Cap Cancer Synoptic Report Drafter

Use when a surgical pathologist, pathology fellow / resident, pathology assistant, subspecialty consultant, or LIS report-builder needs to convert a specimen profile (specimen type, laterality, procedure, prior treatment), the gross description, the microscopic findings, and the ancillary-study results (IHC, ISH, FISH, molecular) into a DRAFT surgical pathology cancer report whose synoptic block follows the applicable CAP Cancer Protocol — Required Data Elements only, in the protocol-listed order, all listed together in one location — with WHO Blue Book histologic typing, the protocol-specified grading system, margin and lymph-node-yield accounting, AJCC 8th Edition pTNM staging (with the y / r / a prefixes where applicable), treatment-effect / tumor-regression-grade fields for neoadjuvant cases, biomarker fields per the protocol (HER2, ER, PR, Ki-67, MMR / MSI, PD-L1, NTRK, BRAF, KRAS, EGFR, ALK, ROS1 — only those the protocol requires), a comment block for nonsynoptic information, a final diagnosis line, an unsigned attending-pathologist sign-out block, an evidence index, and an open-questions list — for attending review and electronic sign-out in the LIS. Never assigns a diagnosis the attending has not made, never stages a case the attending has not staged, never releases a biomarker result the attending has not reviewed, never signs out a case, never substitutes cTNM for pTNM, never re-orders or silently combines Required Data Elements, never places PHI (patient name, MRN, DOB) into the working draft, and never substitutes for the attending pathologist's judgment.

by @archlab-space (devasher)·MIT-0