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    
Control #64.9