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    This document provides a reporting proforma for axillary fine needle aspiration cytology (FNAC). The proforma collects key patient details like name, date of birth, sex, hospital, and dates. It records information about the procedure such as the side and location of the lymph node sampled and the cytological opinion which is categorized from 1 to 5 based on the level of suspicion of malignancy. Space is provided for comments. SNOMED codes are included to classify the tumor and morphology. The pathologist and date the report was made are also recorded.

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    This document provides a reporting proforma for axillary fine needle aspiration cytology (FNAC). The proforma collects key patient details like name, date of birth, sex, hospital, and dates. It records information about the procedure such as the side and location of the lymph node sampled and the cytological opinion which is categorized from 1 to 5 based on the level of suspicion of malignancy. Space is provided for comments. SNOMED codes are included to classify the tumor and morphology. The pathologist and date the report was made are also recorded.

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    2 views1 page

    For Axillary

    Uploaded by

    John Smithy
    This document provides a reporting proforma for axillary fine needle aspiration cytology (FNAC). The proforma collects key patient details like name, date of birth, sex, hospital, and dates. It records information about the procedure such as the side and location of the lymph node sampled and the cytological opinion which is categorized from 1 to 5 based on the level of suspicion of malignancy. Space is provided for comments. SNOMED codes are included to classify the tumor and morphology. The pathologist and date the report was made are also recorded.

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    Appendix I Reporting proforma for axillary FNAC

    Surname: ……………………………… Forenames: ………………… Date of birth: …………….…


    Sex: ….………………………………… Hospital: …………….………. Hospital no: ...………….…..
    NHS no: ……………………………….. Date of surgery: ……………. Date of report: ………....…..
    Authorisation: …………………………. Report no: ………………….. Date of receipt:…….……….
    Pathologist: …………………………… Surgeon: ……………………………………….…………..…

    Side†: Left □ Right □

    Location†: Axillary LN □

    Cytological opinion†: LC1 □ (Inadequate/unsatisfactory)


    LC2 □ (Benign)
    LC3 □ (Uncertain)
    LC4 □ (Suspicious)
    LC5 □ (Malignant)

    Comment:
    .............................................................................................................................................................

    .............................................................................................................................................................

    SNOMED† codes: T …….… M …..……

    Date reported ............................................. Pathologist ............................................

    †
    Data items which are currently part of the Cancer Outcomes and Services Dataset (COSD) version 8.

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