for extraneous variables, such as pH and carbon levels of the soil. All other factors that could affect plant height were tightly controlled to isolate the effects of nitrogen levels, resulting in high internal validity for this study.

Your conclusion should be the final section of your lab report. Here, you’ll summarize the findings of your experiment, with a brief overview of the strengths and limitations, and implications of your study for further research.

Some lab reports may omit a Conclusion section because it overlaps with the Discussion section, but you should check with your instructor before doing so.

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A lab report conveys the aim, methods, results, and conclusions of a scientific experiment . Lab reports are commonly assigned in science, technology, engineering, and mathematics (STEM) fields.

The purpose of a lab report is to demonstrate your understanding of the scientific method with a hands-on lab experiment. Course instructors will often provide you with an experimental design and procedure. Your task is to write up how you actually performed the experiment and evaluate the outcome.

In contrast, a research paper requires you to independently develop an original argument. It involves more in-depth research and interpretation of sources and data.

A lab report is usually shorter than a research paper.

The sections of a lab report can vary between scientific fields and course requirements, but it usually contains the following:

  • Abstract: summarizes your research aims, methods, results, and conclusions
  • References: list of all sources cited using a specific style (e.g. APA)
  • Appendices: contains lengthy materials, procedures, tables or figures

The results chapter or section simply and objectively reports what you found, without speculating on why you found these results. The discussion interprets the meaning of the results, puts them in context, and explains why they matter.

In qualitative research , results and discussion are sometimes combined. But in quantitative research , it’s considered important to separate the objective results from your interpretation of them.

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Introduction to clinical pathology: A brief course of laboratory medicine in the field for medical students

Navid omidifar.

1 Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

Ali Keshtkari

3 Department of Pediatrics, School of Medicine, and Emam sajad Hospital, Clinical Reseach Center, Yasuj University of Medical Sciences, Yasuj, Iran

Mohammadreza Dehghani

Mansoureh shokripour, objectives:.

Teaching of clinical pathology to medical students has been ignored in many countries such as Iran. We aim to introduce a practical brief course and its proper timing.

MATERIALS AND METHODS:

Three groups of medical students from consecutive years of entrance passed a 1.5 working day practical course on the field. Their level of knowledge was assessed by pre- and post-tests. Their idea and satisfaction were gathered by questionnaires.

Knowledge of students became significantly higher after the course. Their satisfaction was high. Students in later year of education got significantly higher marks. Most of the students wished such a course should be away from basic sciences period and as near as possible to internship.

DISCUSSION:

Due to overloaded curriculum of general medicine in Iran, we decided to run a brief practical course of laboratory medicine education for medical students. Although the course was practical, the knowledge of students became higher. Students with more clinical experience and knowledge absorbed more. Being actively involved in the classes lit the enthusiasm of students and made them satisfied with the course. It seemed that the course should be placed in later years of clinical training to get the best uptake and results.

Introduction

According to different studies, about two-third of medical decisions are based on laboratory results[ 1 ] surely because of objective data that they can provide for the health-care providers.[ 2 ] Besides, laboratory tests can provide data that help doctors to screen early risk factors; consequently choose preventive and less-invasive actions, monitor suitable remedy, and track the fate of diseases.[ 3 ] Due to increasing pressure on physicians to visit more patients in different and even odd conditions that limits the time for proper history taking and physical examination, they count on paraclinic results such as laboratory medicine.[ 4 ] Obviously, as a medical specialty, this area has been markedly become more sophisticated as a matter of number, kind, and complexity of tests and methods recently. The little attention paid to clinical pathology (laboratory medicine) subjects in medical school curricula has been mentioned in literature, especially in Iran.[ 5 ]

Based on literature, it has been observed that active learning approaches improve comprehension and learning,[ 6 ] critical thinking, communication abilities, requested attitudes and manner;[ 7 ] decreasing misconceptions and expanding motivation.[ 8 , 9 ] Active teaching–learning methods in clinical pathology disciplines are needed to raise the interaction and interest among the students and to help them have more permanent remainder of knowledge, especially in a crowded discipline.

General medicine in Iran is a 7-year course with the following four phases: basic sciences (2.5 years), physiopathology or preclinical (1 year), clinical clerkship (2 years), and finally internship (1.5 years). Two comprehensive examinations have been put after basic sciences phase and before internship. During the course, at least 290 official and standard units should be passed by the students. Among them, about 12 units belong to pathology. Until now, unfortunately, the major focus has been on general and surgical pathology; consequently clinical pathology has been ignored as a key part of practice of medicine to be learned by medical students classically. We noticed the lack of laboratory medicine teaching in official curriculum and by considering the possibility of overload, we decided to run a short course of introduction to laboratory medicine. On the other hand, we did not have any experience or evidence to know where this course should be taken place in different phases of general medicine education in Iran, so we tried the course in different phases after basic sciences phase.

We hope such studies can help officials to decide how, where, and when to prepare a place for teaching of clinical pathology to undergraduates of medical schools in Iran and all over the world to make them better physicians who can cope better with the rush of data coming from this area of expertise.

Materials and Methods

A convenience sampling method was used in the study. Informed consent was obtained from participants after explaining the study plan. The target population was year 3 (first semester of preclinical years), 4, and 5 (1 st and last year of clinical clerkship) medical students who voluntarily enrolled to take part in the study. The preliminary introduction and short explanation of the course was done by clinical pathologists. Three groups of medical students in the following order agreed to participate in the study: in the last year of clinical-phase training (21 students), in the 1 st year of clinical-phase training (22 students), and physiopathology-phase students (23 students). They all took pretest including twenty multiple choice questions (MCQs) prepared by two clinical pathologists and appraised by clinicians according to goals determined for a medical student to know about clinical pathology laboratory for this crash course as follows:[ 10 ]

  • Being familiar with the structure of a general laboratory in a public hospital
  • Basic understanding of health information system/laboratory information system, reception and reporting sections
  • Basic understanding of laboratory errors and their causes
  • Basic attempts in specimen handling and being familiar with special anticoagulants
  • Basic approach/tests in clinical microbiology section
  • How to do Gram-staining and examine the slides
  • Most important test in clinical hematology and fundamentals of instruments
  • How to prepare peripheral blood smear and examine the slide
  • How a clinical biochemistry section and an autoanalyzer work out
  • Basic approach to an emergent test and a critical value
  • Basic rules in blood banking (concepts, different tests and forms, types of products…)
  • Basic tests in parasitology and urine analysis
  • Basic concepts and tests in hormonal assay, immunology, and serology
  • Basic rules and statistics in quality control of different sections and quality assurance.

Course plan

There was a session for knowing about the basic construct, rules, protocols, official chart, and variety of tests and theoretical concepts of clinical pathology presented with a clinical pathologist. The overall importance and duty of a clinical laboratory was presented by a clinician. A general tutorial was performed in laboratory for the trainees in experiment group. Then, students were randomly divided in small groups of 4–6 people. In different days, they attended hematology and blood bank, biochemistry, microbiology, urine analysis, parasitology, immunology, and serology sections of clinical laboratory. It took three working days (8 am–2 pm) for a given small group to finish the course. At the end, the posttest was performed. A questionnaire was given to each student with the following questions:

  • I am satisfied with the course
  • The course should take place at basic science years
  • The course should take place at pathophysiology years
  • The course should take place after starting clinical years
  • The course should take place before starting internship
  • The course should take place after starting internship.

They could rank the questions as: 1 (the most agreed), 2, 3, 4, and 5 (the least agreed). Their general opinion about the course was asked at the end as an open-ended question. Questions of the tests were divided into five parts according to the goals.[ 10 ]

To determine whether there was an increase in knowledge, we compared the before and after quiz results using a paired t -test. ANOVA test was used to compare the results of all groups in the same examination. An open-ended anonymous survey was used to assess student satisfaction with the introduction to clinical pathology (ICP). To obtain facilitator feedback, we used an anonymous survey that contained a combination of open-ended and specifically graded questions.

Ultimately, we could get the results of three groups at two categories of knowledge and satisfaction. Knowledge-based MCQ test was completed by 63 students (19, 21, and 23, respectively) who were involved in the statistical analyses. Other volunteers were not included in the statistical analysis due to incompletion of before or after tests.

Maximum and minimum ages of participants were 20 and 27 years (22.3810 ± 1.33717), respectively. Gender distribution of groups was (male vs. female) 11 versus 8, 17 versus 4, and 11 versus 12, respectively, in Groups 1, 2, and 3. Mean pre- and post-test results in all participants were 9.1429 ± 2.9830 and 16.1270 ± 2.28947, respectively. The difference was statistically significant ( P < 0.05). Tukey's test showed that there was significant difference between the two groups.

There was a significant difference between pre- and post-tests of each group ( P < 0.05). It is shown in Figure 1 .

An external file that holds a picture, illustration, etc.
Object name is JEHP-6-84-g001.jpg

Result of knowledge-based multiple choice questions pre- and post-tests of different groups

Comparison of posttests of all groups showed a significant difference ( P < 0.05). Tukey's test showed that there was a significant difference between the two groups except Groups 2 and 3.

Satisfaction opinion of students about the course was evaluated by Likert scale as 1 for the best and 5 for the worst. The mode of data was 2 (good) and there was no 5. Percentage of each mark distribution was 41.3% (great), 44.4% (good), 12.7% (mediocre), and 1.6% (bad) as shown in Figure 2 .

An external file that holds a picture, illustration, etc.
Object name is JEHP-6-84-g002.jpg

Satisfaction opinion of participants in percentage

When participants were asked about the recommended time of this course, most of them (57.1%) thought the best time to be preinternship (clinical clerkship). Distribution of student's opinion is shown in Figure 3 .

An external file that holds a picture, illustration, etc.
Object name is JEHP-6-84-g003.jpg

Distribution of students’ opinion about the best timing for introduction to clinical pathology

Previous reports mentioned medical graduates are not capable of responding to related inquiries about laboratory tests. Also they cannot infer laboratory results in the most efficient approach. These problems are, because of insufficient compulsory knowledge about clinical pathology and all parts of laboratory medicine.[ 4 , 10 , 11 , 12 , 13 ] The main cause of this knowledge insufficiency is likely owed to the absence of official curriculum of education in clinical pathology field. Teaching of medical students and residents with focus on clinical education without attention to laboratory medicine as a separate core for can causes lack of complete ability to handle the patients paraclinic data in proper manner.[ 4 , 6 ]

An ideal course of teaching should finally bring trainees suitable knowledge and competency according to major goals of the curriculum.[ 14 ] Attaining the enough amount of knowledge can be easily determined by pre- and post-ICP quiz results.[ 3 ] Knowledge of the participants regardless of their level of education was improved through a 1.5 working day curriculum as shown by test results; however, it disclose a restricted extent of knowledge gained newly. Results revealed that a rather proper improvement of laboratory medicine knowledge can be absorbed by medical students in different years of their course using just a short period of a pure practical crash course of training. Unfortunately, no study has yet done to show that after graduation this knowledge can be useful in practice for better service. This issue possibly can be evaluated by following and comparing the practice of experiment and control group in the near future.

In fact, one of the main purposes of this course was to make the atmosphere of clinical laboratory in a general hospital known for medical students. This makes them a good opportunity to get familiar with clinical pathologists’, technologists’, and technicians’ domain. Such a mentioned opportunity in the current official curriculum is not available for them classically. In open-ended questionnaire, some of the participants wrote that getting familiar with clinical pathology laboratory and its personnel was an exciting experience for them. It can be predictable that having a good mental background about laboratory can help them to cooperate with this ward better when they are in real practice.

As a matter of fact, the main problem of performing such a course is locating the specified time in an already overloaded curriculum. Hence, we decided to run a brief package. Obviously, a 1.5-day ICP course is too short for teaching the whole recommended material;[ 4 , 10 ] however, that time was more than what all other students get during their entire education.

An interesting result came out of the study as we compared posttests of three groups that showed a significant difference in mean s. The difference was significant between the 5 th year students with other two groups. There was a difference between two other groups in favor of 4 th year students over 3 months but it was not significant. We assumed that, with more number of participants, the difference would be statistically significant. With regard to this part of results, we conclude that the more the students would have been trained in clinical medicine, the better they can get through laboratory techniques and knowledge. This would prepare us a good recommendation for choosing a good placement for timing of the course. We hypothesized that this course needs to be accomplished in clinical training phase near to internship; as we see that the more clinical knowledge the students had, the better they perform in laboratory and the faster and the stronger they learn.

We believe that for designing a better scheduled and more efficient period, such course or something similar should be used by other universities and should be implemented at various time periods during the official curriculum. Finally, the results should be obtained together and an ultimate recommendation should be derived.

Some advice from participants and some experiences from facilitators surely made us a better way to perform much better. Most students did not like prolonged lectures, otherwise they liked the concepts in practice, especially when they were with some fun and competition; for example, results of Gram-staining and counting on a peripheral blood smear. The tours around different parts of laboratory were well accepted by most of the participants. Involvement of laboratory staff would make some students more comfortable at laboratory, which was mentioned by some researchers.

Conclusively, we have designed a 1.5-day introductory course for learning clinical pathology for medical students. Through the ICP, 63 medical students visited general medical laboratories under the supervision of a clinical pathologist, watched and performed selected major tests of each branch laboratory medicine, and achieved general concept of techniques and science of clinical pathology through interaction with clinical pathologists, technologists, and technicians. A 20-MCQ pre- and post-test demonstrated a statistically significant increase in knowledge. Similar ICP formats could be implemented by other medical schools to successfully impart laboratory medicine concepts to medical students.

We highly recommend our colleagues in different institutions to have more studies trying to evaluate more models and patterns of teaching clinical pathology. It will also be curious to find how this course may have affected the later practice of participants in comparison with others who did not contribute.

Recommendation

The authors strongly suggest putting a course of clinical pathology at the phase of clinical clerkship like other practical rotations of clinical wards for students. It should include lectures for general information and protocols, round and rotations in different sections of a general laboratory for seeing and doing tests under direct supervision of a clinical pathologist, an introduction of quality control, laboratory informatics and economy, and finally interpretation of tests.

Financial support and sponsorship

This study was financially supported by the Quality Improvement in Clinical Education Research Centre, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.

Conflicts of interest

There are no conflicts of interest.

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A pathology report is a medical document written by a pathologist. A pathologist is a doctor who diagnoses disease by:

Explaining laboratory tests

Evaluating cells, tissues, and organs

The report gives a diagnosis based on the pathologist’s examination of a sample of tissue taken from the patient’s tumor. This sample of tissue, called a specimen, is removed during a biopsy. Learn about the various types of biopsies .

By looking at and testing the tumor tissue, the pathologist is able to find out:

If the tissue is noncancerous or cancerous. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A noncancerous, or benign tumor, means the tumor can grow but will not spread.

Other specific details about the tumor’s features. This information helps your doctor figure out the best treatment options.

Your doctor will receive these test results as they become available. It may take a few days to a few weeks to receive the full report. The timing depends on the testing needed. You are allowed by law to receive a copy of your pathology report. But you should expect the report to contain highly technical medical terms. Ask your doctor to explain the results in the pathology report and what they mean.

Parts of a pathology report

Different pathologists use different words to describe the same things. But most pathology reports include the sections discussed below.

Patient, doctor, and specimen

This section lists the following items:

Patient's name, birth date, and other personal information

An individual number assigned to the patient to help identify samples

The pathologist’s and oncologist’s contact information, as well as the laboratory where the sample was tested

Details about the specimen, including the type of biopsy or surgery and the type of tissue

Gross, or obvious, description

This section describes the tissue sample or tumor as seen with the naked eye. This includes the general color, weight, size, and consistency.

Microscopic description

This is the most technical section of the report. It describes what the cancer cells look like when viewed under a microscope. There are several factors noted in this section that affect diagnosis and treatment.

Whether the cancer is invasive. Tumors of many types may be noninvasive (in situ, which means “in place”) or invasive. Invasive tumors can spread to other parts of the body through a process called metastasis. Although noninvasive tumors do not spread, they may grow or develop into an invasive tumor in the future. For invasive tumors, it is important for the pathologist to note how much the tumor has grown into nearby healthy tissue.

Grade. Grade describes how the cancer cells look compared with healthy cells. In general, the pathologist is looking for differences in the size, shape, and staining features of the cells. A tumor with cells that look more like healthy cells is called "low grade" or "well differentiated." A tumor with cells that look less like healthy cells is called "high grade," "poorly differentiated," or "undifferentiated." In general, the lower the tumor’s grade, the better the prognosis. There are different methods used to assign a cancer grade for different types of cancers. Learn more about grading for specific cancer types .

How quickly cells are dividing, mitotic rate. The pathologist usually notes how many cells are dividing. This is called the mitotic rate. Tumors with fewer dividing cells are usually low grade.

Tumor margin. Another important factor is whether there are cancer cells at the margins, or edges, of the biopsy sample. A “positive” or “involved” margin means there are cancer cells in the margin. This means that it is likely that cancerous cells are still in the body.

Lymph nodes. The pathologist will also note whether the cancer has spread to nearby lymph nodes or other organs. Lymph nodes are tiny, bean-shaped organs that help fight disease. A lymph node is called “positive” when it contains cancer and “negative” when it does not. A tumor that has grown into blood or lymph vessels is more likely to have spread elsewhere. If the pathologist sees this, he or she will include it in the report.

Stage. Usually, the pathologist assigns a stage using the TNM system from the American Joint Committee on Cancer (AJCC) . This system uses 3 factors:

The size and location of the tumor (Tumor, T)

Whether cancer cells have spread to the lymph nodes located near the tumor (Node, N)

Whether the tumor has spread to other parts of the body (Metastasis, M).

Pathologic stage, along with the results of other diagnostic tests, helps determine the clinical stage of the cancer. This information guides a person’s treatment options. Learn more about the stages of cancer .

Results of other tests. The pathologist may perform special tests to identify specific genes, proteins, and other factors unique to the tumor. The results of these tests may be listed in a separate section or in a separate report. These additional tests are especially important for diagnosis because choosing the best treatment option may depend on these results.

This section provides the "bottom line." You may find this section at the beginning or the end of the report. If cancer has been diagnosed, the section may include the following:

The type of cancer, such as carcinoma or sarcoma

Tumor grade

Lymph node status

Margin status

Any other test results, such as whether the tumor has hormone receptors or other tumor markers

Synoptic report, or summary

When the tumor was removed, the pathologist will include a summary. This lists the most important results in a table. These are the items considered most important in determining a person’s treatment options and chance of recovery.

Comments section

Sometimes, a cancer may be difficult to diagnose or the development of the cancer is unclear. In these situations, the pathologist may use the comments section. Here, he or she can explain the issues and recommend other tests. This section may also include other information that can help the doctor plan treatment.

Sampling differences

Sometimes, the pathology report for a biopsy may be different from a later report for the entire tumor. This happens because the features of a tumor can sometimes vary in different areas. Your doctor will consider all of the reports to develop a treatment plan specific to you.

Questions to ask your health care team

To better understand what your pathology report means, consider asking your health care team the following questions:

What type of cancer do I have and where did it start?

How large is the tumor?

Is the cancer invasive or noninvasive?

How fast are the cancer cells growing?

What is the grade of the cancer? What does this mean?

Was the entire cancer removed? Are there signs of cancer cells at the edges of the sample?

Are there cancer cells in the lymph vessels or blood vessels?

What is the stage of the cancer? What does this mean?

Does the pathology report specify the tumor characteristics clearly? Should we get another pathologist’s opinion?

Do any tests need to be done again on another sample or in another laboratory?

Getting a second opinion

It may be helpful to talk with more than one doctor about your diagnosis and treatment plan. This is called a second opinion. It is important to get a copy of the pathology report and any other medical records.

If you choose to get a second opinion, you will want to share these with the second doctor. Some doctors work closely with their own pathologists and may want their own pathologist's opinion too. Other tests can also be done on the biopsy sample if needed. The tissue sample is kept for a long time and is available upon request. Learn more about getting a second opinion .

Related Resources

Spotlight On: Pathologists

When the Doctor Says Cancer

More Information

College of American Pathologists: How to Read Your Pathology Report

National Cancer Institute: Pathology Reports

Navigating Cancer Care

More in this section.

Timely. Trusted. Compassionate.

Comprehensive information for people with cancer, families, and caregivers, from the American Society of Clinical Oncology (ASCO), the voice of the world's oncology professionals.

Find a Cancer Doctor

Dana-Farber Cancer Institute

Understanding Your Pathology Report

Medically reviewed by Stuart J. Schnitt, MD , and George L. Mutter, MD

A pathology report describes the findings in a tissue sample (biopsy or excision), which are always submitted to a pathologist after being removed from a patient. The tissue is sliced very thin and stained on a glass slide for a pathologist to examine under a microscope to determine if there is disease present, and if so, what kind.

“Pathology is the hub around which oncology rotates; it’s the center of patient management,” says Stuart J. Schnitt, MD , a pathologist at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC).

Oftentimes, the terminology of these reports can be difficult for patients to understand. In particular, be cautious about complicated abbreviations you do not understand, as their meaning may change with context. Google searches also often produce erroneous or misleading interpretations.

Your doctor will explain the results of your pathology report to you and can answer any questions you have.

What are the different components of a pathology report?

Patient and specimen identifiers

This information includes the patient’s name, birth date, and other personal information. It also details clinical history, the type of biopsy or procedure, and the type of tissue being analyzed.

Procedures often generate multiple specimens that are submitted together to the pathologist in separate containers. In these cases, a letter or number is assigned to identify these different samples submitted. The individual container labels are carefully recorded, including any specific designation (such as “cervical biopsy at 3 o’clock position”) that allows the pathologist to know where it is from. 

Gross description

“Gross” refers to what is apparent to the naked eye. This section is a detailed description of what the tissue looks like, including the size and appearance of the sample on the outside and cut surface. Abbreviations are especially common in this section; examples include “R” for right and “ESS” for entire specimen submitted. An index, or key, of samples prepared by the pathologist for microscopy is also included.

Procedures that generate multiple specimens are labeled accordingly so the clinician knows where each sample came from. “For example, with a colon biopsy, if only one specimen of several has cancer, the clinician needs to be able to relate that to an anatomical location in the patient,” explains DF/BWCC pathologist George L. Mutter, MD .

In the case of tumors, or localized lesions excised with adjacent tissues attached, visual inspection and measurement to nearest structures — like margins — may be included. These measurements as recorded in the Gross Description are only preliminary, as the pathologist does not yet have the definitive microscopic preparations (slides) required to verify where the actual tumor cells are in the specimen.

The final assessment of tumor extent and margins appears in the Diagnosis section, and may be a bit different from what was suspected grossly.     

This is the “take-home message”: the most important section of a pathology report, according to Schnitt. It can be found at the beginning or the end of the report and serves as a concise summary of information from the entire pathology report. It is based on the gross description, microscopic examination, and sometimes special biomarker studies. 

It is important to note that each specimen part has its own separate diagnosis. “Read the diagnosis for all parts,” advises Schnitt. “Patients may see in the report that a margin is positive but may not realize that an additional specimen taken from the same margin is negative — which means that the final margin is negative, not positive.”

Reports that include cancer in the specimen will classify the specific tumor type and any additional information, such as tumor distribution (stage), biomarker status, and molecular findings that may be useful in management. Some tumors will be assigned a grade — often numbered from 1 to 3, corresponding to well, moderately, or poorly differentiated — that describes how abnormal the cells look under the microscope. A higher number means the tumor cells are more abnormal.

Results of specialized marker studies are not typically ready at the time the pathology report is initially issued and are often reported separately.   

The pathologist will note if the cancer has spread to nearby lymph nodes or organs if those are submitted for examination. If a lymph node or surgical margin contains cancer, it is labeled as “positive,” and if it does not, it is “negative.”  

A recent addition to some pathology reports is “synoptic reporting.” This is an additional, standardized summary of cancer type and stage for surgical resection specimens. The content and format structure, including coded abbreviations, is customized to each tumor type by agreement amongst pathologists worldwide.  

Mutter advises readers to “be prepared: these are medical records that are complicated, factual, the language and vocabulary may be very unfamiliar.”

Talk to your doctor if you have any questions about your pathology report. “Don’t take your report to the internet: your doctor is the best person to help you interpret your report,” Mutter says.

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Pathology Lab Report

  • A standard pathology report typically includes basic patient details such as name, identification number, and relevant medical history, as well as information on the type of specimen, the source of the specimen, and any relevant details about the collection and handling of the specimen.
  • The report also includes the name and degree of the referring doctor and the signature of the lab in charge and the pathologist in charge.
  • It also includes the TAT (Turn Around Time) information and registration number.
  • The test results are presented in a standardized template, with the layout and format depending on the nature of the test being conducted.
  • It is common to see results presented in tables, graphs, or images, depending on the type of test.
  • It is the latest trend to provide QR-coded lab reports, which helps in verifying the authenticity of the report and increasing the confidence of the patient and the doctor in the diagnostic process.
  • This can help to ensure that the treatment is performed efficiently and accurately.

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Qr coded lab reports.

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Pathology Lab Report Format

A pathology lab report typically includes the following sections:

1. Patient Information

  • This section includes the patient's name, identification number, age, sex, and relevant medical history.

2. Specimen Information

  • This section includes the type of specimen, the source of the specimen, and any relevant details about the collection and handling of the specimen.

3. Clinical Information

  • This section includes information provided by the ordering physician, such as the reason for the test and any relevant clinical findings.

4. Laboratory Results

  • This section includes the results of the laboratory tests performed on the specimen, including any relevant measurements or observations.

5. Interpretation

  • This section includes the pathologist's interpretation of the laboratory results and their relationship to the patient's clinical condition.

6. Conclusion

  • This section includes a summary of the main findings and any recommendations for further testing or treatment.

7. Signature

  • This section includes the signature of the pathologist who reviewed and interpreted the results.

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Pathology Lab Report Example

Here is an example of a pathology lab report

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Pathology Lab Report Types

There are several different types of pathology reports, depending on the type of specimen and the tests being performed. Some scientific pathology report common types include:

CSF Examination Example, Format, Sample and Template - Drlogy Lab Reports

Panel Report Formats

What are panels.

The panel typically refers to a group of laboratory tests that are ordered and conducted together to gather comprehensive information about a particular medical condition or to assess multiple aspects of a patient's health.

For example, a lipid panel is a group of tests that measure different types of cholesterol and triglycerides in the blood, providing insight into a person's cardiovascular health. Similarly, a metabolic panel includes tests to evaluate kidney function, electrolyte balance, and blood sugar levels.

Here is an example of a Panel Report Formats.

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Hematology Test Report Formats

What is hematology test report.

A hematology test report is a document generated by a laboratory as a result of various tests performed on a blood sample. These tests are collectively known as hematology tests and focus on the analysis of blood components, including red blood cells, white blood cells, and platelets, as well as other parameters like hemoglobin levels, hematocrit, and more.

Here is an example of a Hematology Test Report Formats.

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Biochemistry Test Report Formats

What is biochemistry test report.

A biochemistry test report, also known as a clinical chemistry report, is a document generated by a medical laboratory after conducting a battery of tests to analyze various chemical components present in a person's blood, urine, or other body fluids.

Here is an example of a Biochemistry Test Report Formats.

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Clinical Pathology Test Report Formats

What is clinical pathology test.

A Clinical Pathology Test Report is a document generated by a clinical pathology laboratory that provides the results of various laboratory tests conducted on a patient's samples, such as blood, urine, or other bodily fluids.

Here is an example of a Clinical Pathology Test Report Formats.

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Histopathology Test Report Formats

What is histopathology test report.

A histopathology test report is a document generated by a pathology laboratory that provides detailed information about the microscopic examination of tissue samples removed from a patient's body.

Here is an example of a Histopathology Test Report Formats.

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Cytopathology Test Report Formats

What is cytopathology test report.

Cytopathology is a branch of pathology that deals with the study of cells, particularly those that are shed or extracted from various parts of the body. A cytopathology test report provides information about the microscopic examination of cells obtained from body fluids, lesions, or tissues.

Here is an example of a Cytopathology Test Report Formats.

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Microbiology Test Report Formats

What is microbiology test report.

Microbiology tests are laboratory procedures performed to study microorganisms such as bacteria, viruses, fungi, and parasites. These tests are conducted to identify, characterize, and understand the properties of microorganisms and their interactions with human health and the environment.

Here is an example of a Microbiology Test Report Formats.

Microbiology Report Example, Format, Sample and Template - Drlogy Lab Reports

Serology and Immunology Test Report Formats

What is serology and immunology test report.

A serology and immunology test report is a document that provides the results of laboratory tests related to the study of antibodies and immune responses in the body.

Here is an example of a Serology and Immunology Test Report Formats.

Immunopathology Report Example, Format, Sample and Template - Drlogy Lab Reports

Endocrinology Test Report Formats

What is endocrinology test report.

An endocrinology test report is a document that presents the results of various medical tests related to the endocrine system.

Here is an example of a Endocrinology Test Report Formats.

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Imaging & Radiology Report Formats

What is imaging & radiology report.

An Imaging & Radiology report is a document generated by a radiologist or medical imaging specialist after analyzing the results of various diagnostic imaging tests. These reports provide detailed information about the findings from imaging procedures such as X-rays, CT scans, MRIs, ultrasounds, and more.

Radiology Report Example, Format, Sample and Template - Drlogy Lab Reports

Pathology Lab Report Format in Word

  • Instead of using Pathology Lab Report Format in Word, You should use the online pathology lab report format.
  • The report would be written in paragraphs and may include headings, tables, and images to present the information in a clear and easy-to-understand format.

Here is an example of how such information may be presented in a word format:

Patient Information:

  • Name: Yash Patel
  • Date of Birth: 01/01/1976
  • Medical Record Number: 123456
  • Specimen Information:
  • Type of Specimen: Skin biopsy
  • Date and time of collection: 01/01/2021 12:00 PM
  • Test Requested: Biopsy of suspicious skin lesion
  • Results: Microscopic examination revealed a proliferation of atypical cells consistent with malignant melanoma. Immunohistochemical stains were positive for S-100 and Melan-A.
  • Interpretation: The findings are consistent with a diagnosis of malignant melanoma, a potentially deadly form of skin cancer. The patient should be referred to a dermatologist or a surgical oncologist for further management.

Pathology Lab Report Format in Excel

A pathology report in excel format would typically include the following information organized in columns and rows

Here is an example of how such information may be organized in excel:

It's worth noting that the example above is a simple representation of how the data could be organized, and the actual format of a pathology report in excel may vary depending on the lab, the specific test, and the data being collected.

But Instead of Pathology Lab Report Format in Excel & Word or pathology lab report pdf, you should use the Online pathology lab report format. Here are some benefits of that.

Pathology Lab Report Benefits

There are several benefits to having online pathology reports, including

  • Convenience : Online pathology reports can be accessed from anywhere and at any time, making it easier for healthcare professionals and patients to access and review test results.
  • Faster turnaround time : Online pathology reports can be generated and shared more quickly than traditional paper reports, which can lead to faster diagnosis and treatment.
  • Improved communication : Online pathology reports can be shared easily among healthcare professionals, allowing for better coordination of care.
  • Reduced errors : Online pathology reports can be designed to include built-in quality control checks, which can help reduce the risk of errors.
  • Reduced costs : Electronic pathology reports can be less expensive to produce and distribute than paper reports, which can lead to cost savings for healthcare organizations.
  • Better data management : Online pathology reports can be stored and organized electronically, which makes it easier to track and analyze patient data over time.
  • Easy to share with patients : patients can access their own reports, which can lead to better patient engagement and education about their health.
  • Improved data security : online pathology reports can be more secure than paper reports, as they can be password-protected and stored on secure servers.

Overall, the use of online pathology reports can improve the efficiency, accuracy, and communication of pathology results and enhance the quality of patient care.

Pathology Software Lab Report FAQ

What is a lab report in the pathology lab.

  • A lab report in a pathology laboratory is a document that describes the results of tests and examinations performed on samples of tissue, blood, or other bodily fluids.
  • The report typically includes information about the patient, such as their demographic information and relevant medical history, as well as the results of the tests or examinations that were performed.
  • This information can include the results of microscopy, histology, and various molecular assays.
  • The report should also include a summary of the findings, a diagnosis if one is made, and any relevant clinical information or recommendations.
  • The purpose of a lab report in a pathology lab is to provide accurate and detailed information about the patient's condition to the physician or other healthcare provider, who will use this information to make a diagnosis and plan the appropriate treatment.

What are the 7 sections of a lab report?

A typical lab report includes the following sections:

Please note that, depending on the experiment, the professor may require additional or fewer sections, and may also change the names of the sections.

What is the most important part of a lab report?

  • The most important part of a lab report is the discussion or interpretation section, where the results of the experiment are interpreted, analyzed, and explained in relation to the research question or hypothesis.
  • This is where the results are explained in detail and their significance is discussed.
  • The discussion should clearly link the results to the hypothesis being tested, should explain the patterns and trends in the data, and should provide an explanation of any unexpected results.
  • In addition, the discussion should also be the place where the researcher highlights the limitations and any sources of error in the experiment.
  • It is also the place where the researcher can make recommendations for future research.
  • It is also important that all sections of the lab report are well-written, clear, and concise.
  • The introduction should provide enough background and context, the methods should be clearly described and the results should be accurately presented and clearly discussed.
  • The conclusion should summarize the main findings and link them back to the research question or hypothesis.

Overall, the use of QR codes in lab software can help increase efficiency, improve patient care, and reduce errors in laboratory environments by providing quick and secure access to information.

What is a pathology report?

  • A pathology report is a document that describes the findings of a pathological examination of a tissue sample.
  • It is usually prepared by a pathologist, a medical doctor who specializes in diagnosing diseases by examining tissue samples under a microscope.
  • The report typically includes information about the type of tissue sampled, any abnormal cells or structures present, and a diagnosis or a list of possible diagnoses.
  • Pathology reports are important for guiding treatment decisions and monitoring the progression of a disease.

What is on a pathology report?

A pathology report typically includes several key pieces of information, including

It is important to note that the content of the pathology report may vary depending on the type of tissue sample and the reason for the examination. The report is usually signed by the pathologist who performed the examination.

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Interpretation of Pathology Report (ppt)

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Good communication and transfer of information between the pathologist and the oncologist.

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An accurate pathological assessment of core biopsies or resection specimens provides important information on the major features of breast cancer, such as tumor type, size, biological characteristics, lymph node status, stage, and extent of residual disease in case of neoadjuvant chemotherapy, and is crucial for ensuring an appropriate patient management. In the era of molecular medicine and tailored therapies, the pathologic assessment of primary tumor still represents an essential guide for oncologists and surgeons to inform the choice of the best treatment options available for individual patients. Therefore, the management of patients with breast cancer detected through imaging or symptomatic presentation depends heavily on the quality of the pathology service.

Jon Plumley

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Abstract Pathology reporting is evolving from a traditional narrative report to a more structured synoptic report. Narrative reporting can cause misinterpretation due to lack of information and structure. In this systematic review, we evaluate the impact of synoptic reporting on completeness of pathology reports and quality of pathology evaluation for solid tumours. Pubmed, Embase and Cochrane databases were systematically searched to identify studies describing the effect of synoptic reporting implementation on completeness of reporting and quality of pathology evaluation of solid malignant tumours. Thirty-three studies met the inclusion criteria. All studies, except one, reported an increased overall completeness of pathology reports after introduction of synoptic reporting (SR). Most frequently studied cancers were breast (n = 9) and colorectal cancer (n = 16). For breast cancer, narrative reports adequately described ‘tumour type’ and ‘nodal status’. Synoptic reporting resulted in improved description of ‘resection margins’, ‘DCIS size’, ‘location’ and ‘presence of calcifications’. For colorectal cancer, narrative reports adequately reported ‘tumour type’, ‘invasion depth’, ‘lymph node counts’ and ‘nodal status’. Synoptic reporting resulted in increased reporting of ‘circumferential margin’, ‘resection margin’, ‘perineural invasion’ and ‘lymphovascular invasion’. In addition, increased numbers of reported lymph nodes were found in synoptic reports. Narrative reports of other cancer types described the traditional parameters adequately, whereas for ‘resection margins’ and '(lympho)vascular/perineural invasion’, implementation of synoptic reporting was necessary. Synoptic reporting results in improved reporting of clinical relevant data. Demonstration of clinical impact of this improved method of pathology reporting is required for successful introduction and implementation in daily pathology practice.

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Table of Contents

Handbook for writing lab reports in biology.

  • Need Help? Ask a Librarian This link opens in a new window
  • A. Strategy for writing your lab report
  • B. Finding references for a lab report
  • C. Writing style
  • D. Components of a lab report
  • E. Sample lab report
  • F. Acknowledgements
  • G. Bibliography

Last revised 9/20/15

  • Lab Report Handbook 09.20.15

A.   Strategy for writing your lab report

1.     read the directions.

Seriously, don’t skip this step.  If you read the directions right away, you are less likely to leave out mandatory parts of the lab report, you will be able to ask your instructor for clarification if necessary, and you can get set aside an amount of prep time appropriate to the scope of the project.  Teaching assistants may also be able to provide guidance.

When reading the directions, be sure to make note of the due date(s).  Depending on the assignment, there may be a single due date for a complete lab report or multiple due dates for different lab report components and/or drafts.

2.     Find and read relevant literature

Your instructor has most likely provided you with information about the number and/or types of sources that should be cited in your lab report.  For more information about finding the references used in a lab report, see Section B below.

3.     Outline your lab report

Start by listing the required sections noted in the directions for the assignment.  For the discussion section, also list the required topics (sources of error, future studies, etc.).  Next, list the topics or even topic sentences for paragraphs in each section; in the results section be sure to note the locations for your figures and/or tables.  If you haven’t created your figures and tables yet, sketch an outline of how they will be set up (axis labels for figures, column and row headings for tables).

4.     Start writing

Different writing guides will suggest different sections to start with – our suggestion is that you start with whichever section, in your opinion, will be easiest.  As you write, focus on the big picture for each section before focusing on detail; that is, set up a logical flow of paragraphs before worrying too much about the specific wording in the paragraphs. For more information about writing style, see Section C .  For detailed descriptions of the standard components of a lab report, see Section D . A sample lab report is provided in Section E .

5.     Review & revise!

Finish your lab report at least a few days early whenever possible.  This will allow time for you to set it aside and review it with fresh eyes, and to hand it to friends and classmates so they can check for errors.  Confirm that all of the required components listed in your directions are addressed in your lab report! 

B.   Finding references for a lab report

                   

Primary vs. secondary references

In most, if not all, of your lab reports you will have to put your work in the context of previous research – that is, you will have to discuss your work as it relates to research described in primary references.  A primary reference is a peer-reviewed, original description of a research study.  Typically this is a journal article describing original research.  Since a several types of article are published in research journals (e.g. review articles or commentaries in addition to original research), you cannot assume that all articles published in journals will qualify as primary references.  Since scientists must be able to reproduce each other’s work, a primary reference will always include a description of the research methods.  Sometimes it will be obvious from an abstract that an article contains a description of original research (the research methods may be summarized); at other times you will not realize until you look at the full text if you have a primary reference or a secondary reference.

A secondary reference can also be very valuable in preparing your lab report, even though it will not count as one of your required primary references.  Many journals publish review articles, for example, that give you an overview of a specific topic.  The authors of a review article might summarize the results of a hundred or more individual studies in a given research area, while evaluating the merits and drawbacks of the different studies and putting the findings into context.  Review articles can be invaluable when trying to learn about an unfamiliar area of research.  Other examples of secondary references include textbooks, commentaries and magazine articles. A lab report will typically require use of at least one secondary reference in the Introduction.

Since it can take some time to find, read and decide if you can use references, it is critical that these sources be identified well in advance of the due date for your lab report.

Search resources

A simple google search is unlikely to provide you with the references that you will need as you prepare your lab report.  Your instructor may direct you to specific search resources or databases, but the two search resources most commonly used to find journal articles for biology courses are Google Scholar ( http://scholar.google.com ) and, for biomedical studies, PubMed ( http://www.ncbi.nlm.nih.gov/pubmed ).  Effective use of these resources will require some judicious use of search terms.  If you feel that your search terms are not yielding the types of articles that you are looking for, consult a research librarian, your instructor or your teaching assistant for assistance.

The biology libguide ( http://mcla.libguides.com/biology ) hosted by Freel Library contains a variety of search resources, including links to the online collections of journals housed in the Academic Search Premier and JSTOR databases.  If you do your literature search through one of the links on the libguide (e.g. the Google Scholar link on the databases page http://library.mcla.edu/az.php ), the articles freely available through the MCLA databases should appear as free full text in your search.

Full-text journal articles

If you have a lot of relevant articles at your disposal, you can limit the articles retrieved in a PubMed search to those with free full text.  In Google Scholar, free articles are usually indicated with links on the right-hand side of the screen.  In most cases, however, the articles most relevant to your work will not be freely available.  You have several options for obtaining these articles.

  • Use interlibrary loan .  An option, though not the quickest option.  See a reference librarian for assistance with this.
  • Email the corresponding author.  This is a good option, though you might need to do some detective work to find the author’s email address.  Sometimes it is listed with the abstract, otherwise you can do a search for the name of the corresponding author (if noted) or the last author (the boss) combined with the institution (university or company at which they did the work), and you should be able to find an up-to-date email address.  In your email, politely and professionally ask for a PDF copy of the article.  Be sure to note the title, year and journal for the article.  In most cases you will receive a reply within a few days.
  • If you don’t have a few days and the corresponding author is not responding, see if Williams College ( http://library.williams.edu/ ) has the article.  If so, get someone to drive you there – there are public access computers at Sawyer Library (the main library) and Schow Library (the science library) at which you can access the college’s journal articles.  You will not be able to save the PDF, unfortunately, but you can purchase a print card and print the article(s) there.
  • Purchase the article.   You will not even consider this option, because it would mean you procrastinated to the point that none of the other options are possible.  You would never do that, right??

Websites of suitable authority

Depending on the instructor and the assignment, you may or may not be permitted to use websites as references.  (Note that journal articles that are available in print but can be accessed online are considered to be journal articles, not websites, for reference and citation purposes).  If you do intend to use a website as a reference, take care to evaluate it to determine if it is a suitable source.  Is the website published by an institution or individual that would be widely accepted as a reliable and knowledgeable authority?  If you have any doubt, check with your instructor.  When obtaining information from websites, be sure to note the information that you will need for the reference list in your lab report (author, title, revision date or accession date, website; see an APA style guide, e.g. https://www.library.cornell.edu/research/citation/apa ).

Other sources

You can typically cite your textbook and/or lab manual as books in your lab report; other books may also be used for background information.  These will not qualify as primary references.  Articles from newspapers and magazines are not suitable resources for a lab report.

C.   Writing style

A complete review of suitable writing style will not be provided here.  Resources that can help you to improve your writing style can be found under the “Writing Resources” tab of the Biology LibGuide ( http://mcla.libguides.com/biology ).  The following are some of the issues and errors specifically encountered with lab reports in biology:

Watch your language!

Scientific writing is concise, precise and professional.  Words should be chosen with care to avoid vagueness (“we added 100 ml of water” rather than “we added some water”) and unnecessary detail (“the subjects ran up and down a flight of stairs for 5 minutes” rather than “the subjects, who were wearing workout clothes, were timed by an observer with a black electronic stopwatch as they ran up and down the stairs between the first and second floors in the science building from 11:00 to 11:05 am, for a total of 5 minutes”). 

Contractions are typically avoided in scientific writing (“the fruit flies did not wake up from anesthesia” rather than “the fruit flies didn’t wake up from anesthesia”). 

To quote or to summarize?

Quotes are not used in lab reports, and minor rewording to “paraphrase” is also inappropriate for scientific writing.  For the most part you will be summarizing the key ideas in an article.  If you paste a summary sentence from an abstract or a textbook then try to reword it, you will undoubtedly run into problems – in addition, the key point that the article’s authors were trying to make may not be the same point that you are trying to make.  It is best even when making notes to summarize key points (citing the source) rather than copying sections of text.  For more information, see the sections “Quoting, Paraphrasing and Summarizing” and “Taking Notes” in the “Citing and Documenting Sources” tab of the Biology Libguide ( http://mcla.libguides.com/biology ).

Present vs. past tense

Verb tense will vary in a lab report.  The present tense is used for descriptions of information that is widely accepted as true (or at least can be backed up by a published, peer-reviewed reference).  Information that could be found in a textbook will always be written in the present tense (“yeasts are single-celled organisms”). The findings of published research studies are usually written in the present tense (“fruit flies are attracted to rotting bananas”), though a scientist’s actions in a published study are written in the past tense, for example: “Smith et al. (1978) observed that fruit flies were [or are, your choice] attracted to rotting bananas.” 

The description of your own study, since it has not been published and accepted in the field, will be written in the past tense (“carbon dioxide accumulation was higher for plants kept in the dark,” “the bacteria were Gram-positive”).

Passive vs. active voice

There is no strong consensus in the field of Biology with regards to use of the active voice (“I did”) or the passive voice (“it was done”).  Find out from your instructor if he or she will allow the active voice.  If the active voice is acceptable, you may use “I” or “we” as the subject in sentences that describe your actions, though that should still be kept to a minimum. If the instructor prefers exclusive use of the passive voice, there should be no use of “I” or “we” in the document. 

Frequently mis-used words

Significant.

Significant has a very specific meaning in biology.  If you say that there were significantly more brine shrimp on the light side of the tank, or that the plants kept in the dark were significantly smaller, that means you did a statistical analysis of your data and found a difference with a p value <0.05.  Do not use the word “significant” in any other way in your lab report.

Data is a plural (singular: datum).  “Data were collected after 12, 24 and 48 hours.” “The data from this experiment support our hypothesis.”

Affect vs. effect

Spell-check and grammar-check will not help you here – you must think consider your word choice every time you use “affect” or “effect” in your lab report.  Affect is a verb (A is for Action); “the loud noises affected the behavior of the fish.”  Effect is a noun; “different effects were observed with different chemicals.”  Effect may, in rare cases, be used as a verb (= to bring about), but unless you are quite comfortable with this use, stick to the previous rules!

Support vs. prove

Biologists must be open to the possibility that ideas about how living things function will change based on new data.  We therefore hate the word “prove,” since “prove” suggests that an answer is final.  A single experiment doesn’t prove anything (particularly not a single, small-scale experiment conducted in a 3-hour lab block).  Your data don’t prove or disprove your hypothesis – they can only support or not support your hypothesis.

Writing numbers and units

Unless followed by a scientific unit, numbers under twenty should be spelled out in the text (fifteen leeches, 4°C, nine plants, 5 mL).  If a number starts a sentence, it must always be written out, even if it is followed by a unit (sometimes it is easier to rearrange your sentence than to write out your number!) 

The abbreviations for scientific units should be used; these need not (and should not) be spelled out at any point in the text.  Use the degree symbol (°) rather than the word degree when describing temperatures – to find this, and to find the “±” for standard deviation and the “µ” for µL, click on the “Insert” tab in Word.  Select “Symbol,” and then scroll through the options till you find the symbol that you need.  Double-click on it or select “insert” from the bottom.

Abbreviations

Some abbreviations are sufficiently standard that you do not need to define them in your lab report (DNA, RNA, mRNA).  Other abbreviations must be defined at first use.  (“The primary antibodies were dissolved in phosphate-buffered saline (PBS) at a ratio of 1:100.  The secondary antibodies were dissolved in PBS at a ratio of 1:1000”).  Minimize the use of abbreviations in your lab report – you are typically not restricted to a maximum number of words in a lab report, so make it as easy as possible for your reader to understand your text.

Chemical names (NaCl, H + ) do not need to be defined, nor do abbreviations for scientific units (mm, µL, min). 

Specialized terminology

If you use specialized terms in your lab report that would not be familiar to most of your classmates, define or explain them in the text.  (“The reduction in herbivory could be due to high levels of phenols, which are defensive chemicals made by plants.”)

Scientific names

Remember that genus and species names must always be written in italics ( Hirudo medicinalis ).  After the first use of the genus name, it can be abbreviated ( H. medicinalis).  The species component of the name must start with a lower-case letter – note that auto-correct might try to make it a capital letter.  When specifically referring to a kingdom, phylum, class, order or family for an organism, the name must be capitalized (“the medicinal leech Hirudo medicinalis belongs to phylum Annelida”), but if you are not using the official name, do not capitalize (“leeches are annelid worms”).

D.   Components of a lab report

The following are the standard components used to describe a research study – you will find them in both lab reports and journal articles, though formats may vary somewhat.

1.     Title 

The title will be a short, informative description of the experimental purpose, research question or research findings.

Sample titles:

     Rate of lactose digestion at different temperatures.

     Dinoflagellate responses to increases in temperature.

     Fruit flies are more attracted to apple cider than to apple juice.

2.     Author

For a lab report you, the writer, are the author.  For group submissions there may be multiple authors.  Your lab partners should also be acknowledged, if they contributed to the research. You can list lab partner(s) below or next to the author name(s).

For some assignments (e.g. drafts submitted for peer review), anonymous submissions will be required.  Do not list the author or lab partners on these drafts!  

Sample author list:  

Author:  Anne Goodwin

Lab Partners: Justin Golub, Sarah Herrick, Jerry Smosky

3.     Abstract

The abstract is a concise summary of the research study.  This section should always be written last, so that you have the key points from each of the other sections to draw from.  Include a sentence (at most, two sentences) addressing each of the following:

  • Introduction.  Provide context for your study, but don’t cite references.
  • Research question or the purpose of the experiment.  Be very clear about why the study was done.
  • Experimental design.  Provide an overview of how the study was done without going into great detail.
  • Results.  Summarize the main findings.
  • Conclusions.  State the take-home message from your study, based on the findings.

Sample abstracts:

The salt content in water that plants take up can potentially affect plants growth and development in different ways. In this experiment, our group watered Brassica rapa plants with a 2% salt water solution from the time of planting to see what its effects would be on their growth and development. We planted eight seeds to be treated with the salt water and eight seeds that would be the control in normal tap water. There were five dependent variables that were recorded after four weeks of growth: stem height, total number of leaves, number of seed pods, number of flowers, and average leaf length per plant. Our results showed that the salt solution affected the total number of leaves that grew on each plant. These result showed that the plants were not as adversely affected by the salt solution as we had thought they would be.

In this lab, Drosophila melanogaster was used as a model to study development because of the wide range of research that has already been performed on this organism. In this experiment dissected and whole individuals were observed to examine physical characteristics including sex, larval body forms, imaginal discs, eggs, and polytene chromosomes. During the experiment we anesthetized flies and examined their body shapes and we dissected individuals to remove the imaginary discs and the polytene chromosomes within the salivary glands. Additionally, we observed larval forms and normal and dechorionated eggs. Based on the results of the lab we were able to recognize and understand the importance of the various life stages of Drosophila melanogaster as well as understanding the purpose of the structures involved in development.

4.     Introduction

The purpose of the introduction is to explain to the reader why it was important that you did your research study.  The introduction will contain the following information:

  • Background about the research topic.  This information will be organized from general (information about your system or test organism) to specific (importance of your particular research question), and all information provided should directly serve to emphasize the relevance of your study.  General information will typically be obtained from secondary references such as textbooks and review articles.  Primary references may or may not be used to introduce your research question, depending on the primary references at your disposal and on the instructor’s directions.  Background information from secondary sources will be written in the present tense, past or present tense may be used in descriptions of research studies from primary references, as noted above. 

The background portion of the introduction is typically two paragraphs in length. Citations must be provided for information that is not common knowledge; see the references section below for instructions for citing references. 

  • Research question or purpose of experiment.  This will typically be a single sentence, phrased as a statement or question.

Sample experimental purposes or research questions: 

The purpose of this laboratory activity was to determine the rate of lactose digestion by lactase. 

This led to the following research question: are fruit flies attracted to sugar?

We therefore wondered if temperature would change the behavior of leeches.

  • Hypothesis (if appropriate).  If the experiment addressed a research question, include the hypothesis at the end of the introduction.  The hypothesis should be written as a statement expressing a prediction.

Sample hypotheses:

I hypothesized that leeches would be attracted to warm water.

The hypothesis was that fruit flies would be attracted to a solution containing sugar.

We predicted that heart rate would increase with exercise.

If fruit flies are attracted to sweet things, then fruit flies will be caught in greater numbers by a solution containing sugar.

Sample introduction:

Dinoflagellates are single-celled organisms that life in freshwater and saltwater environments. Some species live in symbiosis in corals, including the species Symbiodinium adriaticum , which is what our experiment is using. The experiment we are performing falls under the question of “How do changing ocean conditions affect dinoflagellates?” The oceans of the world are undergoing changes such as salt content and the increasing depths of the ocean from the melting polar ice caps. How will these factors affect marine life, including symbiotic dinoflagellates in corals? Costa et al studied the effects of seasonal dynamics in the coastal reefs off Picãozinho in Northeast Brazil and their effects on cell density and photosynthetic pigment contents of the zooxanthellae hosted by the dinoflagellate species Montastrea cavernosa (Costa et al, 2004). They found that cell numbers were greater in the rainy season, photosynthetic pigments were greater in the dry season, and that both parameters drastically dropped in amount during heavy rains. They speculated that this pattern is because of the rain cycles and how they affected the water clarity and the seasonal physiological condition of the cells (Costa et al , 2004).

Perhaps, when the water is clouded and murky, the dinoflagellates could not absorb enough light of their preferred spectrum to carry out photosynthesis, and therefore could not survive. Our group decided to test a similar aspect of water quality. We wanted to see if the color of the water, rather than the turbidity of the water, had any effect on dinoflagellate survival. Symbiodinium adriaticum have brown photosynthetic pigments, so we decided to color the water in the experimental flasks brown using food dye. This way, the water stayed clear, but it was a different color for light to pass through. In a natural setting, a change in water color could be due to an algae bloom or if a chemical got into the water that caused it to change color. An example of change in water color but not clarity in a contained ecosystem would be if you were treating a household aquarium with medicine containing Malachite Green to treat a fish parasite infection. It causes the water to turn a bright blue color, but doesn’t affect the clarity of the tank water. Our group hypothesized that water colored brown by food dye will have a negative effect on the growth of the S. adriaticum populations in the three test flasks.

5.     Methods

The methods section is a critical component of a lab report or a published research study, as scientists must be able to reproduce each other’s work.  Your methods section should be written in such a way that a classmate could reproduce your experiment based on the information provided.  The methods section must be written in the past tense, using paragraphs rather than a list format.  A separate list of materials is not included in biology lab reports; key materials are simply mentioned as they are used in the experimental setup and measurement procedures.  Be sure to include the following information in the methods section:

  • Experimental setup.   Note which research organisms were used, if appropriate, and how those research organisms were obtained.  Describe your experimental procedure, citing the lab manual if appropriate.  Include all information needed to reproduce the setup and interpret the results, but do not provide excessive detail – that is, information not needed for reproducing the experiment or interpreting the results (for example, it is not necessary to include the fact that cups were labeled 1-6, that volumes were measured using a graduated cylinder or that temperature was measured at 1:56 pm – someone could reproduce your experiment without any of this knowledge).
  • Human studies (if appropriate): If you used humans as the subjects in your experiment, explain how the subjects were recruited and note the rules used to exclude subjects from your study.  Provide a subject characteristics table containing the ages, sexes and any other relevant information about your subjects.  Do not include the subject names here or anywhere else in your lab report.  Do note that the experimental protocol received IRB approval.
  • Data collection.   Note how observations were made, how measurements were done and any other information relevant to how the data were collected.
  • Statistical analysis.   Note which statistical tests were used, and name the statistical software used to conduct the statistical tests.

Sample methods:

We observed and collected data on populations of shaving brush algae in Little Lameshur Bay on the island of Saint John in the United States Virgin Islands. We counted algae over a one-quarter square meter area at multiple sites. We were able to locate three suitable seagrass beds each containing Manatee Grass and Turtle Grass. Within each seagrass bed, one group member positioned our quadrat at one-half meter intervals. At each of the seagrass beds, we placed the quadrat into each seagrass bed at the decided interval five times, giving us a total count of 15 observations. For each time we placed the quadrat down, we performed a visual count of the number of algae individuals, and then we photographed the site for later examination in order to prevent any miscounts. An analysis of variance was carried out to determine the difference between group means.

6.     Results

The results section will provide a written summary of your findings that can be understood independently from – and is complementary to – your figures and tables.  Summarize your findings, citing each figure and table, and provide appropriate statistical descriptions (for example: means, standard deviations, p values, t statistics) as requested by your instructor.   Note trends and observations, and be sure to use the word “significant” only in the statistical sense.  Do not provide any interpretation of your results here (no opinons, no notes about the importance of the findings). 

When describing differences between groups or trends in data, take care that your descriptions match your statistical analysis.  For example, you cannot suggest that two groups are different if the p value for the comparison is > 0.05. (“Heart rates were not significantly different between the two groups.  Heart rate was 80 ± 4 bpm for group A and 84 ± 3 bpm for group B, p=0.34.”)

The results section is usually quite short in a lab report.  The results shown in each figure or table will typically be described in a single sentence (for a simple graph) up to, at most, a paragraph (for a complicated graph or table, or for observations).  Again, do not forget to cite each figure and table as you describe the findings!

Sample results:

The SDS-PAGE procedure provided information to determine Rf values for the standard samples. The values vs. log molecular weight were plotted on an xy scatter plot to generate the protein standard curve (Figure 1).  The slope of the line was used to calculate the molecular weights of the samples. Porcine pancreas was calculated to be 151.93 kDa, Bacillus licheniformis 141.82 kDa, and Aspergillus oryzae 141.82 kDa (Table 1). 

 Protein standard markers were used on the Western Blotting nitrocellulose paper to calibrate the molecular weight markers (Figure 2). The results from Western Blotting were the human salivary α-amylase band was present on the nitrocellulose paper however porcine pancreas, Bacillus licheniformis, and Aspergillus oryzae were non-reactive and did not exhibit colored bands (Figure 3).

7.     Figures and tables

Your data will be summarized in the text, but table and figures are essential in allowing the reader to interpret the results of your experiment or laboratory exercise.  Care must be taken to design tables and figures to highlight data trends and key findings for the reader.  Data tables and figures are considered part of the results section, and each table and figure must be cited in the results text; for example, “Heart rate increased after exercise, from 80 ± 4 bpm to 124 ± 9 bpm (p<0.05, Figure 1).”

Figures or tables?

Tables are particularly useful if you are providing descriptive observations, showing information for each of your research subjects, or if a variety of measurements were taken in your experiment.  Graphs are most frequently used for comparisons and to show trends.  Graphs, photographs and diagrams are all considered figures.  Tables and figures that show subject characteristics or aspects of the experimental procedure are typically placed in the methods section; tables and figures that show experimental data are placed in the results section.  Do not place tables and figures at the end of the document unless directed to do so by your instructor.

Sample decisions about how to present data  

Table setup

Each table (and figure) will need a number and a descriptive title.  The title of a table is positioned above the table, and any explanatory information is provided below the table.  Since people typically read from left to right before up to down, it is best to place your subjects as rows and your data measures as columns.  Each row should have a title, and each column should have a heading.  If you are using human subjects, do not include their names in data tables (or anywhere else in the lab report).

Sample table:

Table 1:  Molecular Weight and Rf Values for Standards and Samples.

Graph setup

Graphs are powerful tools for communicating important aspects of your data.  The type and overall appearance of your graph must be carefully considered. 

With the exception of pie charts, each graph will have an x axis and a y axis.  The x axis will typically show the independent variable (the group, category, individual, or variable that you control – for example, the concentration of enzyme in a given tube).  The y axis will typically show the dependent variable (the variable that you measure).

In many cases means (or averages) will be graphed rather than individual data points.  This will allow trends or comparisons to be better visualized than with a depiction of all data points.  When averages are shown, error bars (“whiskers” above and/or below a bar or point) are typically used to show standard deviation or another measure of variability.  Standard deviations should not be graphed as stand-alone bars; see your instructor if you are unsure of how to graph variability for your experiment.

Each graph is considered a figure, and each figure will have a number (Figure 1, Figure 2).  The figure number and figure title will be provided below the graph, as the beginning of the figure caption (called a “legend” in scientific writing).  Additional information needed to interpret the graph should be provided in the legend.  The number of subjects/replicates (“n”), markers of statistical significance (“*, p<0.05) and the measure of variability (“error bars show standard deviation”) are often included in the figure caption/legend.  If abbreviations are used in the figure labels, these should be defined in the figure legend.

Types of graph

Many different types of graphs that can be used as figures in lab reports; these include bar graphs, line graphs, scatter plots, box plots and pie charts. 

Bar graphs are used when you are comparing groups (men vs. women, hot vs. cold, before vs. after, 22°C vs. 37°C).  Error bars will be used to show standard deviation or other measures of variability.  The categories/group names are shown on the x axis and the measured value is graphed on the y axis.  The bars should have informative labels on the x axis (for example, “warm” and “cold” rather than “A” and “B”).  Unless otherwise directed by your instructor, make sure the y axis starts at 0. For more-complicated groups of data (e.g. with more than one series), the two measures you want to compare should be shown next to each other, and an informative key should be used to differentiate the series (see the two-series graphs in the samples below).

Sample bar graphs:

assignment on various pathology lab report

Figure 1 .  Percent of Strongylocentrotus eggs fertilized per condition.  ASW, artificial seawater; CaFSW, calcium-free seawater; NaFSW,  sodium-free seawater.  Error bars show standard deviation.

assignment on various pathology lab report

Figure 2.  Actual heart rate vs. perceived heart rate before, during and after moderate exercise on a rowing machine. The perceived heart rate was calculated by multiplying the rating of perceived exertion (RPE) by 10.  N=3.  Error bars show standard deviation.

Line graphs are used when you want to show average (or individual) measurements made over a continuous variable such as time, temperature or concentration.  The continuous independent variable (time/temperature/concentration) is graphed on the x axis and the measured value is graphed on the y axis.  If two lines are shown, comparisons can be indicated by marking statistically significant differences between the groups at specific times/temperatures/concentrations. Unless otherwise directed by your instructor, make sure the y axis starts at 0.  When averages are graphed, error bars can be added to the points on the line to show standard deviation or another measure of variability.

Sample line graph:

assignment on various pathology lab report

Figure 3.  Behavioral response to predator cues after hatching. Fry from embryos exposed to goldfish (predator; closed circles) or not exposed to goldfish (control; open circles) were challenged by exposing to goldfish starting at 5-7 days after hatching (Initial fry challenge). Fry challenges were repeated 1, 2, 3, 4, 6, 8, and 12 weeks after the initial challenge.  The time to resume normal foraging behavior (recovery time; Log 10 seconds) was recorded for each fry challenge.  Error bars represent 95% confidence intervals.

Scatter plots are used to show trends and correlations; individual data points are graphed rather than averages.  As in a line graph, the x axis must show a continuous variable – either an independent variable or, for correlations, one of two measured variables.  A trendline (“best-fit” line) can be added to the graph to show trends in the data.

Sample scatter plot with trendline:

assignment on various pathology lab report

Figure 4. Protein standard curve for alpha-amylase, as determined by SDS-PAGE, with Rf reflecting the distance the band traveled relative to the log of the molecular weight. 

Box plots are used to emphasize the distribution of data within a group.  The box contains the middle 50% of the data points, with a line showing the median, and “whiskers” extending from the box indicate the minimum and maximum. 

Sample box plot:

assignment on various pathology lab report

Figure 5.  Scores on the first and second exams for a biology course.

Pie graphs are used to show composition of your research populations or observations.

Sample pie graph:

assignment on various pathology lab report

Figure 6 . Taxa composition of sample taken from Site B (n=102). Ephm. = Ephemeroptera.

Photographs or diagrams  may be useful in describing results or in describing experimental methods (for the latter case, the figure should be cited in the methods section). 

8.     Discussion

The discussion section allows analysis of the implications of your findings.  Take care to frame the discussion around your actual results, not the results you hoped for or predicted based on your hypothesis.  Unless otherwise directed, you must cite at least one primary reference in the discussion section; a description of the appropriate format for in-text citations is provided in the “References” section below.

There are several standard topics that are typically addressed in a discussion.

  • Relate your findings to your hypothesis or to the purpose of the experiment. If your research was hypothesis-driven, note if the results supported or did not support your hypothesis. Do not say that your hypothesis was proven/disproven, or that your hypothesis was true/false – a single experiment can only support or not support a hypothesis.  If your experiment was organized around an objective rather than a hypothesis, note whether the objective was met, based on your results. 
  • Compare your results to those of published findings, if appropriate .  You must typically use at least one primary reference in this part of the discussion.  You will note if your findings agreed with those described in the published study, and you will describe how your study was similar to and different from the published study in terms of methods.  This comparison will typically require one paragraph per primary reference.  You will use the past tense in describing the methods and results of both studies.  Don’t forget to cite the published study.
  • Speculate about unexpected results and provide sources of error.  In the introduction, you explained why you expected certain results. The discussion is the appropriate location for speculation about unexpected results.  You might have noted aspects of the procedure or conditions during the experiment that might have influenced the results.  Furthermore, statistically significant trends are rarely shown when sample sizes are small and variability high (that is, most experiments carried out in biology labs).  This speculation will typically account for a paragraph in your discussion.

Whether your results were expected or unexpected, experimental procedures can typically be improved in a variety of ways.  Provide possible sources of error related to your experimental design or the way in which you carried out the procedures.  (If you already addressed some of these in detail in speculating about unexpected results, you can mention these briefly here, without going into great detail again.)  Follow up by explaining how the experimental design could be improved to address some of these sources of error.  This section will typically account for one or two paragraphs in the discussion.

  • Describe a future study, if appropriate.  A future study is not simply a new study that addresses procedural flaws described in the sources of error section.  A future study must logically take the experiment in a new direction – for example, by addressing a new or revised hypothesis or research objective, or by using a new procedure to address the same hypothesis or research objective.  Provide some description of the new experimental strategy.  This section will typically account for one paragraph in your discussion.
  • Conclusion.   End your discussion with a sentence or two summarizing the take-home message(s) of your lab report.  Feel free to be very obvious about this, for example by starting the sentence with “In conclusion”.

Sample discussion:

Data analysis has shown that there is no significant statistical difference in population numbers of Penicillus capitatus between different species of seagrass beds. Wilson and Ramsook (2007) performed a study that examined population densities of epiphytal foraminiflora on seagrasses and algae, such as Penicillus capitatus . During the course of their study, they noted that populations of Penicillus capitatus grew in abundance in both species of seagrass beds, just as was the case in our experiment.

During our data collection, there were several possible sources of error that could have impacted our results. For one, we only took 15 population counts for each type of seagrass bed over the course of two days. Our data would be more valuable if we were to take more population counts overall. Second, only one of the bays we planned to use before arriving in the Caribbean was usable for data collection, significantly limiting the area we were able to work in. Therefore, we were able to get population counts for Penicillus capitatus , but those population counts may only be relevant in the one bay we worked in. In the future, it will be beneficial to alter experimental design so that more population counts can be recorded and multiple locations can be used for experimentation.

A potential future study could be to examine populations of Penicillus capitatus on several different types of substrates, including different species of seagrass beds. This study should be performed ideally over several months, with several hundred population counts in order to gain more viable data. In conclusion, the experimental data revealed an insignificant difference in population means for Penicillus capitatus among different species of seagrass , but further experimentation should be performed in order to gain the most feasible results.

9.     References

Include all references cited in the text – and only those cited in the text.  Consult the directions for your lab report to confirm the required numbers and types of references.  Unless otherwise directed, use the modified APA format described here for in-text citations, and use standard APA format for the reference list.  Online APA formatting guides and links to reference management programs such as EasyBib and RefME are provided in the “Citing Resources” tab of the Biology Libguide ( http://mcla.libguides.com/biology/citing ). 

In-text citations

A modified version of the APA in-text citation style will be used for in-text citations in biology lab reports.  Do format your in-text citations as (name, year), as in APA style.  Type the author’s last name (no first name, no initials), then a comma, then the year of the publication.  For two authors, provide both names, then the year. For three or more authors write “et al.” after the first author’s last name, without listing all of the subsequent authors’ names.  et al. = et alia = and others; take care to put a period after the “al”, as this is an abbreviation.  In APA style, up to five authors are listed when a reference is first cited; the “et al.” even at first use is more typical for publications in biology.  If the author names are provided as part of the sentence, put the year only in parentheses at the end of the sentence.

Sample in-text citations:                  

Smosky and Billetz (1995) observed that fruit flies were more attracted to overripe bananas than to underripe bananas; similar results were reported by Goodwin et al. (2015).

Leeches can sense a variety of stimuli, including chemicals and heat (Herrick, 2014).  Leech feeding behavior is influenced by these and other stimuli (Golub et al., 2015). 

General rules for the reference list

Put the references in alphabetical order by the last name of the first author; do not change the order of the authors listed in the publication.  Use initials rather than full first and middle names.  Provide the author name(s), year of publication and title of the resource, followed by information specific to the resource type, as noted below.  If a reference requires more than one line in the text, indent all lines after the first.

Instructions and extensive lists of examples for references in APA style can be found at https://www.library.cornell.edu/research/citation/apa and   https://owl.english.purdue.edu/owl/resource/560/06/ , among other websites.   Examples for some common types of references are provided below.

Journal Articles

Author. (Date). Title of article. Journal, volume, pages.  [if accessed online, also include one of the following:] doi: [insert doi number] OR retrieved from: [insert url].

Smosky, J. (1980).  A strain of fruit flies that is resistant to anesthesia.  Journal of Interesting Research, 5, 76-87.  doi: 123456789

Goodwin, A. M., & Billetz, A. (2000).  Identification of bacteria swabbed from door handles in Venable Hall.  Journal of Interesting Research, 25, 112-121.  doi: 987654321

Golub, J., Goodwin, A. M., & Herrick, S. (2014).  Statistical misconceptions commonly encountered in seminar courses.  Journal of Interesting Research, 39, 50-59.

Author or Editor. (Date). Title of book.   City of publisher: Publisher.  Pages [if only a portion of the book is being cited].

Krzyzanowicz, R. , & Hoyt, P. (2010). Four thousand three hundred sixty-two strategies for taping an ankle.  North Adams, MA: MCLA Press.  pp. 20-30.

Unpublished lab manual

     Golub, J. L. (2015). BIOL 340: Developmental Biology Lab manual . pp. 1-4.

Author [or title, if no author found]. (Year or n.d. if no date found). Title of website [unless used in place of author] . Retrieved from [insert url].

Cornell University Library PSEC Documentation Committee. (2011). APA Citation Style. Retrieved from https://www.library.cornell.edu/research/citation/apa.

Biology. (n.d.).  Retrieved from http://www.mcla.edu/Academics/undergraduate/academic-programs/biology/. 

E.   Sample lab report

Relationship between an overnight fast and blood pressure

Steven Miller

Lab Partner: Ashley “Erin” Kelley

One in four Americans is predicted to develop metabolic syndrome, which includes high blood pressure.  Modern medicine views hypertension as related to diet and lifestyle.  The reason for this experiment was to see if an overnight fast had a decremental effect on blood pressure.  It is known that postprandial changes in mean arterial pressure and heart rate are significant, but the effects of a short term fast are not known.   A group of young, healthy students from a college class fasted overnight and their mean arterial pressure was monitored for changes. These results were compared to those of similar students who did not fast overnight.  No significant difference in mean arterial pressure was observed between fasting and nonfasting students.  The hypothesis that lower blood pressure would be seen in the experimental (fasting) group was not supported by the data.

Introduction

A full third of Americans have hypertension and there is a greater than 90% risk of developing this condition within one’s lifetime (Bakris 2007).  When one’s diet is based on fruits and vegetables, low-fat foods, and reduced saturated fats, blood pressure goes down dramatically (Appell et al., 1997).  It is noted that these foods have a high water content and that subjects in that study drank increased amounts of water.  Going a step further, many people generally believe that a water fast will dramatically lower blood pressure. 

It was decided to test the idea that a very short term water fast would lower blood pressure.  If it did, then perhaps a regimen of fasting every other day or every three days might be a suitable method of controlling blood pressure.  Dr. Mark Mattson, a popular proponent of calorie restriction as a way to health and longevity, noted in a piece of research that intermittent fasting (in rats) can reduce the normal growth related increase of end systolic and end diastolic volumes (Wan et al., 2010) that determine stroke volume.  On the opposite side of the fence, another study showed that cardiac output, heart rate, stroke volume, and systolic and diastolic pressures all increase after a meal (Varady et al., 2009).  In fact, one is urged by the study authors to never to have a postprandial cardiac evaluation because it will be abnormal!  The hypothesis of the current study is that overnight fasting from solid food through breakfast time (12 hours) will significantly lower blood pressure from normal levels in a healthy person.

Materials and Methods

In this experiment eight student volunteers were solicited from the anatomy and physiology class.  Effort was made to select people as randomly as possible, however it is noted that most class members were young females with normal blood pressure.  Many of them had been athletically conditioned.  Two chosen subjects were males with widely differing ages, neither of whom had high blood pressure.  Subjects were divided into two groups so that there were four reasonable replicates in each group.  Directions for a fasting event were given, allowing no food or snacking after the evening meal until class the following morning, roughly 12 hours.  Students were to allowed to drink as they normally would, or if thirsty, but no extra beverages were allowed to compensate for lack of food.  Two groups were formed.  The experimental group agreed to an overnight fast and the control group ate and drank as they normally would.

Blood pressure was measured with an aneroid sphygmomanometer. A stethoscope was available.  Blood pressure data were recorded for each person before and after the fasting event.  Data were entered into a spreadsheet as systolic pressure, diastolic pressure, and pulse rate.  The Mean Arterial Pressure (MAP) was calculated as [diastolic pressure + 1/3(systolic pressure – diastolic pressure]. To compare the difference in MAP between fasting and nonfasting groups, the final MAP was calculated as a per cent of the original .  Numbers greater than 100% were therefore increases, and those less than 100% were deceases, from base line MAP.

Differences were analyzed using the t-test in Microsoft Excel.  Using the paired t-test, it was assessed whether the mean change of MAP was statistically different within the fasting group or nonfasting group.  Using the unpaired t-test, it was assessed whether the mean change of MAP was statistically different between the fasting or nonfasting group.  In all cases the level of significance was α = 0.05.

For fasting students, there was no significant difference in MAP before and after the fast (78.24 ±11.01 vs. 81.13 ±8.36, P = 0.66, Figure 1).  For nonfasting students, there was also no significant difference in MAP on the first or second measurement days (82.47 ±15.63 vs 76.47 ±11.47, P = 0.27, Figure 2).  Comparing the blood pressures for fasting and nonfasting students, the final MAP as a percentage of the original MAP for fasting students was not significantly different from that of nonfasting students (105.07% vs. 93.64%, Figure 3). 

assignment on various pathology lab report

Figure 1.  Mean arterial pressure (MAP) for fasting students before and after fasting.  N=4. Error bars indicate standard deviation. P=0.66.

assignment on various pathology lab report

Figure 2.  Mean arterial pressure (MAP) for nonfasting students before and after the designated fast day.  N=4. Error bars indicate standard deviation. P=0.27.

assignment on various pathology lab report

Figure 3.  Final mean arterial pressure (MAP) as a % of the original MAP for fasting and nonfasting students.  N=4. Error bars indicate standard deviation. P=0.26.

In this study all subjects maintained their normal blood pressure with or without a fast.  Maintaining the same blood pressure was, of course, totally expected from nonfasting students.  It was not expected in fasting students.  Clearly, the data do not support the hypothesis that a 12 hour fast in normally healthy subjects will significantly lower blood pressure and heart rate. 

In our study focusing on normotensive students, a single fast did not reduce blood pressure.  A significant decrease in systolic pressure from 124±5 to 116 ±3 (P < 0.05) was observed after an alternate day fasting protocol over 10 weeks (Varady et al., 2009), a fasting protocol that was much longer than ours.  The study described by Varady et al. (2009) involved more subjects, and the subjects were obese.

Errors might have been made in measuring blood pressure.  A more rigorous process for this study would have been to be sure the arm was level with the heart, to have subjects seated for several minutes before taking measurements, to use the stethoscope rather than just looking at the needle on the aneroid sphygmomanometer, and to have the same person doing all measurements.  In addition, it would make for a sounder protocol to take multiple measurements and average them together for the data analysis, or to use a much larger and broader sample.  Another limitation of this study was the homogeneity and limited number of the subjects and, perhaps more specifically, that they all had normal pressure that did not need to be lowered.  Therefore, even had the results shown a drop in blood pressure and heart rate from fasting, one would be remiss in suggesting a fast for lowering blood pressure for hypertensive individuals. 

That fasting students maintained mean arterial pressure may be the result from the power of homeostasis and the inability of a short-term fast to modify the strength of long-term hormonal (ANP vs aldosterone) controls on blood pressure.  It would be interesting to try a longer fast of perhaps 24 hours.  Alternatively, a study might be done with a focus on repeated fasts.  It would be interesting to experiment with the hypothesis that an 18 hour fast, two days per week, for three months will significantly lower high blood pressure and, perhaps, in certain age groups, the risk of a cardiovascular event.

In conclusion, a decrease in blood pressure was not seen for students without hypertension who did an overnight fast.

Appel, L. J., Moore, T. J., Obarzanek, E., Vollmer, W. M., Svetkey, L. P., Sacks, F. M., Bray, G. A., Vogt, T. M., Cutler, J. A., Windhauser, M. M., Lin, P.-H., Karanja, N., Simons-Morton, D., McCullough, M., Swain, J., Steele, P., Evans, M., Miller, E. R. & Harsha, D. W. (1997). A clinical trial of the effects of dietary patterns on blood pressure. New England Journal of Medicine, 336, 1117-1124. doi: 10.1056/NEJM19970417336160.

Bakris, G. L. (2007). Current perspectives on hypertension and metabolic syndrome. Journal of Managed Care Pharmacy , 13.5, S3-S5. Retrieved from http://www.amcp.org/data/jmcp/JMCP%20Supp_June%2007_All.pdf.

Varady, K. A., Bhutani, S., Church, E. C. & Klempel, M. C. (2009). Short-term modified alternate-day fasting: a novel dietary strategy for weight loss and cardioprotection in obese adults." American Journal of Clinical Nutrition, 90, 1138-43. doi: 10.3945/ajcn.2009.28380.

Wan, R., Ahmet, I., Brown, M., Cheng, A., Kamimura, N., Talan, M. & Mattson, M. P. (2010). Cardioprotective effect of intermittent fasting is associalted with an elevation of adiponectin levles in rats. Journal of Nutritional Biochemistry , 5, 413-417. doi: 10.1016/j.jnutbio.2009.01.020.

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assignment on various pathology lab report

  • Jun 23, 2023

Understanding Your Pathology Report: A Comprehensive Step-By-Step Guide

assignment on various pathology lab report

If you’ve had surgery or a biopsy, the biological sample from your procedure will be sent to a pathologist working in a laboratory. The pathologist will study your sample and create a pathology report providing important information about what was found in your sample. Your pathology report will be reviewed carefully by your oncology team, and you should discuss it with your doctors to ensure you understand your specific situation.

Before you receive or review your pathology report, however, you may be looking for more information about what exactly this report is and what you can expect it to contain. You may feel some anxiety waiting for your pathology report, and deciphering the medical jargon and dense information can be daunting. Continue reading to understand the process and your pathology report in a simple, step-by-step format.

What Is a Pathology Report?

A pathology report is a document that contains the findings of a pathologist who has examined a patient’s biological samples under a microscope. The samples are usually obtained through biopsy, surgery, or a medical examination and can include findings from body tissues, fluids, or cells.

Your pathology report provides valuable insight into the nature of your disease. It includes detailed information about the type, grade, and extent of your cancer, as well as the margins of the removed tissue. Pathologists play a critical role in diagnosing diseases like cancer, and their reports guide physicians in determining the appropriate course of treatment.

Why Understanding Your Pathology Report Matters

Understanding your pathology report empowers you to participate actively in your healthcare decisions with your oncology team. It helps you grasp the severity and nature of your condition and set expectations for your treatment. For more insights on why understanding your pathology report is crucial, refer to resources provided by The American Cancer Society.

Understanding the Structure of Your Pathology Report

A pathology report usually contains the following sections:

Patient Information: Your name, patient ID, date of birth, and the name of the physician who requested the test.

Specimen Information: The type and location of the sample, how and when pathology received it, and who provided it. It may include information about the margins — the edges of tissue that was removed during the biopsy or surgery. Since the goal of surgery is to remove all of the cancerous tissue, it’s vital to ensure that the margins are clear or negative (meaning that no cancer cells are detected on the edges). If any lymph nodes were removed during the procedure, the pathology report will also state whether cancer cells were found in them.

Gross Description: What the pathologist observed with the naked eye, including the color, size, and weight of the sample.

Microscopic Description: A description of what the pathologist observed under the microscope, including cell structures and abnormalities.

Diagnosis: The pathologist’s interpretation of the findings and the final diagnosis.

Reading Your Pathology Report

Now that you know what a pathology report includes, here’s a guide to understanding your report:

Verify Patient Information: Ensure that the patient details are correct. Mistakes, although rare, can happen.

Understand the Specimen: Knowing what type of specimen was taken and where it was taken from can give context to the report.

Gross Description: While this section can be technical, look for descriptors of size, shape and color, which can give you an idea of the sample’s normality.

Microscopic Description: This section might be complex, containing detailed observations of cellular structures. Look for terms like benign, malignant, normal, abnormal, etc. to get a sense of what was found.

Interpret the Diagnosis: Again, the final diagnosis as stated by the pathologist might be technical and challenging to understand. You can use reliable medical dictionaries like MedlinePlus to understand them.

Remember, it’s essential to discuss these findings with your healthcare provider to fully understand your condition and to determine the next steps in your care.

Count On Us for Information, Resources, and Support

Understanding your pathology report is a critical step in managing your health. The knowledge contained in your report can help you better understand your diagnosis. This will empower you to navigate and make informed decisions about your treatment. Consult with your healthcare provider for clarifications and concerns. Please contact us if you have questions about speaking with your doctor regarding your pathology report!

Whether you’re newly diagnosed with breast cancer , are navigating survivorship, or are the loved one of someone experiencing breast cancer, you can count on SurvivingBreastCancer.org to keep you informed. We provide educational information to help you better understand symptoms , testing, treatment options , surgery, etc., and podcasts that feature professionals, advocates, and caregivers that share valuable information.

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Note: This article is designed to provide general information and not meant to replace professional medical advice. Always discuss your pathology reports with your healthcare provider.

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Microbiology Writing Guide: Lab Report Format

Organization and format, basic outline.

Scientific writing can be in the form of a laboratory report, a thesis, a journal article, or some other written communication used to disseminate the results of scientific research. The exact format required depends upon the type of written communication and often will vary from source to source.

Preparation of a Laboratory Report

A lab report differs from a paper in that it has defined sections. The sections required vary from laboratory to laboratory but the standard outline for most lab reports in the biological science include: title, your name, purpose of the experiment, methods, results, discussion and conclusion, references. Some lab reports may include a section of questions that must be answered concerning the experiment. Most laboratory courses will require that data be immediately written into a lab notebook in pen. Some labs will require you to attach these data pages to your report. Normally a lab report should be typed, spell checked and proofread before being submitted.

When writing a thesis, article for publication, or a report to turn into your supervisor, your first draft will be reviewed by your mentor and/or co-workers and then undergo revision. No matter how good a writer is, most reports require some revision. It is best to write your first draft and then let it sit for a few days before you read it the next time. Many times you are too “close” to the material after the first writing to see obvious errors. (This has definitely been true of this document!)

Sections of a Laboratory Report

Title : The title should be concise and specific and tell the reader what you did

Purpose : Most lab reports do not include a formal introduction and instead substitute a purpose. The purpose of the experiment should be stated in one or two sentences. You should know the purpose of the experiment before you start.

Methods: Most lab reports do not include all the details a journal article requires. Normally the procedure can be listed and referenced to the appropriate laboratory manual pages. If modifications have been made to the methods in the lab manual, these need to be clearly described.

Results : All data and observations should be included in the lab book; however, what you think should have happened or the methods section are not included. Types of results may include:

  • Measurements. Report measurements using standard metric units. Any time a number is presented, it must have units. Abbreviations of units are used without a following period. Use the prefixes m, m, n, and p for 10 -3 , 10 -6 , 10 -9 , and 10 -12 , respectively. Numbers should be written as numerals when they are greater than ten or when they are associated with measurements; for example, 8 mm or 20 g. In a list of objects including both numbers over and under ten, all numbers may be expressed as numerals. Example: 17 bacteria, 2 yeast, and 1 protozoan. If a number starts a sentence spell out the number, do not use a numeral. Example: ten mannitol salt agar plates were streaked…
  • Calculations. The equation should be indicated. In a lab report, even if you use a calculator, you must set up the problem.
  • Tables. Number each table and provide a title and legend that contains all the information needed to interpret the data. The reader should be able to understand the content without the text. The title should be located at the top of the table. Columns and rows should be labeled clearly. All notes should be placed below tables. Any abbreviations, units, calculations, or statistics used should be described in headers or footnotes (see Table 1 for an example). Symbols such as #, *, ! ; and superscripts such as 1 and 2 can be used to identify these footnotes. Use bold type to make these obvious.
  • Figures. Figures include graphs, photographs, drawings, diagrams, maps, and all other illustrations. All figures should be numbered and have a title and legend that contains all the information needed to interpret the data. The reader should be able to understand the content without the text. Figures should be labeled at the bottom. For a graph, units are specified on the abscissa and ordinate. If the photograph is of an object under the microscope, the total magnification should be indicated. Photographs of gel electrophoresis data should include a number on each lane, and the legend (or the figure itself) should indicate the contents of each lane.
  • Plate counts. Include results for all dilutions, even if they are too numerous to count (TNTC) or 0. You should indicate the type of medium plated and temperature of incubation. See Table 1.

Table 1. Results of viable cell count of diluted Escherichia coli grown at 37 o C in nutrient broth (1 ml plated).

*In this example, only 249, 235 and 35 are significant counts. These data are averaged:

249/10 -3 + 235/10 -3 + 35/10 -4 or 2.5 X 10 5 + 2.4 X 10 5 + 3.5 X 10 5 /3

= 2.8 X 10 5 CFU/ml

The text should refer to each table and figure and they should appear after, but close to, text that refers to them, (i.e., at the end of a paragraph or section). Alternatively, tables and figures may be placed at the end of the paper. Tables and figures are numbered independently of each other, and they are assigned numbers in the order they are mentioned in the text. The in-text reference to a table or figure should not repeat the caption (e.g. ‘table 1 shows “Title on table” ’). Instead, it should draw attention to key features (e.g. “Table 1 shows that the number of bacteria in the culture increased markedly between hours 1 and 4.”).

Discussion/Conclusion: The discussion section interprets the meaning of the results and draws conclusions from the data that have been presented. The authors should show how their observations relate to each other to form a cohesive story. If data can be interpreted in more than one way, all possibilities should be mentioned and the authors should indicate which alternative they think is correct and why. Results should be discussed even if they are unexpected or negative. For example, the presence of unexpected bands on agarose gels should be explained. This section should also address any discrepancies between these results and other papers. Material obtained from another source should be referenced.

The meaning of your results should be summarized in two to three sentences at the end of the section. This includes the potential implications of the research, and possibilities for future research that would contribute more to the field. In lab reports, experiments do not always work. This section allows the researcher to explain what might have gone wrong with an experiment.

References: The reference section gives complete details about sources that were cited, in any section of the text. A "Bibliography," on the other hand, refers to a list of materials used to obtain background knowledge on a subject. There are several standard styles for listing references. Depending on what type of scientific writing you are doing, you may be directed to follow a particular format. If so, follow the format that has been specified exactly. When references are cited, either the reference number or the author’s last name and the publication year are used. Example: “Some strains of E. coli can grow in orange juice (1)…” or “Some strains of E. coli can grow in orange juice (Brown, 1999)….” In this class, we will use the reference style of the American Society for Microbiology Journals. When references are cited within the paper , only the number is used. References are numbered in the order in which they appear in the article (citation-sequence reference system). No reference should be included that is not cited in the paper. Remember that ALL information within the report that is not your original work or idea should be referenced. Statements by other authors are usually paraphrased or summarized – direct quotations are rare in scientific writing.

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Laboratory fundamentals in biological engineering, guidelines for writing a lab report.

A formal lab report is the principle way scientific data are conveyed to the rest of the scientific community and preserved for future examination. Each scientific journal has its own idiosyncrasies regarding particulars of the format, but the most common elements of a scientific report, in order of presentation, are:

  • List of Authors

Introduction

Materials and methods.

  • Results, including figures and tables

The requirements for each section are outlined below. This information is given in the order that you might actually write your report rather than the order in which the parts are presented in the final report. If you want more information, you can find parts of this text in an on-line collection of instructional materials used in the Purdue University Writing Lab . Other parts are inspired by Robert A. Day’s book, How to Write and Publish a Scientific Paper from Oryx Press, a copy of which is available in the teaching lab.

This is often the subject of many heated discussions and hurt feelings when only one report can be submitted to describe many people work. Since each of you will submit your own report, questions about who the authors will be, in what order, and what responsibilities each will have are moot. However you should list the name of your partner on your report since she contributed to the work.

Figures and Tables

Some readers begin by scanning the figures first. The figures, with the legends, should provide a self-explanatory overview of your data. Decide what the data show, then create figures which highlight the most important points of your paper.

Tables are used to present repetitive data that is numerical. Graphs or illustrations, collectively called figures, are used to present numerical trends, raw data (like a picture of a gel), or a model that explains your work.

When you prepare your figures and tables, keep in mind that it is significantly more expensive for journals to publish figures and tables than text, so try to present the data in a way that is worthy of such added expense. The table below is an example of an ineffective table.

The information in Table 1 could be presented in one sentence, such as: “In ten experiments carried out at 24°C, ion flow was detected only in the presence of cortical cells.” This is a clearer and more concise way to present the information. In addition, all tables and figures must have numbers, titles and legends.

Figure and Table Legends

Legends to the figures and tables explain the elements that appear in the illustration. Conclusions about the data are NOT included in the legends. As you write your first draft, state in a short simple sentence, what the point of the figure or table is. In later drafts, make sure each element of the figure or table is explained. Your figure legends should be written in the present tense since you are explaining elements that still exist at the time that you are writing the paper.

To write the results section, use the figures and tables as a guide. Start by outlining, in point form, what you found, going slowly through each part of the figures. Then take the points and group them into paragraphs, and finally order the points within each paragraph. Present the data as fully as possible, including stuff that at the moment does not quite make sense.

Verbs in the results section are usually in the past tense. Only established scientific knowledge is written about in the present tense, “the world is round,” for example. You cannot presume that your own data are part of the body of established scientific knowledge, and so when you describe your own results, use the past tense, “a band of 1.3 KB was seen,” for example. There are, however, exceptions to this general rule. It is acceptable to say, “Table 3 shows the sizes of the DNA fragments in our preparation.” It is also acceptable to say, “In a 1991 paper, Ebright and coworkers used PCR to mutagenize DNA.”

This is like a cooking recipe. Include enough detail so that someone can repeat the experiment. It is important that the reader be able to interpret the results knowing the context in which they were obtained.

The Materials and Methods section should be written in the past tense, since your experiments are completed at the time you are writing your paper.

This is the section of the paper for you to show off your understanding of the data. You should summarize what you found. Explain how this relates to what others have found. Explain the implications.

Introduce what your question is. Explain why someone should find this interesting. Summarize what is currently known about the question. Introduce a little of what you found and how you found it. You should explain any ideas or techniques that are necessary for someone to understand your results section.

The abstract is a very short summary (usually around 150-250 words) of what the question is, what you found, and why it may be important.

The importance of abstracts is increasing as more scientists are using computers to keep up with the literature. Since computers can only search for words in a paper’s title and abstract, these may be the only parts that many people read. The abstract may also be the way a journal’s editor decides whether to send your paper out for peer review or reject it as uninteresting and not generally relevant. Consequently, a well written abstract is extraordinarily important.

The title should be short (about 10 words), interesting, and it should describe what you found.

Include only those references that pertain to the question at hand. Journals vary considerably in their preferred format for the reference list. For this class, you should list the references alphabetically by the first author’s last name. Include all the authors, the paper’s title, the name of the journal in which it was published, its year of publication, the volume number, and page numbers. Please carefully follow the punctuation and format requirements. A typical reference should look like

Pavletich N. P., C. O. Pabo. “Zinc Finger-DNA Recognition: Crystal Structure of a Zif268-DNA Complex at 2.1 A.” Science 252 (1991):809-817.

In the body of your report, this article would be cited as follows: “The crystal structure of the Zif268-DNA complex has been solved (Pavletich 1991).”

If two or more articles can be cited for this finding, then they are listed alphabetically, separated by a comma.

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FIRST-PAGE REPORT HEADER

Subsequent-page header and footer, diagnosis field, gross/macroscopic description, intraoperative consultation, microscopic description, comments/notes, addendum reports, amended reports, other data elements, conclusions, acknowledgments, reporting guidelines for clinical laboratory reports in surgical pathology.

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Jeffrey D. Goldsmith , Gene P. Siegal , Saul Suster , Thomas M. Wheeler , Richard W. Brown; Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology. Arch Pathol Lab Med 1 October 2008; 132 (10): 1608–1616. doi: https://doi.org/10.5858/2008-132-1608-RGFCLR

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Context. —The surgical pathology report (SPR) is an essential part of patient care because it documents the pathologic findings in tissues removed from patients for diagnostic or therapeutic reasons. Despite the importance of the SPR, exhaustive guidelines outlining the various elements of the SPR have not, to our knowledge, been published.

Objectives. —To outline recommendations delineating the required, preferred, and optional elements that should be included in the SPR. These guidelines, if implemented, will bring uniformity to the reporting of surgical pathology specimens.

Data Sources. —The Surgical Pathology Resource Committee of the College of American Pathologists compiled and prioritized the elements that have been included in various institutional SPRs. Additional data sources include the College of American Pathologists Laboratory Accreditation Program checklists and the recommendations of the Association of Directors of Anatomic and Surgical Pathology. Each element was assigned a priority of required, preferred , or optional. These priorities were discussed and consensus was reached. This report does not address issues of formatting or style substantively.

Conclusions. —These recommendations afford a framework for the creation of an SPR containing all of the components that are required or optimal for patient care.

The surgical pathology report (SPR) is the final written product of the surgical pathology laboratory, and it contains critical information that drives patient care, especially in the oncologic setting. A variety of individuals, including physicians, nurses, statisticians, epidemiologists, support personnel, and patients, use the information contained in the SPR. Because of the variety of people who access the SPR and the importance of the information contained therein, the report must contain a minimal amount of standard content and must be presented in such a way as to efficiently and accurately convey its information.

The College of American Pathologists (CAP) has developed guidelines for the content of SPRs. Similar guidelines were developed in the past by the Association of Directors of Anatomic and Surgical Pathology (see http://www.adasp.org/papers/position/Standardization.htm , last accessed March 14, 2008); additionally, various organizations have called for report standardization. 1 In this article, we have compiled an exhaustive list of elements to be included in the SPR. Some of these recommendations are contained in the CAP Laboratory Accreditation Program checklists (see http://www.cap.org , last accessed March 14, 2008). This article is meant to convey guiding principles regarding the elements that should be contained in the SPR. Additionally, this article serves to rank these elements by degree of importance.

A summary of the body of the recommendations is contained in Tables 1 through 10 . These tables are organized by the various sections of a typical SPR. It is not the intent of this article to dictate the format of the report, which might include properties such as font, type size, and position of the various elements on the typed page, nor is it our intent to dictate that the various elements be located in the particular sections delineated in the tables. However, it is clear that a well-designed SPR more effectively conveys critical information to the reader. 2 The location of the constituents within the SPR is ultimately at the discretion of its creators. The exception to this is text color, which should always be black because many methods of duplication (eg, copy machines, facsimile) do not reproduce nonblack colors well. It is our intent, however, to provide a standardized list of the content elements to be included in the various sections of the SPR so that all readers, be they certified coders, billing clerks, or paramedical or medical personnel, can be assured that all required information will be present in the SPR, regardless of the laboratory of origin.

First-Page Report Header

The SPR is being generated with ever-increasing frequency in electronic format. These guidelines should be applied to the SPR, regardless of the mode in which it is published; however, certain elements, such as the subsequent-page header or footer ( Table 2 ), might be eliminated if SPRs are generated in a purely electronic format. In the tables of this manuscript, some elements are not preceded by a symbol. These are deemed required elements that must be included in all reports. Other elements are considered preferred , as designated by the * symbol. The preferred entries are considered important to convey to the reader and should be included in some fashion, unless their inclusion is precluded by hospital policy or some other extenuating circumstance. A few of the elements are considered optional and are designated by a dagger (†).

Subsequent-Page Header and/or Footer§

The content that follows includes a detailed description of the SPR elements and the reasoning behind our decisions regarding the necessity of the various constituents.

The header on the first page of the SPR ( Table 1 ) contains critical information, including information about the laboratory, the patient, and the type of report. As such, a delimiter, such as a box or line, below the header is often used to separate its contents from the remainder of the report. Within this header, one group of elements is the detailed laboratory identifying information that must, minimally, include the laboratory's name, address, and main phone number. If the laboratory has multiple phone numbers, which might include customer service, billing, or reporting offices, these may be included as well. These identifying elements must be present on every report for easy recognition of the responsible laboratory by the reader. Additionally, the laboratory's or hospital's identifying logo or trademark, if available, should appear on every report. We recognize that some laboratory information systems may not support the inclusion of such graphics on reports; however, we feel that this is an element that provides easy identification of the origin of the SPR, and thus, we have categorized this element as preferred. Additional optional elements that provide contact information or data regarding the laboratory's credentials include facsimile phone numbers, uniform resource locator (URL) for electronic access via the World Wide Web, and Clinical Laboratory Improvement Amendments of 1988 (CLIA) number. As a preferred element, the name of the laboratory's medical director should also appear in the portion of the header that contains the laboratory's contact information. We consider this an important component of the SPR because it provides the reader with supervisory contact information, should the pathologist-of-record be unavailable, or if a discussion with the laboratory's leadership is required.

If a secondary laboratory is involved in the routine processing of tissue or ancillary testing, such as immunohistochemistry or histochemical staining, and no separate report is issued by that laboratory, that reference laboratory's contact information, including address and phone number(s), should also appear in the report. The inclusion of this information is essential for quality assurance because it may provide the only documentation of the site at which those technical services were performed. The information regarding the laboratory that provides those services need not be included in the first-page report header, but it must be included somewhere within the report.

The patient's identifying information is, without doubt, one of the most crucial aspects of the report. As such, this information should be displayed prominently within the header. The patient's name is often formatted as last name, first name, middle initial. However, other formatting conventions are acceptable as hospital or laboratory policy dictates. Additionally, it is common in Hispanic cultures for patients to use both the paternal and maternal last names. When that is the case, the paternal and maternal last names should be joined by a hyphen so the paternal surname is not confused with the middle name (eg, Jose Luis Martinez-Rendon). The inclusion of the patient's full middle name is regarded as an optional element because it may help resolve some identity issues. Additional patient identifying information must include the patient's medical record number (if applicable) assigned by the institution and date of birth (see GEN.40750 in the CAP Laboratory General Checklist, available at http://www.cap.org ). Some institutions incorporate a billing or fiscal number in addition to the medical record number to track individual physician visits. If such a tracking system is in place, that number may also be included. Many institutions also use other patient identifiers, such as age and sex. Both age and sex are considered preferred elements because they give pathologists additional, readily accessible information that often has a clinical bearing on the case. Additionally, conspicuous reporting of age and sex may occasionally serve to highlight and resolve patient identity discrepancies. The name of the submitting physician must be included in the report; the submitting physician's office phone number, however, is a preferred element. Inclusion of the phone number is preferable because it gives readers direct, efficient access to the submitting clinician's contact information; however, some laboratories may elect not to include it because of clinician preference. Similarly, the submitting physician's pager information, URL, and facsimile number may be included; these data are considered less important than the clinician's direct office phone number. In addition to the submitting clinician, other clinicians who are to receive additional copies of the report must be included. This gives readers quick access to other physicians who are directly involved in the patient's care.

Clearly, the surgical pathology accession number is one of the most critical elements contained in the report because it serves as a unique identifier for the case. As such, the accession number should be prominently placed on the first-page header of the report. Additionally it must be placed on the header or footer of subsequent pages (see below).

The various elements that constitute the history portion of the report include the patient's clinical history provided by the clinician, preoperative diagnosis, postoperative diagnosis, and clinical laboratory data. Of these components, all but the relevant clinical laboratory data must be included in the report because they provide documentation of the information that is conveyed to the laboratory by our clinical colleagues and give the clinicians important feedback that the time they took to write a clinical history on the requisition slip was noted by the pathologist. These clinical data are often critical in the proper interpretation of the case. Relevant clinical laboratory data are often included in the SPR from particular anatomic sites, such as liver, renal, and bone marrow biopsies; inclusion of these data adds a more comprehensive view of the patient's underlying pathologic condition and obviates the need to look in multiple places for sometimes disparate laboratory and anatomic pathology results. In such cases, only the laboratory data relevant to the pathologic specimen should be included. Many modern laboratory information systems contain functionality that automatically imports particular laboratory results into reports to decrease the possibility of transcription errors.

The date of specimen collection and the date the specimen was received in the laboratory are critical data in the tracking of specimens and the creation of turnaround time reports; these data are also included in information that is sent to insurance companies for billing. As such, these elements are required. The time of specimen collection and the time that the specimen arrived in the laboratory are categorized as preferred elements. Tracking these times is important for accurate construction of turnaround time reports and may help resolve issues of specimen tracking in medical centers where ancillary personnel transport specimens to the surgical pathology laboratory. Additionally, inclusion of these times on the report more accurately communicates issues of turnaround time and chain of custody to the reader. Lastly, these data are becoming more critical as time of fixation and similar measures are needed to maximize standardization for biomarker interpretation. Prefixation ischemic time and fixation time are regarded as essential data elements by the CAP; however, they are categorized as preferred with the knowledge that these data may not be attainable in all circumstances and that some laboratories prefer to record these data internally rather than in the body of the report. Optionally, the site of specimen collection may be included as well and serves to inform the reader which department within the institution collected the specimen. This information might assist in specimen resolution or identity discrepancies.

The title of the report is an important component because it gives the reader a conceptual framework from which to interpret the report. Most laboratories simply use the title “Surgical Pathology Report.” However, some laboratory information systems allow various types of reports to create different formats that cater to various clinician subsets, for example, “Dermatopathology Report” or “Hematopathology Report.” The report type should be preceded or followed by the report status indicator. Report status indicators might include “Final Report” and “Addendum Report.” These designators inform the reader about the report's contents; for example, “Addendum Report” notifies the reader that the report's contents are intended to convey additional information that expounds on the original final diagnosis (see below for further details).

Both the page number and the total number of pages must be displayed on every page of the report, but they do not need to appear in the header on the first page (see below). The time and date that the original report was printed is a required element. This information gives the reader a time point from which further copies of the report can be referenced and, thus, can be instrumental in accounting for changes in the report's content over time, especially for addendums or amended reports. The actual time that a particular hard copy of the report is printed (“Report print date and time” in Table 1 ) is considered a preferred element; its presence on the report provides a comparison to the original report date and time and may, in certain circumstances, provide data to account for changes in the report's content.

Certain critical identifying elements must appear in the header or footer ( Table 2 ) of each page of the SPR after the first page. These elements include the patient's name, preferably in the same format as in the first-page header (see above), medical record number, and surgical pathology accession number. These components serve to inform readers of the patient's identifying information on each page and obviate potential identification issues should a multipage report be separated into individual pages. The report page number and total number of pages must appear so that the reader can account for every page in the report and can be informed of the total number of pages. The presence of the report print date and time could be useful to include because they tell the reader the age of the hard copy. If the print date is quite removed from the current day, it might alert the reader that a more current version of the report may exist.

In general, the diagnosis field ( Table 3 ) contains all the information that pertains to the pathologic diagnosis. Not surprisingly, this is perhaps the most highly examined portion of the report, and as such, it is often positioned directly after the header on the first page of the report.

Diagnosis Field

The SPR, by definition, gives readers diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen should be separated by a specimen designator, which may be arabic numerals, roman numerals, alphabetic characters, or should be clearly linked back to a summary table, such as the block summary or the list of submitted blocks in the gross description. Following this specimen designator, the specimen title appears, which includes the body site, body subsite, and surgical procedure and is typically formatted as “Body site, subsite, surgical procedure,” for example, Right breast, upper inner quadrant, excisional biopsy for calcifications.

If a portion of the specimen title is quoted directly from the surgical pathology requisition, it may be contained in quotation marks. The use of this format standardizes the specimen-labeling syntax and allows readers of SPRs to expect the same format from institution to institution. We understand that the inclusion of the surgical procedure portion of the specimen title might not be desirable because, in some institutions, the exact surgical procedure might not be known and may lead to discrepancies in the medical record should the procedure be assumed by the pathologist of record. Because of this possibility, we have classified the surgical procedure as a preferred element. The pathologic diagnosis is self-explanatory; however, there must be a diagnosis for each specimen submitted, and it should be placed in the report in such a way as to facilitate its easy identification by readers.

The use of cancer-reporting checklists has received much attention of late. These checklists have been created by several national and international associations and serve to standardize the reporting of key pathologic findings in definitive cancer resections. These checklists also ensure inclusion of all relevant pathologic parameters. Therefore, all information from the relevant cancer-reporting checklist should be included in appropriate cases. Laboratories may use any nationally or internationally approved reporting scheme, which might include those developed by the CAP ( http://www.cap.org , last accessed March 14, 2008), the Association of Directors of Anatomic and Surgical Pathology ( http://www.adasp.org/Checklists/checklists.htm , last accessed March 14, 2008), or the International Federation of Gynecology and Obstetrics ( http://www.figo.org/docs/staging_booklet.pdf , last accessed January 4, 2008) for gynecologic malignancies. It should be noted, however, that the use of the CAP templates is mandated in the standards for accreditation of tumor registries. Alternatively, institutions may elect to create one or more documents that fulfill their own particular clinical or individual needs. These homemade checklists should, at minimum, contain the mandatory elements present in nationally or internationally accepted checklists. Although a synoptic report format is not required, provided that all the checklist elements are included in the report, use of synoptic reports is strongly preferred because they have been shown to increase both the completeness of the reporting and the comprehension by the reader. 3 If reported synoptically, the checklist may appear in another field of the SPR; however, it should be referenced in the diagnostic fields (eg, “see tumor summary”).

Some laboratories use pictorial diagrams to visually identify the biopsy site, especially for the prostate or the gastrointestinal tract. These diagrams are purely optional and might appear within the diagnostic section or elsewhere in the report.

Most surgical pathology laboratories accession cases that have been previously interpreted by other laboratories, when second opinions are requested by pathologists or clinicians from other institutions. Additionally, when patients are referred from other institutions, their relevant pathology is often reexamined by the pathology department at the receiving institution. In these cases, the date of original specimen procurement, outside accession number, block/slide designations, and the name and location of the outside laboratory should be contained within the diagnostic field, for example, Left thigh, core biopsy (Beth Israel Deaconess Medical Center Department of Pathology, Boston, MA; S07-XXXXX, slide A; 1/1/06). This information must be included in every consultation report to ensure accurate documentation of the material examined. However, some laboratories might elect to include these data in the gross description field (see below) and, therefore, inclusion of these elements in the diagnosis field is regarded as preferred.

If applicable, the transcriptionist's name and initials are optional. The presence of the transcriptionist's initials on the report can aid in the resolution of typographical or transcription errors and would help in quality assurance issues surrounding report accuracy. However, this element is not mandatory because many laboratory information systems automatically store this information within its databases so that it can be accessed easily without requiring these initials on the report.

The gross/macroscopic description section ( Table 4 ) contains the written description of all tissue or removed foreign materials received by the surgical pathology laboratory; it also includes vital documentation of the specimen's handling within the laboratory and the tissue's disposition.

Gross/Macroscopic Description

The specimen title or designation is typically reproduced verbatim from the information contained on the surgical pathology requisition form. A list of these specimen designations following the specimen number might be organized in a tabular format that precedes or follows the gross description. Alternatively, it might be incorporated into the gross description itself.

The body of the macroscopic description is most commonly written in a prose style with each specimen described separately and separated into paragraphs. When series of similarly sized biopsies are described, most commonly in the case of prostate or gastrointestinal biopsies, some laboratories elect to condense the gross description of all specimens into one paragraph that aggregates the specimen measurements into one measurement (eg, “the specimens measure from 0.1 cm to 0.3 cm in greatest dimension”). Although this approach does simplify the gross description of specimens, we feel that the creation of separate gross descriptions for each specimen, with distinct sets of specimen dimensions, is preferable because this information can more accurately be used to resolve block or slide labeling discrepancies.

The body of the gross description begins with the specimen number, which is immediately followed by the designation written on the specimen label. As noted above, the specimen label should be reproduced verbatim from the label written on the specimen container. When there is no site designated on the specimen container or when there is a discrepancy between the sites designated on the specimen container and on the requisition, that information should be clearly stated in the gross description. Most often, the specimen label is followed by the state of the specimen upon receipt in the laboratory, which might include, for example, fresh or fixed in formalin.

The macroscopic description follows the specimen number, specimen label, and specimen state. The description should be a concise, yet substantive, description of the type of specimen, salient macroscopic findings, processing information, and the disposition of the tissue. A comprehensive description of the appropriate treatment and description of gross specimens is beyond the scope of this article, and many texts have been published on the subject. 4 , 5 However, all gross descriptions must contain the size and weight of the specimens, as appropriate. A description is required for the specimen's orientation, or lack thereof, and the presence of clinically important surgical margins. A detailed description of the of specimen's inking in relation to the specimen's orientation is a required element.

Other optional elements that might be included within this portion of the report include specimen diagrams. These graphics can be quite helpful in orientation of complex resection specimens. The inclusion of these diagrams clarifies the origin of microscopic sections taken from the specimen. However, the integration of specimen diagrams or photographs is difficult for some laboratory information systems, and thus, these materials may be kept in the paper record. If gross photographs were taken, a statement to that effect should appear in the report because it informs the reader about the existence of gross photographs; the same holds true for specimen radiographs. The name or initials of the grossing personnel must appear as a separate element in the report because it informs the reader of the person(s) who was responsible for grossing the case and is important for quality assurance and tracking of the specimen's chain of custody. As an optional element, the transcriptionist's name or initials may appear in the report. Again, the inclusion provides ready access to this information for all readers of the report. However, with most modern-day laboratory information systems, this information is easily accessed by laboratory staff; in which case, the transcriptionist's identifying information does not need to be present on the report.

One of the key portions of the gross description is the method by which the specimen was processed. Mandatory elements include the type of fixative or preservative in which the tissue was submitted and the presence or absence of decalcification. Inclusion of the type of fixative or preservative is critical in informing the reader about the state of the tissue and the existence of tissue fixed by other means. This information is particularly important as molecular testing becomes more commonplace because that testing often requires tissue be treated differently from routine formalin fixation. The presence or absence of decalcification treatment has direct billing implications because charging for decalcification ( Current Procedural Terminology code 88311) requires the process be documented in the SPR. Although decalcification performed must be documented in the report, the type of decalcification and the estimated time for decalcification are optional elements. The various types of commercially available decalcification solutions are known to variably affect the antigenicity of proteins in the tissue, which may significantly affect the results of immunohistochemistry. As such, the inclusion of the type of decalcification solution might inform the reader as to the state of the decalcified tissue. Similarly, the time the tissue was exposed to preservative or fixative can be an optional element in the report. Again, the time the tissue is exposed to fixative affects the results of the assays performed on that tissue. It is known that excessive or inadequate exposure to formalin fixation alters the reactivity of the tissue to certain antigens, 6 , 7 and thus, the documentation of fixation time will likely increase in importance as initiatives that call for the standardization of tissue-based assays increase. 8  

Another fundamental portion of the gross description section is the documentation of the tissue's disposition. Critical elements of this portion include a key to the paraffin blocks submitted; a tabular format is preferred because it is easier to read. However, many laboratories integrate the block key into the gross description. Further, a statement in the gross description or specimen key must include whether the tissue was submitted in its entirety or if it was sampled in a representative fashion. If additional blocks are submitted after the case has been signed out, they must be added to the report, typically, as an addendum report (see below); if the diagnosis is modified as a result of the findings in these additional blocks, that must be changed as well, usually in the format of an amended report (see below). Also, if tissue is procured for additional studies within the laboratory, such as flow cytometric, cytogenetic, or molecular testing, that must be mentioned within the gross description.

Increasingly, tissue is sent to ancillary laboratories for additional testing, stored for possible future research purposes, or sent to biorepositories. If any of these activities are performed, they must be documented in the report. In the case of additional testing done at an outside laboratory, the name of the outside laboratory must be included. Optionally, the preservation method for this retained material or tissue sent to outside laboratories might be included.

The format of the gross description is modified when slides from outside surgical pathology laboratories are examined. In this situation, required elements include the name and full address of the submitting laboratory (if available), the original date of service, and the outside accession number(s). The nature of the material received must be explicitly documented in this type of report, which includes the quantity of slides received, slide labels, type of stain present on the slides (eg, hematoxylin-eosin, trichrome stain), and paraffin block designators (if applicable). In the case of immunohistochemically stained slides, the stain name and antibody clone, if available, should also be included in the gross description. A sentence documenting that the patient's name and slide labeling information matches the accompanying original SPR is a preferred element. Addition of this statement explicitly confirms to the reader that this information was checked and verified by the accessioning personnel. Additionally, portions of the original gross description might be included in cases that require that information for full pathologic interpretation. For example, the tumor size should be included in cases of gastrointestinal stromal tumors because tumor size is a major determinant of prognosis. Although that information should be added to the gross description, it may appear in another area of the report, as necessary. Lastly, the disposition of the consult slides or blocks after the consult is an optional element (eg, “all slides and blocks were returned to the submitting institution”); that information provides explicit documentation of the handling of consult materials after the consultation is complete.

The intraoperative consultation (IOC; Table 5 ) is defined as a service performed on tissue resected in an operative setting that results in immediate information that affects the procedure as it is being performed. The elements that pertain to the IOC can be placed into a separate section of the report or, more commonly, can be integrated into the gross description. As described above in the diagnosis section, the IOC diagnosis should be preceded by the specimen designator, body site, and the surgical procedure. However, in the IOC section, the possibility of typographical errors or discrepancies in the specimen designator might result in unnecessary confusion when compared with the final diagnosis; as a result, some laboratories elect to exclude specimen designators from the IOC section, and they are, therefore, regarded as preferred elements. Possible intraoperative procedures include frozen section, gross examination, intraoperative cytology (eg, fine-needle aspirations, smear preparations), and dissection with the intent of procurement of tissue for ancillary procedures, including flow cytometry, cytogenetics, molecular studies, and electron microscopy. The exact procedure performed must be included in the report for both documentation and billing purposes. The IOC diagnosis is self-explanatory; however, at least one diagnosis must appear for each specimen examined in the intraoperative setting. Documentation about the pathologist(s) who rendered the IOC diagnosis must also appear. The time, date, and name of the physician or staff member who received the diagnosis are optional elements. The inclusion of this information in the report ensures its formal documentation in the patient's medical record.

Intraoperative Consultation (IOC)

Classically, the microscopic description section ( Table 6 ) describes the salient histopathologic findings of the case. However, in the modern era of high-volume surgical pathology laboratories, the microscopic description is becoming less common. Because this portion of the report does little to assist readers in the interpretation of the clinical impact of the diagnoses, the section is optional. However, many laboratories use this section to record the results of histochemical and immunohistochemical stains. If such results are entered here, the documentation of appropriate positive and negative control staining, as well as all pertinent information regarding the stain method or antibody clone used, should be included; if reference ranges are applicable, they might also be documented. The results of each special stain must be included in the report, although they need not be present in the microscopic description section. As mandated by the CAP Laboratory Accreditation Program, Anatomic Pathology Checklist, ANP.12425, a disclaimer regarding the use of class I analyte-specific reagents, if applicable, must be stated in reports that use these reagents. This disclaimer may appear in the microscopic description section or elsewhere in the report.

Microscopic Description (Optional)

The comments/notes field ( Table 7 ) is optional and typically includes supplementary information that documents or expounds on additional information that is directly relevant to the pathologic diagnoses rendered in the diagnosis section. These notes are usually added when subtleties of differential diagnosis or when correlation with the clinical, laboratory, or radiologic data is required. Further, this area might be used to document specimen discrepancies or to provide an explanation of disagreements in the interpretation of frozen section diagnoses.

Comments/Notes (Optional)

If previous pathology was reviewed in the course of interpretation of the case, the fact that this material was reviewed must be documented in the report (see also CAP Laboratory Accreditation Program, Anatomic Pathology Checklist, Item ANP.10050). When clinicians are contacted regarding the pathologic findings or to clarify aspects of the case, these conversations must be documented in the report. Potential scenarios where clinicians might be contacted regarding pathologic diagnoses include an unexpected finding of malignancy, the lack of chorionic villi in a missed abortion sample, or the unexpected finding of infectious organisms. In addition to the name of the clinician or medical staff, the time and date of the conversation might be included. Lastly, references to the relevant medical literature may be included. Many laboratories include this informational material in the case of rare or diagnostically difficult cases. The comment field may also contain recommendations for further treatment or biopsy from the pathologist.

An addendum report ( Table 8 ) is a type of ancillary report that contains additional information, typically the results of ancillary diagnostic studies completed after the original SPR has been released; addendum reports, by definition, only add information to a report that has been previously finalized. If the intent of this ancillary report is to change a previously rendered diagnosis or to change other content, then the report should be titled “Amended Report” (see below). For example, an addendum report might be issued to report the results of adjunct studies (eg, flow cytometry, electron microscopy, histochemistry, immunochemistry, immunofluorescence, molecular/genetic studies, cytogenetics, or microbiologic cultures of tissue), microscopic findings in additional or decalcified tissue sections, results of deeper sections if they do not change the diagnosis, the findings on slides from reprocessed or re-embedded blocks, and the results of extradepartmental consultations. If any of the ancillary studies were performed at an outside laboratory, the name and location of this laboratory must be included.

Addendum Reports

The name of the pathologist who signed out the addendum report, the original pathologist of record, and the date/time of addendum sign-out must also be included. However, the original sign-out pathologist need not be reproduced in the addendum if the original, final SPR is included when the addendum is printed or displayed electronically. If the results contained in the addendum were discussed directly with a physician or other medical staff, the name of the physician must, and the date and time of this conversation should, be included in the report for the purposes of documentation. Additionally, the name of the transcriptionist, if applicable, is optional.

Like addenda, amended reports ( Table 9 ) are added after the completion of the final report. However, amended reports are created to correct errors or discrepancies in the original final report. Typical reasons to create an amended report include correction of typographical errors, modification of the final diagnosis, or documentation of the resolution of a specimen-labeling discrepancy. In the case of typographical errors, an amended report must be issued only if that error could potentially lead to a misinterpretation of the diagnosis. When amended reports are created, the amended portion of the report must also include a reproduction of the original, unamended entry, or a reference to the incorrect information that was originally reported. It is generally desirable to provide an explanation as to why the amendment was created. The remaining elements listed in Table 9 are identical to those in the addendum section ( Table 8 ); see above for additional explanation.

Amended Reports

These other data elements ( Table 10 ) do not have an intuitive location within the report; however, that does not discount their importance. The critical elements in this table include the name of the sign-out pathologist(s) with the sign-out date and time. Although these data must appear somewhere in the report, the location of these entries varies. Some laboratories place these data into the header on the first page or immediately following the diagnosis, whereas others place the sign-out pathologist at the very end of the report. Most laboratories use electronic signature technology and, if applicable, the phrase “Electronically Signed by” must also be included. The name of the diagnosing pathologist should be preceded or followed by “Diagnosing Pathologist,” “Sign-out Pathologist” or similar wording. The pathologist's full name and credentials (eg, MD; MD, PhD; or DO) should be included. Some institutions may choose to add the name or initials of pathologists who are involved in specific portions of the pathologic examination. For example, if one pathologist performed the macroscopic examination and another examined the microscopic slides, the name or initials of the grossing pathologist might optionally be included in the report. The date of sign-out is a required element and is typically located adjacent to the sign-out pathologist's name. The time of sign-out is optional and might be included as data to facilitate quality assurance documentation, such as turnaround time reports. Many laboratories also include a statement attesting that the pathologist of record personally reviewed the pathologic material referenced in the report; this statement is an optional element because it only emphasizes the implicit responsibility of the sign-out pathologist. In laboratories that support pathology-training programs, the name or initials of the responsible trainee should be present. The inclusion of these data assist clinical staff in contacting the resident or fellow for additional information, if this is in agreement with hospital or departmental policy. Information pertaining to the patient's previous pathology testing may be included as an optional element. The inclusion of these data on the report gives readers quick access to information on the patient's previous pathology results. Additionally, the amount of information included in this element varies. Many laboratories simply list previous accession numbers, whereas others include the specimen designators as well.

Other Data Elements

Representative reproductions of photomicrographs or other images are included in the reports by some surgical pathology laboratories; however, their inclusion is optional. Additionally, some laboratories include educational or prognostic information, in certain instances. For example, some laboratories include the Partin tables, which are prognostic nomograms for prostatic adenocarcinoma, whereas others add diagrams and biopsy-site labels for both prostate biopsies and luminal biopsies of the gastrointestinal tract. Although the inclusion of this material might add some ancillary information to the interpretation of the report, it is considered strictly optional. Lastly, some laboratories include billing and diagnostic coding information in the report to more readily track that data. Possible codes that might be added include the International Statistical Classification of Diseases and Related Health Problems ( ICD-9 ), Current Procedural Terminology ( CPT ), and the Systematized Nomenclature of Medicine (SNOMED); again the inclusion of this information is optional.

The SPR is a critical document, used by many parties in medical care; it has the potential to guide diagnosis, treatment, and prognosis in a variety of disease processes. As such, this report must be clearly constructed and must include a variety of elements in pursuit of this goal. In this article, the Surgical Pathology Committee of the CAP puts forth its recommendations regarding the required, preferred, and optional elements that should be included in SPRs. Adoption of these guidelines will go far in standardizing these reports, which should minimize errors, and thus, improve patient care.

To provide feedback, please forward your comments to [email protected] or [email protected] . These and updated versions of these guidelines will be posted on the CAP Web site at http://www.cap.org .

These guidelines were developed by the College of American Pathologists' Surgical Pathology Resource Committee. We would like to thank Paul Valenstein, MD, for his thoughtful review of the manuscript. Additionally, we thank Douglas Murphy and Patricia Vasalos, for their able support of this effort, and Kumarasen Cooper, MBChB, for his insightful comments.

Additional members of the Surgical Pathology Committee include Mary Beth Beasley, MD; Hagen Blaszyk, MD; Daniel John Carter, MD; Liang Cheng, MD; Arthur R. Cohen, MD; Michael T. Deavers, MD; Megan K. Dishop, MD; Andrew L. Folpe, MD; Sanjay Kakar, MD; Robert H. Knapp, MD; Dylan V. Miller, MD; Talat M. Nazir, MBBS; Marisa R. Nucci, MD; Vijaya B Reddy, MD; Mary S. Richardson, MD DDS; and Marie E. Robert, MD.

The authors have no relevant financial interest in the products or companies described in this article.

Author notes

Reprints: Jeffrey D. Goldsmith, MD, Pathology and Laboratory Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 ( [email protected] )

Recipient(s) will receive an email with a link to 'Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology' and will not need an account to access the content.

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