The “Surgical Pathology; Patient Delivery” protocol provides instructions for preparation of slides and/or blocks to be sent to an outside institution; pickup and delivery of the slides/blocks is by the patient or patient designee.
Always discourage patient carry; offer to send directly to the reference laboratory, whenever possible.
Only staff trained in the Anatomic Pathology send out area are to prepare surgical pathology slides/blocks for referral. If a request must be processed during off-hours, the Pathologist on-call must be contacted.
1. Obtain relevant clinical information and supporting documents from the requesting source. Including:
A. The original request for material send out received from the doctor’s office. If the material is requested by the patient, a signed consent for Authorization to Release Health Information must be completed.
B. The name of the reference laboratory, name of the physician and department to whom the slides/blocks are to be delivered; including physician’s full address, telephone number and FAX number.
C. The patient name, date of birth and case number(s)
D. A signed consent form for the release of slides/blocks (see II.7.)
Note: "Authorization to Release Health Information" form is stored in the Pathology Forms folder within the UCL Forms folder on the Medusa server. A form can be printed directly to a local printer from this document.
E. Loan of Anatomic Pathology form.
F. The date the materials are to be ready for pickup.
2. Locate the slides/blocks and corresponding pathology report.
Note: Place a marker in the block/slide drawer indicating what was sent, when, where it was hand carried by the patient.
3. Contact the Pathologist of record to review the slides.
Note: If the Pathologist of record is unavailable, another Pathologist should be contacted.
4. After the review, the Pathologist will select the slides/blocks to be sent.
Note: The slide and/or block preparation for referral is to be carried out to its completion at the time the request is made. Partial completion is not acceptable, in that after-hours pickups would require untrained staff and personnel to complete the task.
5. Record the following information in the SSO tab in CoPath:
A. Requesting physician and the date of the appointment, if possible
B. Patient name
C. Case number(s)
D. Number of slides and/or blocks sent
Note: Indicate the specific slides/blocks, i.e. A1X4, A2, etc.
E. Other (i.e.: letter or frozen tissue)
F. Destination physician and institution address
G. Date of pick-up/send-out
H. Transported (indicate mode of transport as well as the preparer’s initials)
Note: If the patient pick-up will be from another facility (e.g. Oncology) attach a note to the materials requesting the staff at the pick-up facility to get the form signed and return the signed form to UCL-Pathology Dept.
6. Packaging: The slides/blocks are placed into the appropriate transport containers.
Note: If blocks are being sent between May and September, indicate the material should be kept in a cool place.
A. A copy of the corresponding report is placed in the padded mailing envelope accompanying the slides and/or blocks.
B. Include patient insurance information.
Note: Insurance information may be needed if the material is left with the consulting physician(s) and they send off to another area pathologist or laboratory.
C. Staple a “NOTE TO PATIENT” form to the material prepared for patient carry. Place a copy of the Loan of Anatomic Pathology form along with the Authorization to Release Information form with the prepared material. Indicate when the patient appointment is scheduled and with whom on the Loan of Anatomic Pathology form.
A. Pickup at UCL: If the patient or their designee is coming to UCL to pick up the material, the consent form must be signed and witnessed by UCL office person at that time. The signed consent is scanned into the image gallery of CoPath and retained in the designated file in the Pathology Department.
B. Pickup at another facility: If the material is being picked up at another facility, send the consent form with the slides and attach a note to the staff at the pick-up facility instructing them to have the patient sign and witnessed by office the form and return the signed form to UCL-Pathology Dept to be scanned and filed.
8. Return of slides and/or blocks:
Record in the SSO what materials were returned, the date returned and the initials of the person responsible for logging them in.
Note: If all materials are not returned, record this in the SSO. Contact the referral institution and inform them: “Our company and liability carrier requires our retention of all materials. They may continue to use them while the patient is being cared for in their institution”. Exceptions should be discussed with the Pathology Associates (PA) Pathologist who originally read the slides or, if not available, another PA Pathologist.
9. Receipt of the consultation report from the referral institution:
Record, in the SSO, the date the report was received and to whom it was given; initial the entry.
A. Attach a “CoPath Pics Plus” form to the report, “x” the CORRELATION NECESSARY box and give to the Pathologist who is currently reviewing correlations, along with the CoPath report. Enter the information in the Anatomic Correlations book located in the paperwork office. The book is divided by Pathologist. Enter the case information on the sheet corresponding to the Pathologist on the case. If more than one doctor is involved, make sure all see it.
B. Notation is made in the “Inter-Departmental Anatomic Pathology Correlations Log” by the Pathologist, whether he/she agrees or disagrees with the findings.
C. The report is distributed according to the Pathologist’s direction on the “CoPath Pics Plus” form.
i. September 2002 D. Willis
ii. March 2003 N. Schmitt/D. Willis (Revised: for patient delivery only)
iii. July 2010 A. Kass, L. Theisen (Revised: II.1.A-F., 5.D.,G.,H.;
Interim Review: September 2011 B. Wederquest (Revised: II.2., 5.A., 6., 7., 9.)