Difference between revisions of "Anatomical pathology laboratory processes"

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 ===Case assembly===
 *Who does this is tracked.
+==The list of data elements==
+*Case identifier, e.g. 12:SU123.
+**12 = year.
+**SU = surgical case.
+**123 = case number.
+*Patient identifier, i.e. medial record number (MRN) or medical care plan (MCP) number.
+**First name.
+**Middle name(s).
+**Last name.
+**Date of birth.
+**Sex.
+*Clinician identifiers.
+**Who ordered the test.
+**Where the case is sent to - ordering physician, other physicians.
+*Specimen descriptors:
+**How many parts, i.e. how many containers.
+***One container = at least on diagnosis.
+***Anatomical site of the parts, e.g. kidney biopsy.
+*Grossing report - description of each part:
+**Specimen dimensions, +/-weight, type of tissue.
+**Identification of [[gross pathology]] - and characterization/description.
+**Submission of tissue - in "blocks" - tissue may be completely submitted (in toto) or incompletely submitted (representative).
+***Each block is described in the gross report.
+***Each block is tracked in the process.
+*Block information:
+**Number of blocks - for each part.
+*Slides - generated from the block.
+**Type of cut on each block (levels, deepers).
+**Slides distributed to the pathologist are numbered.
+**Type of stain/immunostain recorded.
+*Pathologist - elements.
+**Microscopic description.
+**Diagnosis.
+**Diagnosis comment.
+**Synoptic reports.
 ==See also==

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