These are your unique identifying information. Your name, age, gender, hospital number and a unique surgical pathology identification number which is found on the left upper outer corner. This number starts with PB / XXXX / YEAR. This ensures that no two patients even if they have the same name are mixed up. Accessioning starts the moment the patient submits a specimen to our laboratory.
This gives a history of your condition and the reason for requesting the histopathological test. In addition, it states the type and site where a sample was taken from and the procedure that was done with any relevant findings.
This is a description of the specimen which was received at the laboratory. It documents the characteristics of every tissue that is received as a baseline for further microscopic examination. In addition, it documents how the specimen was sampled for processing. Finally, it lists the number of samples that are taken from each specimen, ensuring that adequate samples from relevant positions are taken and documented. These samples ultimately provide the information needed to make a diagnosis, type a tumor, grade a tumor and finally stage it when they are examined under the microscope.
This is a description of the microscopic appearances of every specimen submitted to the histopathology laboratory. It forms the basis for rendering histopathological diagnosis. In addition, it describes criteria for grading, staging and determining the adequacy of excisions.
States the diagnosis as well us grade and stage of cancer if applicable.
These include immunohistochemistry (IHC) and insitu hybridization (ISH). Holds information on any further tests done to determine prognosis or for drug therapy