Each case in VipLIMS has one report. The report is built from the sections in the case type's template, and once authorised, it becomes a fixed version that cannot be changed. This article explains how to write, code, authorise and issue a report, and how to add a supplementary report later.
Before you start
- You need the Pathologist role (your laboratory may call it Doctor, Consultant or Scientist) and the case must be assigned to you and accepted. See Case workflow.
- Your Administrator should have checked the report templates for your case types. Templates in speciality packs are examples and must be reviewed before live use.
Report sections
The sections you see depend on the template for the case type. A histopathology template might include:
| Section | Typical content |
|---|---|
| Clinical details | The clinical information supplied with the request |
| Macroscopy | Description of the specimen as received |
| Microscopy | Microscopic findings |
| Conclusion | The diagnosis or summary |
| Comment | Further explanation, recommendations or notes for the clinician |
Other laboratory types use different sections. Administrators can adjust templates in Settings.
Step 1: Write the report
- Open the case from your Worklist or from Cases.
- Start the report. The case moves to In progress.
- Type into each section. Basic formatting such as bold, italics, lists and tables is available.
- To reuse text from Word, copy it and paste it in. The formatting is kept.
Your work is saved automatically as you type, so you will not lose it if you are interrupted.
Step 2: Complete synoptic forms
If the template includes a synoptic form, such as a structured cancer dataset, complete each item in the form. Synoptic answers are stored as structured data and printed in their own block on the report.
The content of synoptic forms shipped in speciality packs is illustrative. Your laboratory must make sure each form matches the current dataset it follows.
Step 3: Add codes
- In the coding area of the report, start typing a term or code.
- Choose the matching entry from the terminology packs your laboratory has enabled, such as SNOMED CT.
- Add as many codes as you need.
If the terminology you need is not available, ask your Administrator to enable or import it. See Importing terminology.
Step 4: Send for a second check (optional)
Some laboratories require a second person to check reports before release. If yours does:
- When the report is complete, send it for authorisation.
- The case moves to Awaiting authorisation.
- The authorising pathologist reviews it and authorises it.
Step 5: Authorise
- Read the whole report through.
- Authorise the report.
Authorising does three things:
- it creates a fixed version of the report, recording who authorised it and when. That version can never be edited;
- it moves the case to Reported / Completed;
- it makes the report visible to the referring institution in the referrer portal.
Where several pathologists are assigned to a case, the primary pathologist normally authorises the main report. The others can add supplementary reports afterwards.
Step 6: Download or print
Every authorised report can be produced as:
| Format | Use it for |
|---|---|
| Printing, emailing and filing. Uses your laboratory letterhead | |
| Word | Where a recipient needs a copy in Word format for their own records. Uses your letterhead |
| Plain text | Pasting into other systems that cannot accept formatted documents |
All three are produced from the same authorised version, so their content is the same.
Sending results electronically to other systems through HL7 or FHIR interfaces is on our roadmap, not yet available.
Adding a supplementary report
If further information arrives after authorisation, such as additional test results or a second opinion:
- Open the case.
- Add a supplementary report.
- Write and authorise it in the same way as the main report.
Supplementary reports never overwrite the original. They appear on the report in date order, and the case status becomes Supplementary added. The referrer can see each supplementary report once it is authorised.
What if I made a mistake?
You cannot edit an authorised version. This protects the record and is what accreditation bodies expect. Instead, add a supplementary report that explains the correction. The original version, the supplementary report and the audit trail together show exactly what was issued and when.