Processing the Products of Surgery (including Surgical Specimens and Excised Tissue)
POLICY: The Processing of Specimens and Communicating Biopsy
Communication of biopsy results to the patient in a timely
fashion is important.
Polyps or other tissue from colonoscopy and/or biopsy
from upper endoscopy
The surgeon must document in the operative report the number,
type and condition of all exempt specimens, for example,
'Exempt specimen removed: one grossly cataractous lens', etc.
In the case of exempt status, the material may or may not be
sent for examination, at the discretion of the surgeon, with
the exception that all tissues must be sent for examination
when a biopsy is the primary purpose of the procedure.
When possible, prepare labels, requisition forms, and proper
containers prior to the excision/surgery.
Excised or collected specimens for pathologic examination
will be carefully identified with the name, the source of the
specimen, the date and time, patient age and gender,
provider's name, and studies required. Specimens should be
packaged, per the directions of the pathology services which
will be conducting the testing. Confirmation of the patient,
specimen and other information will be the responsibility of
the clinical personnel in attendance and this confirmation
will be performed before placing the specimen container in
the pickup area. During this identification time, staff
participating in this process will not be interrupted.
All excised tissue should be maintained on the sterile
surgical field in a safe, visible location until the surgeon
approves removal. However when it is removed, the container
will be labeled immediately with all required information.
Should the specimen be a needle aspiration, the specimen
should be delivered to a container rather than sent for
examination in a syringe.
All labels on specimens should clearly identify the need for
precautions and the presence of biohazardous materials.
Specimen labels must be legible and only utilize acceptable
The specimen is kept in the laboratory specimen box until
pickup by the laboratory. If the box is in a common hallway,
outside the building or other unsecured area, the box is
tapper proof. Pickups are arranged via a telephone call to
the laboratory and occur on the same day.
The patient's chart will indicate that a specimen(s) has been
sent to pathology. The specimen log will be completed for
each patient on whom a specimen was sent as well as the
number of specimens, the laboratory where the specimen was
sent and upon receipt of the pathology report, documentation
that the report was returned to the organization.
The pathologist's report referable to the examination of any
specimen should become a part of the respective patient
record and when applicable a copy sent to the surgeon.
In the case of surgical specimen procedure:
All specimens are tracked to assure that reports are received
on every specimen that is sent out of the facility.
1. Surgical specimens will be transported to the pathology
laboratory for examination.
2. Routine specimens will be transported immediatetly The
pathology results will be overnight mailed to the
organization within 72 hours per agreement.
3. Once the pathology results are received they will be
reviewed by the provider of care responsible for this
4. If the biopsy is negative the patient will be notified
by phone and mail.
5. If the biopsy is positive/malignant the patient will be
notified phone and mail
6. Should the organization be unable to reach the patient
to communicate the results of a pathology report after
7 days, the following will occur. Chart, physician,
referring physician will be notified
Approved By Governing Board