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General Practitioner Template

Histology Result

A professional General Practitioner template for healthcare professionals.
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About this template

Streamline your clinical documentation with our 'Histology Result' template, meticulously designed for General Practitioners and other specialists managing patient pathology. This template simplifies the recording of crucial biopsy and specimen findings, ensuring all essential details from macroscopic descriptions to microscopic analyses and final diagnoses are captured accurately. Ideal for GPs referring patients for biopsies, it helps maintain comprehensive patient records and facilitates informed decision-making. Utilise Heidi's AI medical scribe to automatically populate this template from your consultations, ensuring consistent, detailed, and easily retrievable histology reports without missing vital information like specimen type, pathology lab, or the requesting consultant. Enhance your practice's efficiency and diagnostic workflow with this indispensable tool.

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Date of Procedure: 1 November 2024 Specimen/Specimen Type: Excisional biopsy of skin lesion from left forearm, 0.8 cm diameter. Pathology Lab: City General Hospital Pathology Department Requesting Consultant: Dr. Eleanor Vance, GP Clinical Information: 45-year-old male with a darkly pigmented, irregularly shaped mole on his left forearm, noted to have changed in size and colour over the past 3 months. Suspected melanoma. Macroscopic/Gross Description: - Irregularly shaped, dark brown to black skin ellipse measuring 1.2 cm x 0.9 cm x 0.4 cm. - Central raised area of 0.7 cm diameter with focal ulceration. - Margins appear clear grossly. Microscopic Description: - Histological examination reveals an atypical melanocytic proliferation within the epidermis and dermis. - Features consistent with superficial spreading melanoma, Breslow thickness 0.9 mm. - Invasion noted into the papillary dermis. - No evidence of lymphovascular invasion or perineural invasion. - Surgical margins are clear; closest margin 0.2 cm at the deep aspect. - Mitotic rate: 2 mitoses/mm². Diagnosis: Superficial Spreading Melanoma, left forearm. (ICD-10: C43.6) Comments: Further discussion regarding sentinel lymph node biopsy is recommended given Breslow thickness. Pathologist: Dr. Thomas Kelly, Consultant Histopathologist. IMC Registration: 12345 Date of Report: 1 November 2024
Date of Procedure: [Date of procedure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Specimen/Specimen Type: [Specimen type including tissue or sample description] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Pathology Lab: [Name or location of pathology or histology lab] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a lab name.) Requesting Consultant: [Name and title of requesting doctor, consultant, or specialist] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a clinician name.) Clinical Information: [Relevant clinical information provided with the specimen] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Macroscopic/Gross Description: [Macroscopic or gross description of the specimen including size, shape, colour, and texture as described] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use as many lines or bullet points as needed.) Microscopic Description: [Microscopic description of the specimen including histological findings as described] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use as many lines or bullet points as needed.) Diagnosis: [Diagnosis as stated by the clinician based on pathological findings including condition name and ICD-10 code if available] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) Comments: [Any additional comments or notes on the report] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Pathologist: [Full name and title of pathologist] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a clinician name.) [Pathologist Medical Council, IMC, or statutory registration number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Date of Report: [Date of report] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (Never include patient details, assessments, plans, interventions, evaluations, or plans for continuing care that have not been explicitly mentioned in the transcript, contextual notes, or clinical note. Do not state in your output that information has not been mentioned. Simply omit the relevant section entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
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Specialty

General Practitioner

Used

1 times

Type

Note

Last edited

17/3/2026

Created by

Isabelle Fallon

Heidi AI

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