Documenting Surgical Pathology Requests

---
name: documenting-surgical-pathology-requests
language: en
description: Structures surgical pathology requisitions with clinical history, specimen description, and specific diagnostic questions. Use when submitting pathology specimens, writing pathology requisitions, or requesting special studies.
tags:
  - documentation
  - surgery
  - clinical
  - surgical
metadata:
  author: casemark
  practice_areas:
    - General Surgery
    - Surgical Subspecialties
  document_types:
    - Clinical Documentation
  skill_modes:
    - Documentation
---

# Documenting Surgical Pathology Requests

Structures surgical pathology requisitions with clinical history, specimen description, and specific diagnostic questions.

## Why This Skill Exists

Surgical pathology requisitions are a critical handoff between the operating surgeon and the pathologist. The College of American Pathologists (CAP) reports that inadequate clinical information on requisition forms is one of the top causes of pathology errors, diagnostic delays, and the need for addendum reports. A vague requisition like "tissue — please examine" forces the pathologist to guess the clinical question, potentially leading to missed margin assessments, incorrect specimen orientation processing, or failure to order necessary ancillary studies.

Joint Commission standard PC.02.01.01 requires that specimens be labeled and accompanied by sufficient clinical information. CAP accreditation standards further require that clinical history accompany every specimen. This skill ensures that every pathology requisition provides the pathologist with the information needed to answer the right clinical question on the first pass.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What specimen(s) are being submitted? (List each separately.) **Default: [VERIFY — obtain from operative report]**
2. What is the clinical or pre-operative diagnosis? **Default: [VERIFY]**
3. Is there a specific diagnostic question (e.g., margin status, lymph node metastasis, degree of dysplasia)? **Default: routine histologic examination**
4. Was the specimen oriented with sutures or ink? If yes, describe the orientation scheme. **Default: not oriented**
5. Was the specimen sent fresh, in formalin, or requiring frozen section? **Default: formalin-fixed**
6. Is there a prior pathology report that the pathologist should reference? **Default: no**
7. Were any intraoperative consultations (frozen sections) performed? **Default: no**
8. Are special studies anticipated (immunohistochemistry, flow cytometry, molecular testing, cultures)? **Default: routine H&E only**

### Documents to Request

- Operative report with specimen descriptions
- Prior pathology reports from biopsies or previous resections
- Relevant imaging reports (tumor size, location, extent)
- Tumor board or multidisciplinary conference recommendations
- Molecular test requisitions (if send-out testing planned)
- Institutional specimen handling protocol for the specimen type

---

## Step 1: Specimen Identification and Labeling

Each specimen container must be labeled with:

| Required Field | Description | Example |
|---|---|---|
| Patient name | Full legal name | Jane A. Doe |
| MRN | Medical record number | 123456 |
| Date and time of collection | When removed from patient | 2025-03-15 10:32 |
| Specimen source | Anatomic site with laterality | Right breast, upper outer quadrant |
| Specimen designation | Container identifier matching requisition | Specimen A |
| Collector identity | Surgeon or designee | Dr. Smith |

**For multiple specimens from the same case**: Number containers sequentially (Specimen A, B, C) and ensure each container label matches the corresponding line on the requisition form. Never place specimens from different anatomic sites in the same container.

**Orientation markers**: Document the suture or ink scheme used (e.g., "short suture = superior, long suture = lateral, double stitch = deep margin"). Confirm the pathologist receives this information in writing.

---

## Step 2: Clinical History and Context

Provide a structured clinical narrative including:

1. **Reason for surgery** — What prompted the operation (e.g., suspicious mass on imaging, failed medical management, malignancy staging).
2. **Relevant clinical findings** — Physical exam findings, imaging characteristics (size, location, LI-RADS or BI-RADS category), tumor markers (CEA, AFP, CA 19-9, PSA).
3. **Prior pathology** — Reference any prior biopsy results by pathology accession number (e.g., "Core biopsy S25-12345: invasive ductal carcinoma, ER+/PR+/HER2-negative").
4. **Treatment history** — Prior chemotherapy, radiation, or surgery to the same site that may alter histologic appearance (treatment effect).
5. **Specific clinical concern** — State explicitly what you need the pathologist to evaluate beyond routine examination (e.g., "Please assess all six margins individually," "Rule out lymphovascular invasion," "Evaluate for treatment effect per CAP synoptic protocol").

---

## Step 3: Specimen Description and Handling Instructions

For each specimen, document:

- **Specimen type**: Excisional biopsy, segmental resection, total organ, lymph node dissection, etc.
- **Dimensions**: If measured in the OR, provide three-dimensional measurements in centimeters.
- **Condition**: Intact vs. fragmented, opened vs. unopened (e.g., bowel segments should be sent unopened if tumor location must be assessed).
- **Fixation**: Formalin-fixed (routine), fresh (for frozen section, flow cytometry, cytogenetics, research), or special medium (Michel's for immunofluorescence, glutaraldehyde for electron microscopy).
- **Special handling requests**: Fresh tissue for tumor bank, touch preps, cultures, molecular testing.

**Frozen section requests** must include:
- Specific question to answer (e.g., "Is the deep margin positive?" not "frozen section please")
- Whether the surgeon is waiting in the OR for results
- Contact phone number for callback

---

## Step 4: Synoptic Protocol Selection

For oncologic resections, specify the applicable CAP cancer protocol:

| Tumor Site | CAP Protocol | Key Elements |
|---|---|---|
| Breast | Breast Invasive Carcinoma | Margins, LVI, receptor status, nodes |
| Colon | Colon and Rectum | Depth of invasion (pT), nodes examined (≥12), MMR/MSI |
| Lung | Lung — Non-Small Cell | Margins, pleural invasion, lymph nodes |
| Thyroid | Thyroid — Differentiated | Extrathyroidal extension, margin, variant |
| Skin (melanoma) | Melanoma of Skin | Breslow depth, ulceration, mitotic rate, margins |
| Prostate | Prostate Gland (Radical) | Gleason/ISUP grade, margins, EPE, SVI |

Include the AJCC staging edition applicable (currently 8th edition) and request synoptic reporting.

---

## Step 5: Ancillary Testing Requests

Document any additional studies needed:

- **Immunohistochemistry (IHC)**: Specify markers (e.g., ER, PR, HER2, Ki-67, PD-L1, ALK, MMR panel)
- **Molecular testing**: KRAS/NRAS/BRAF, EGFR, microsatellite instability (MSI-H), BRCA, next-generation sequencing panel
- **Flow cytometry**: For lymphoma workup — submit fresh tissue in RPMI or saline
- **Cytogenetics/FISH**: HER2 FISH if IHC equivocal (2+), ALK FISH for lung adenocarcinoma
- **Microbiology**: Tissue for culture (bacterial, fungal, AFB) — send in sterile container, not formalin

State whether testing should be performed in-house or sent to a reference laboratory, and whether results are needed for a tumor board date.

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Does each specimen container label match the corresponding requisition line exactly?
2. Is the clinical history sufficient for the pathologist to understand the diagnostic question without reviewing the entire chart?
3. Are orientation markers described on the requisition and communicated to the pathology team?
4. Have specimen handling requirements (fresh, formalin, special media) been correctly ordered?
5. Are ancillary testing requests documented with the correct specimen and handling method?

---

## Quality Audit

- [ ] Every specimen container is labeled with patient name, MRN, date, anatomic site, and laterality
- [ ] Requisition form completed for each specimen with matching container designation
- [ ] Clinical history includes reason for surgery and relevant prior pathology with accession numbers
- [ ] Specific diagnostic question stated explicitly (not just "please examine")
- [ ] Orientation scheme documented if specimen was oriented with sutures or ink
- [ ] Fixation method specified and appropriate for requested studies
- [ ] Frozen section requests include specific question and callback number
- [ ] CAP synoptic protocol identified for oncologic resections
- [ ] Ancillary testing requests specify markers, method, and specimen handling
- [ ] Multiple specimens from different sites are in separate, correctly labeled containers
- [ ] Prior treatment history documented if it may alter histology
- [ ] AJCC staging edition specified for cancer specimens
- [ ] Specimen chain of custody documented (collector, transporter, receiver)

---

## Guidelines

1. Never place multiple specimens from different anatomic sites in the same container — this creates an irrecoverable labeling error.
2. Always state the specific clinical question you need answered; "pathology" is not a sufficient order.
3. For oriented specimens, use a consistent institutional suture-marking convention and confirm the pathologist has received the orientation key.
4. Fresh tissue for molecular testing or flow cytometry must reach pathology within 1 hour of removal — coordinate with pathology before the case begins.
5. Reference prior pathology accession numbers so the pathologist can directly compare current and prior histology.
6. For synoptic cancer reports, verify that all elements required by the AJCC/CAP protocol can be assessed from the specimen submitted — if not, document what is missing and why.
7. When requesting frozen section, the clinical question must be answerable on frozen section (margin assessment = yes; receptor status = no).
8. If the specimen was damaged, fragmented, or inadvertently opened in the OR, document this on the requisition so the pathologist can account for it in their gross description.