#06-5558 Accrd Manual V7 - COLA

HISTOPATHOLOGY>Do the tissue examination reports include:865. EA comparison of clinical information, when available in the laboratory, with the tissue examination report?866. EA review of all prior tissue examination slides and reports, if applicable?The laboratory should establish a mechanism documenting and tracking incidents when discrepancies arisebetween current and prior findings.867. EA correlation of all special stains, immunohistochemical stains and electron microscopic photomicrographs, ifappropriate?868. EAre all reviews completed before patient results are reported?For the final report to be of full use to the attending physician, any relationship between the current case andprior histology exams must be considered in the total context. Initial reports and frozen section reportsshould be communicated to the ordering physician without delay, so as to permit ongoing diagnostic and/ortreatment decisions. However if further information comes to light the laboratory must immediately updatethe ordering physician.869. EAre records of initial examinations and all intra- and extra-departmental consultations documented andretained by the laboratory?870. EWhenever a verbal report of frozen section examinations is given, does the pathologist communicate personallywith the surgeon?Frozen sections are often used by surgeons help determine the type and extent of surgery while the patientremains under anesthesia. Any miscommunication of frozen section results from the pathologist to the surgeoncan have dire consequences. Verbal reports from the pathologist must be communicated personally tothe surgeon rather than through and third party.The laboratory shall have a Quality Assessment Program, which addresses all aspects of the operation of thehistopathology laboratory.871. EDoes the histopathology laboratory meet the general quality assessment requirements for COLA accreditation?The laboratory shall be in compliance with all criteria within this subsection (864- 870) and General QualityAssessment requirements (QA 1 – QA 22).Reporting ResultsThe laboratory shall establish and follow written policies and procedures to ensure the appropriate evaluationand reporting of histology results.872. EDo qualified personnel examine and authorize reports before their release?Only those personnel meeting the requirements to qualify as a technical supervisor in histopathology mayauthorize reports. Refer to personnel tables to determine qualifications of specific individuals.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org103