Appropriate format of diagnostic line:
All diagnostic lines should be formatted as shown below.
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Organ, subsite, procedure:
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Brain, frontal lobe, right, needle biopsy
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These lines must include the surgical procedure as best as the pathologist can determine.
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If a diagnosis is more than one line, the diagnoses should be divided into separate lines defined by letters.
Brain, parietal lobe, biopsy-
A. Metastatic adenocarcinoma consistent with colon primary
B. Gliosis
A. Metastatic adenocarcinoma consistent with colon primary
B. Gliosis
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A diagnostic line must be created for each separate part of a submitted specimen.
Part 1: Dura, right biopsy-
Chronic inflammation
Part 2: Brain, temporal lobe, left, needle biopsy
A. Adenocarcinoma
B. Focal atrophy
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Microscopic comment: If a comment is not generated, a “canned” comment must be placed in the body of the report:
“Microscopic examination substantiates the diagnosis indicated above.”
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Attestation statement: must be placed somewhere in the report. This will be done automatically in Client Server for all but Children's cases.
“My signature is attestation that I have personally reviewed the gross specimen(s) and/or glass slides of the submitted material(s) and that the above diagnosis reflects this evaluation.”
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To insert the attestation statement for Children’s cases please do the following:
Add two hard paragraph returns below the Final Diagnosis (or below the Comment, if there is one)
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Type in “attest” and click on the Quick Text button.
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NEW DIAGNOSIS OF A TUMOR AT CHILDREN’S HOSPITAL MUST HAVE A SECOND PATHOLOGIST CONCUR.
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Before the case is signed out:
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Go to the QA Diagnosis Review in the Task Menu
Scroll down the options and choose “Review type: Second Review (newly diagnosed tumors”.
Enter in name of the pathologist and choose “agree”.
Close
Enter in name of the pathologist and choose “agree”.
Close
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Gross only specimens: Same format but after diagnosis indicate in parentheses: “gross diagnosis only”.
Peritoneum, left inguinal, herniorrhaphy-
Hernia sac (gross diagnosis only)
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Stains and number of slides performed on a case: at bottom of report there must be a list of stains which includes (This will be automatically in Client Server):
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# of H&Es
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# and type of special stains
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# and type of immunostains
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Example:
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3 H&E*
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1 PAS
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1 PASD
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1 S100
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1 cytokeratin
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*Decal H&Es must be separately designated.
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Recommendation for gross processing prior to CoPath entry:
Every block should be designated by the part # (1, 2, 3, etc.) and a letter (usually beginning with A). Each submitted cassette needs to have a description of what it represents.
Example #1: After a description of a temporal lobe –“Sections submitted as follows:
1A – anterior pole
1B – posterior margin
1C – hippocampus
1D – purple 1.5 cm hemorrhage nodule
1B – posterior margin
1C – hippocampus
1D – purple 1.5 cm hemorrhage nodule
Example #2: If the above specimen in example #1 also had a part #2 submitted, after the gross description of the part #2 specimen, e.g. dura and temporal bone:
2A – representative portion of dura
2B – representative portion of bone
2B – representative portion of bone
Frozen sections: In the body of the pathology report, there must be a written record of the intraoperative diagnosis rendered on this material. The frozen diagnosis should have the same format as the final diagnosis but it is placed in an “intra-operative consultation” section of the report at the end of the gross description. See examples.
Part # Intraoperative Consultation: Brain, temporal lobe, needle biopsy (Touch prep, smear, FS):
Neoplastic/non-neoplastic/defer. (These are the only options)
Free text description.
Free text description.
Frozen section slides should be labeled with the patient's last name and first initial in addition to the specimen part number and FS, TP or smear description. A subletter (FSA/FSB) indicates if two portions of the same specimen part were frozen. These designations should be in pen on the overlying slide label.