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  • Appropriate format of diagnostic line:
    • All diagnostic lines should be formatted as shown below.
      • Organ, subsite, procedure:
        Brain, frontal lobe, right, needle biopsy
      • These lines must include the surgical procedure as best as the pathologist can determine.
    • 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 diagnostic line must be created for each separate part of a submitted specimen.

      Part 1: Dura, right biopsy-

      Chronic inflammatio

      Part 2: Brain, temporal lobe, left, needle biopsy

      A. Adenocarcinoma

      B. Focal atrophy

  • 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.”

  • 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.”

    • 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)
      • Type in “attest” and click on the Quick Text button.

    • Before the case is signed out:
      • 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
  • Gross only specimens: Same format but after diagnosis indicate in parentheses: “gross diagnosis only”.

    Peritoneum, left inguinal, herniorrhaphy-

    Hernia sac (gross diagnosis only)

  • 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):
    • # of H&Es
    • # and type of special stains
    • # and type of immunostains
    • Example:
      • 3 H&E*
      • 1 PAS
      • 1 PASD
      • 1 S100
      • 1 cytokeratin
    • *Decal H&Es must be separately designated.

  • 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
      • 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

  • 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.
    • 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.