#06-5558 Accrd Manual V7 - COLA

HISTOPATHOLOGY873. EAre unsatisfactory specimens identified and reported as unsatisfactory?The laboratory must define what constitutes an unsatisfactory specimen. This should include tissue specimensthat have inadequate material for a definitive diagnosis (too few cells, lack of proper preservative),specimens lacking identification or specimens which exhibit fixation artifacts that preclude diagnosis.874. EDo the reports use acceptable terminology of a recognized system of disease nomenclature in reportingresults?Tissue examination reports should use the terminology of a recognized system of disease nomenclature asestablished by international medical societies and organizations and published in medical journals andmedical text-books.875. EAre all consultations within the laboratory or with other laboratories documented in the final report?The histopathology laboratory must maintain records of all consultations both within the laboratory andwith other laboratories. These consultations should be documented in the final tissue examination report.876. EAre discrepancies between frozen section reports and final reports reconciled in the final report?Whenever there are differences between a frozen section diagnosis and the final report, the discrepanciesmust be reconciled in the final report. Discrepancies can result from sampling differences between the frozensection slides and additional permanent section slides, poorer resolution in frozen sections compared withpermanent sections or the additional information available from special studies on permanent sections.877. EAre discrepancies between prior tissue examination reports and current final reports reconciled in the finalreport?878. EDoes the laboratory notify the patient’s physician and issue amended reports, if significant discrepancies areidentified upon review of previously reported examinations?The laboratory should have a policy regarding when amended reports are required and a mechanism to documentdiscrepant findings when identified. The surveyor will assess the laboratory’ adherence to stated policybased on review of discrepancy files.879. EDo all corrected or amended reports issued by the laboratory indicate the basis for the change in the report?The laboratory shall establish the format of reports.880. EDoes the histopathology laboratory meet the general examination report requirements for COLA accreditation?The laboratory shall be in compliance with all criteria in this subsection, as well as general COLA criteria forLaboratory Reports (PST 3 – PST 16).104. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org