Optional data elements are identified with and although not required for CAP accreditation purposes, “+” may be considered for reporting as determined by local practice standards. The use of this protocol is not required for recurrent tumors or for metastatic tumors that are resected at a different time than the primary Use of this protocol is also not required for pathology reviews performed at a second institution (ie, secondary consultation, second opinion, or review of outside case at second institution). Synoptic Reporting All core and conditionally required data elements outlined on the surgical case summary from this cancer protocol must be displayed in synoptic report format. Synoptic format is defined as: Data element: followed by its answer (response), outline format without the paired "Data element: Response" format is NOT considered synoptic. The data element should be represented in the report as it is listed in the case summary. The response for any data element may be modified from those listed in the case summary, including be “Cannot determined” if appropriate. Each diagnostic parameter pair (Data element: Response) is listed on a separate line or in a tabular format to achieve visual separation. The following exceptions are allowed to be listed on one line: Anatomic site or specimen, laterality, and procedure Pathologic Stage Classification (pTNM) elements Negative margins, as long as all negative margins are specifically enumerated where applicable The synoptic portion of the report can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all Data element: Responses must be listed together in one location Organizations and pathologists may choose to list the required elements in any use additional methods in order to enhance or achieve visual separation, or add optional items within the synoptic report. The report may have required elements in a summary format elsewhere in the report IN ADDITION TO but not as replacement for the synoptic report ie, all required elements must be in the synoptic portion of the report in the format defined above. CAP Laboratory Accreditation Program Protocol Required Use Date: 2018 CAP Prostate Protocol Summary of Changes Version 4.0.3.0 Significant modifications and additions to the Biopsy Case Summaries
Optional data elements are identified with “+” and although not required for CAP accreditation purposes, may be considered for reporting as determined by local practice standards. The use of this protocol is not required for recurrent tumors or for metastatic tumors that are resected at a different time than the primary Use of this protocol is also not required for pathology reviews performed at a second institution (ie, secondary consultation, second opinion, or review of outside case at second institution). Synoptic Reporting All core and conditionally required data elements outlined on the surgical case summary from this cancer protocol must be displayed in synoptic report format. Synoptic format is defined as: Data element: followed by its answer (response), outline format without the paired "Data element: Response" format is NOT considered synoptic. The data element should be represented in the report as it is listed in the case summary. The response for any data element may be modified from those listed in the case summary, including “Cannot be determined” if appropriate. Each diagnostic parameter pair (Data element: Response) is listed on a separate line or in a tabular format to achieve visual separation. The following exceptions are allowed to be listed on one line: Anatomic site or specimen, laterality, and procedure Pathologic Stage Classification (pTNM) elements Negative margins, as long as all negative margins are specifically enumerated where applicable The synoptic portion of the report can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all Data element: Responses must be listed together in one location Organizations and pathologists may choose to list the required elements in any use additional methods in order to enhance or achieve visual separation, or add optional items within the synoptic report. The report may have required elements in a summary format elsewhere in the report IN ADDITION TO but not as replacement for the synoptic report ie, all required elements must be in the synoptic portion of the report in the format defined above. CAP Laboratory Accreditation Program Protocol Required Use Date: 2018 CAP Prostate Protocol Summary of Changes Version 4.0.3.0 Significant modifications and additions to the Biopsy Case Summaries
cp-malegenital-prostate-18protocol-4030.docx