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#**Data entry - clinical history. | #**Data entry - clinical history. | ||
#**+/-Case assignment. | #**+/-Case assignment. | ||
#Grossing. | #[[Gross pathology|Grossing]]. | ||
#*Pathology assistant/pathology resident/pathologist. | #*Pathology assistant/pathology resident/pathologist. | ||
#**Gross report. | #**Gross report. | ||
Line 17: | Line 17: | ||
#Staining. | #Staining. | ||
#*Routinue stains. | #*Routinue stains. | ||
#*Special stains. | #*[[Special stains]]. | ||
#*[[Immunostains]]. | #*[[Immunostains]]. | ||
#Case assembly and distribution. | #Case assembly and distribution. | ||
#Diagnosis. | #Diagnosis. | ||
#*Pathologist. | #*Pathologist +/- pathology [[resident]]. | ||
#**Tasks: | #**Tasks: | ||
#***More tissue. | #***More tissue. | ||
#***Levels/deepers. | #***[[Levels]]/deepers. | ||
#***Special [[stains]]. | #***Special [[stains]]. | ||
#***Immunostains. | #***Immunostains. | ||
#***Write report. | #***[[Sign out|Write report]]. | ||
#****Consult other pathologists - in house | #****Consult other pathologists - in house (internal consult) or outside (external consult). | ||
#****Discuss with clinician. | #****Discuss with clinician. | ||
==Data elements - sequential== | |||
===Prior to arrival to the lab=== | |||
*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 one [[diagnosis]]. | |||
***Anatomical site of the parts, e.g. kidney biopsy. | |||
The above information is all contained on the requisition. | |||
===Accessioning=== | |||
*Case identifier, e.g. 12:SU123. | |||
**12 = year. | |||
**SU = surgical case. | |||
**123 = case number. | |||
===Grossing=== | |||
{{Main|Grossing}} | |||
*Description of each part: | |||
**Specimen dimensions, +/-weight, type of tissue. | |||
**Identification of [[gross pathology]] - and characterization/description. | |||
**Submission of tissue - in "blocks". | |||
***Each block is described in the gross report. | |||
===Tissue processing=== | |||
*Tissue is sent through the tissue processor - processing dependent on tissue type. | |||
**Date, time, batch recorded. | |||
===Embedding=== | |||
*Tissue is oriented and surrounded by wax. | |||
**Histotechnologist doing this is recorded. | |||
===Cutting=== | |||
*Tissue is cut from the block. | |||
**Pieces of tissue sent to the pathologist are tracked as "levels". | |||
**Who cut the tissue is tracked. | |||
Notes: | |||
*The thickness of the sections can make a difference in the interpretation.<ref name=pmid1915756>{{Cite journal | last1 = Otto | first1 = MJ. | last2 = Löw | first2 = O. | last3 = Schneider | first3 = A. | title = The nominal section thickness--importance of their correction for morphometry. | journal = Exp Pathol | volume = 42 | issue = 3 | pages = 129-36 | month = | year = 1991 | doi = | PMID = 1915756 }}</ref> | |||
**Routine sections are cut at 3-4 micrometres. | |||
***3 micrometres is considered ideal for GI biopsies and prostate biopsies.<ref>LE. 20 January 2015.</ref> | |||
***4 micrometres is a recommendation for immunostains.<ref>{{cite journal |authors=Magaki S, Hojat SA, Wei B, So A, Yong WH |title=An Introduction to the Performance of Immunohistochemistry |journal=Methods Mol Biol |volume=1897 |issue= |pages=289–298 |date=2019 |pmid=30539453 |pmc=6749998 |doi=10.1007/978-1-4939-8935-5_25 |url=}}</ref> | |||
***Sections for [[Congo red|Congo red]] are usually ~10 micrometres. | |||
===Staining=== | |||
*This is done with automated processors. | |||
**When and by who they are run is tracked. | |||
===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. | |||
**Demographics: | |||
***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. | |||
**Time/date. | |||
***When the test was ordered. | |||
***When the lab received the specimen. | |||
***When the specimen was placed into formalin. | |||
**Clinical history. | |||
*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. | |||
**Date report signed. | |||
**Internal messages: | |||
***Clinician contacts (recorded). | |||
***Intradepartmental consults. | |||
**[[Addendum]]s. | |||
***Consultant reports. | |||
***Additional tests. | |||
***Additional opinions that concur with the primary opinion. | |||
**[[Amendment]]s. | |||
==See also== | ==See also== | ||
*[[Quality]]. | *[[Quality]]. | ||
*[[Fixation]]. | *[[Fixation]]. | ||
*[[Laboratory information system]]. | |||
==References== | |||
{{Reflist|1}} | |||
==External links== | |||
*[http://protocolsonline.com/histology/sample-preparation/paraffin-processing-of-tissue/ Sample preparation (protocolsonline.com)]. | |||
[[Category:Quality]] | [[Category:Quality]] |
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