What Is Surgical Pathology?
Pathological reports are usually divided into fast frozen pathological reports and conventional pathological reports. The former refers to the removal of part of the patient's diseased tissue by the surgeon during the surgery, and immediately sent to the pathology department for fast frozen section staining, observation by the pathologist under a microscope, and the results are informed to the surgeon, so that the surgeon can judge Resection range pathology report. The quick freeze report is usually used to diagnose the tumor resection of tumor patients and the infiltration of cancerous tissue in cancer patients, and requires results within 30 minutes. Routine pathological report refers to the steps of fixing, removing, dehydrating, embedding, and sectioning the tissue removed from the patient after the operation is completed, and then HE staining, special staining, immunohistochemistry, fluorescence in situ hybridization, etc. according to the disease situation Technology to diagnose the disease and provide pathological reports for clinical follow-up treatment.
Pathology report
- Chinese name
- Pathology report
- first part
- Visual inspection of biopsy tissue
- the second part
- Describe the results observed under the microscope
- the third part
- Give a professional diagnosis
- Pathological reports are usually divided into fast frozen pathological reports and conventional pathological reports. The former refers to the removal of part of the patient's diseased tissue by the surgeon during the surgery, and immediately sent to the pathology department for fast frozen section staining, observation by the pathologist under a microscope, and the results are informed to the surgeon, so that the surgeon can judge Resection range pathology report. The quick freeze report is usually used to diagnose the tumor resection of tumor patients and the infiltration of cancerous tissue in cancer patients, and requires results within 30 minutes. Routine pathological report refers to the steps of fixing, removing, dehydrating, embedding, and sectioning the tissue removed from the patient after the operation is completed, and then HE staining, special staining, immunohistochemistry, fluorescence in situ hybridization, etc. according to the disease situation Technology to diagnose the disease and provide pathological reports for clinical follow-up treatment.
- The pathology report includes: the appearance of the biopsy tissue, cell structure, and pathological changes or no pathological changes found. The pathology report is crucial for the doctor and patient in charge, because the treatment and what kind of treatment depends on the results of the pathology report.
- first part
- The first part of the pathology report is a visual inspection of the biopsy tissue. Include the full picture of the biopsy tissue, the location of the biopsy, the shape of the suspicious cancer, and whether the edges are clear. The size of the biopsy tissue, such as diameter or length, and weight (in metric units, such as centimeters and grams) should also be described. Using the standard unit of measurement, 2.5 centimeters equal 1 inch, and 454 grams is about 1 pound.
- the second part
- The second part of the pathology report describes the results observed under the microscope. include
- 1. After the pathology report is issued, if non-principle problems are found (such as incomplete diagnosis, or some special examinations required by the clinician to be reported), the form of the report can be modified.
- 2. After the pathology report is issued, if a principle problem is found (such as a wrong diagnosis or a wrong report entry), changes must be made and the clinician must be notified immediately.
- 3. Due to some reasons (including deep sectioning, supplementary material detection, special staining, immunohistochemical staining, decalcification, consultation of difficult cases or prolonged fixation of infectious specimens, etc.), delaying material acquisition, film preparation, or other related technologies When the test fails to sign the pathological diagnosis report as scheduled, the relevant clinician or patient must be informed orally or in writing, explaining the reason for the late pathological diagnosis report.
- 4. Each supplementary or altered pathological report follows the supplementary or altered pathological report system and review and approval process, and must be completely recorded in the pathological file.
- 5. Physicians who issue supplementary, modified or late pathological diagnosis reports are authorized to implement them.
- 6. The compliance rate of pathological report signing and authorization documents is 100%.
- 7. Complete information confirms the effective implementation of the above system.
- 1. Supplementary procedures for pathological diagnosis report: [1]
- 1) After the pathology report is issued, after the self-examination or the clinician finds a problem, such as the discovery of non-principles (such as incomplete diagnosis, or reporting some special examinations requested by the clinician), first communicate with the clinician;
- 2) If the clinician writes, enters incorrectly, or needs to perform some special inspections, the clinician must provide written notification of the change, and the pathologist will modify it in the form of a supplementary report.
- 3) If the pathologist writes, enters incorrectly, or advises the clinician to perform some special examinations on the patient, oral communication with the clinician is required before modification in the form of a supplementary report.
- 4) The above situation must be completely recorded in the pathological file.
- 2. Change procedure of pathological diagnosis report:
- 1) After the pathology report is issued, if a principled problem is found (such as a wrong diagnosis or a report input error), changes need to be made, and the clinician must be notified immediately to explain the reason for the wrong pathological diagnosis report.
- 2) Immediately change the pathology diagnosis report to the clinic and retract the previous error report.
3) The above situation must be completely recorded in the pathological file.
- 3. Late procedure for pathological diagnosis report:
- 1) Due to some reasons (including deep sectioning, supplementary material detection, special staining, immunohistochemical staining, decalcification, difficult case consultation or prolonged fixation of infectious specimens, etc.), delayed material acquisition, film preparation, or other related technologies When the test fails to sign the pathological diagnosis report as scheduled, first inform the clinician or patient concerned orally or in writing, explaining the reason for the late pathological diagnosis report.
- 2) Discuss and formulate the fastest solution with the relevant staff of the pathology department according to the cause and situation of the late onset.
- 3) Communicate with the clinician or the patient, both sides agree to the plan, and agree to follow the plan.
- 4) If the clinician or the patient does not agree with the plan, the plan needs to be re-drafted until the clinician or the patient agrees, and implemented according to the plan agreed by both parties.
- 5) The above situation must be completely recorded in the pathological file.