Anatomic Pathology Specimen Collection Guidelines
Proper specimen handling requires that specimen integrity be maintained by proper preservative (where required), and that the sample identification and patient identification is clearly labeled on the specimen container and test requisition. The information listed below is to assist with that objective.
1. Provide general information
All histology specimens received by the laboratory must be accompanied by a completed surgical pathology requisition which includes the following information:
- Patient’s full name
- Physician(s) name
- Social Security number
- Date of specimen collection
- Patient’s date of birth
- Patient’s gender
- Source of specimen (anatomic site)
- Brief clinical history/pre-operative diagnosis (CLIA requirement)
- Billing information
Correct patient sample labeling is confirmed by comparing all information listed on the specimen container to information written on the requisition and information verbalized by patient or responsible party (if minor or unable to do so).
Verbal verification of the source, nature, number of specimens and appropriate container/preservative occurs between physician and nursing staff prior to delivery of the specimen to the laboratory.
Tissue specimens received in the laboratory after 4:30 pm on weekdays, and on weekends or holidays will be evaluated by laboratory staff to see that they are properly preserved to prevent cellular degeneration, but testing will be held until the next routine processing day.
2. Label specimen containers
- Specimen containers are not pre-labeled, but instead are labeled immediately after the specimen is placed into the container.
- Specimen containers are labeled with the patient’s complete name, a second patient identifier, date of birth, and specimen (anatomic) site.
- Specimens are labeled with patient identification on the bottle, not on the cap. Multiple specimens are placed in individual bottles.
- The surgical specimen is properly identified by listing WHAT the specimen is (mass, tumor, bone, etc.) and WHERE (anatomical site) it was obtained. Include whether the specimen is from a RIGHT or LEFT anatomical site. Sterilization specimens (tubes and vas) are sent in separate containers and labeled as “right” or “left.”
- A review of the completeness and accuracy of the requisition in comparison with the labeling of the specimen container and patient occurs prior to leaving the procedural site.
3. Please follow specimen requirements
Most specimens (but not all) are preserved and delivered to the lab in 10% formalin to avoid cellular degeneration (see specimen listing below for specimens that are not to be placed in formalin). Formalin and a variety of specimen containers are available from individual histology laboratories. Use approximately 3-4 times tissue volume in formalin (30 ml minimum).
- Specimen should be submitted to the laboratory flattened/opened in a tissue cassette.
Frozen tissue sections
- Call the pathology office to inform personnel of scheduled/unscheduled frozen sections.
- Send to lab in sterile container or zip-lock bag with no added fixative
- All labeled specimens are to be accompanied by a surgical pathology requisition printed or stamped with the patient identification criteria, operating suite, and phone numbers.
- Schedule first with histology/pathologist staff at least 24 hours in advance; not to be done after hours or on Fridays.
- Submit immediately to laboratory (before noon) on saline moistened gauze.
Muscle and nerve biopsy
- Inform histology/pathologist staff at least 24 hours in advance; not to be done after hours or on Fridays.
- Muscle/nerve specimen must be wrapped in a moist telfa pad. Bring immediately to laboratory.
Renal calculi analysis
- Use a clean dry screw-capped container (urine container) to submit the specimen(s) to the Laboratory.
- Label clearly with patient’s complete name and date of collection.
- Submit with appropriate requisition.
Cytology FNA intraoperative adequacy
- Call pathology office at least 24 hours in advance to schedule the adequacy procedure.
Please note: Policy on release of surgical specimens to patients No TISSUE specimens will be released to patients.