#06-5558 Accrd Manual V7 - COLA

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CYTOLOGY>Reporting ResultsThe laboratory shall establish and follow written policies and procedures to ensure the appropriate evaluationand reporting of cytology results.782. EDo qualified personnel review and authorize reports before their release?Refer to COLA personnel tables to define education and experience requirements for personnel.783. EDoes the technical supervisor confirm each gynecologic slide reported to show reactive or reparative changes?Does the technical supervisor confirm each gynecologic slide reported to show squamous cell changes toinclude any of the following:784. EAtypical squamous cells of undetermined significance (ASC-US) or cannot exclude HSIL (ASC-H)?785. ELSIL-human papillomavirus (HPV)/mild dysplasia/cervical intraepithelial neoplasia 1 (CIN 1)?786. EHSIL-moderate and severe dysplasia, carcinoma-in-situ (CIS)/CIN 2 and CIN 3 or with features suspicious forinvasion?787. ESquamous cell carcinoma?Does the technical supervisor confirm each gynecologic slide reported to show glandular cell changes toinclude any of the following:788. EAtypical cells not otherwise specified (NOS) or specified in comments (endo-cervical, endometrial, or glandular)?789. EAtypical cells favor neoplastic (endocervical or glandular)?790. EEndocervical adenocarcinoma-in-situ?791. EEndocervical, endometrial or extrauterine adenocarcinoma and adenocarcinoma NOS?792. EDoes the technical supervisor confirm each gynecologic slide reported to show other malignant neoplasms?793. EDoes the technical supervisor review and sign all non-gynecologic specimen reports?794. EDoes the technical supervisor review and sign all gynecologic specimen reports with the diagnoses listed inquestions 783-792?If a computer report is generated, the electronic signature must be authorized by the technical supervisorwho performed the review.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org91
CYTOLOGY795. EAre unsatisfactory specimens or slide preparations identified and reported as unsatisfactory?The laboratory must establish and follow criteria for defining specimen adequacy, to include required cellularity,obscuring blood or inflammation, and sampling of the transformation zone (lack of an endocervicalcomponent). See questions 727-729 also.796. EDo the reports contain a narrative description of the nomenclature for all results?Cytology reports should use the terminology of a recognized system of disease nomenclature as establishedby international medical societies and organizations and published in medical journals and medical textbooks.797. EDoes the laboratory notify the patient’s physician and issue amended reports, indicating the basis for the correction,if significant discrepancies are identified 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 survey will assess the laboratory’ adherence to stated policybased on review of discrepancy files.The laboratory shall establish the format of reports.798. EDoes the cytology 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).In addition to the general requirements for the examination report, does the cytology report include at leastthe following required information:799. EAge or birth date?800. EAccession number?801. EName and signature of reporting cytotechnologist, general supervisor, technical supervisor or pathologist?802. EA narrative explanation of the morphologic findings?803. EComments and recommendations as appropriate?804. EIf a computer report is generated with an electronic signature, is the signature authorized by the individual whoperformed the examination and made the diagnosis?If a computer report is generated, the electronic signature must be authorized by the technical supervisorwho performed the review.92. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org
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#06-5558 Accrd Manual V7 - COLA

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