[Histonet] Grossing question

[Vickroy, Jim]

Our pathologists are wanting to know what other places do with regards to one part of our gross descriptions.

Before CoPath we always had to dictate at the first that the specimen container and the req each had the  patient name..... (John Doe). If the req. was slightly different than the containers such as one might have a proper name and one might have the legal name we had to state that and also dictate how we determined what the legal name was. (such as comparing demographic material, calling the patient, etc.)

When Copath started up we changed to only using a req. and specimen template that simply said, The req. and specimen container each have the same patient name.  We did not dictate small discrepancies such as noted before.   CoPath allowed us to document the information but in order to clean up our gross descriptions we did not enter the problem in the gross description unless it was a major problem such as the site designated on the req. does not match the site listed on the container. We are also using CoPath's automated barcoded tracking which of course has many identifiers.

We also require that all containers have two forms of identification, such as name, DOB, site of biopsy, alternate id number, ss. Security number, etc when submitted to the pathology department.  It is also protocol that the grossers look at all containers and the req to compare identifiers.   Difference between now and the past is that we do not include this in the typed gross description.  What the pathologists want to know is what are others dictating?

We will be implementing Dragon dictation soon and have heard of other institutions using a general template at the beginning of the gross description.

Could anyone share what they are doing with their gross descriptions?

Thanks

James Vickroy BS, HT(ASCP)

Surgical  and Autopsy Pathology Technical Supervisor
Memorial Medical Center
217-788-4046


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