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Difference between revisions of "Anatomical pathology laboratory processes"
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Anatomical pathology laboratory processes (view source)
Revision as of 11:26, 7 December 2012
, 11:26, 7 December 2012→The list of data elements
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**123 = case number. | **123 = case number. | ||
*Patient identifier, i.e. medial record number (MRN) or medical care plan (MCP) number. | *Patient identifier, i.e. medial record number (MRN) or medical care plan (MCP) number. | ||
**First name. | **Demographics: | ||
**Middle name(s). | ***First name. | ||
**Last name. | ***Middle name(s). | ||
**Date of birth. | ***Last name. | ||
**Sex. | ***Date of birth. | ||
***Sex. | |||
*Clinician identifiers. | *Clinician identifiers. | ||
**Who ordered the test. | **Who ordered the test. | ||
| Line 101: | Line 102: | ||
***One container = at least on diagnosis. | ***One container = at least on diagnosis. | ||
***Anatomical site of the parts, e.g. kidney biopsy. | ***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. | |||
*Grossing report - description of each part: | *Grossing report - description of each part: | ||
**Specimen dimensions, +/-weight, type of tissue. | **Specimen dimensions, +/-weight, type of tissue. | ||
| Line 118: | Line 123: | ||
**Diagnosis comment. | **Diagnosis comment. | ||
**Synoptic reports. | **Synoptic reports. | ||
**Date report signed. | |||
**Consultant reports. | |||
**Clinician contacts (recorded). | |||
**[[Addendums]]. | |||
**[[Amendments]]. | |||
==See also== | ==See also== | ||