Protocol for dictating BAL specimens with generic examples

IdentificationPathologist's name; dictating Cytology Case PHC01-1234; Patient's name John Doe; MRN 123-45-6789
AdequacySatisfactory for interpretation (from pulldown menu, not free text)
Primary interpretationNegative for malignant cells (from pulldown menu, not free text)
Secondary free text interpretationNegative for fungal organisms, Pneumocystis, and viral inclusions. Numerous macrophages and lymphocytes seen.
Diagnosis Comment(if any)
Clinical Diagnosis and HistoryThe patient is a 54 year old man status post lung transplant
Ranking CodeN1
Tissue CodeTC1
Agreement FlagAgree, Partially Disagree, or Completely Disagree