Endocrinology Pathology Assessment Form
Please complete this form to review and assess pathology cases related to endocrinology.
Patient Initials
*
Date of Birth
*
-
Month
-
Day
Year
Date
Referring Clinician Name
*
Date of Pathology Review
*
-
Month
-
Day
Year
Date
Specimen Type
*
Please Select
Thyroid biopsy
Adrenal gland biopsy
Pituitary tissue
Parathyroid tissue
Other
Clinical Diagnosis (if available)
Pathology Findings Assessment
*
Rows
Adequacy of specimen
Cellularity
Atypia
Inflammation
Other relevant features
Unsatisfactory
1
2
3
4
5
Satisfactory
6
7
8
9
10
Indeterminate
11
12
13
14
15
Not applicable
16
17
18
19
20
Overall Diagnostic Confidence
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Ancillary Studies Performed
Immunohistochemistry
Molecular testing
Cytogenetics
Other
Final Pathology Diagnosis
*
Comments or Recommendations
Reviewer Full Name
*
First Name
Last Name
Reviewer Role
*
Please Select
Pathologist
Resident
Fellow
Other
Submit Assessment
Should be Empty: