The Flow Of Specimens And Documents

At the time of autopsy, the pathologist selects the gross specimens for preliminary storage. On the back of our preliminary autopsy diagnosis forms, instructions are given for further processing of the specimens, including requests for refrigeration, fixation, preparation for organ review, mounting for museum display (see Chapter 15), photography, roentgenography, and gross staining. Xerox copies of these diagnosis and instruction sheets are prepared for the staff and resident pathologists, the autopsy technicians, and the institutional files. Material for deep freezing and for microbiologic, chemical, or other studies is labeled and sent directly from the autopsy room, together with the appropriate request forms.

When a gross specimen is to be saved, it is immediately identified with a plastic tag that shows the autopsy number and, for paired organs, the side (we identify sides with one punched-out notch for right and two, for left). In the autopsy laboratory, gross specimens are processed as indicated by the written instructions. As a rule, they are stored in plastic containers until the histologic slides have been reviewed by a pathologist. Thus, additional material can be retrieved if the need arises.

Additional clinical information, unsuspected microbiologic test results, histologic findings, or other information may create a need for further study of stored organs, tissues, or body fluids. However, after that has been accomplished, some or all wet specimens can be discarded. If an institutional tissue registry is available, organs intended for permanent storage are entered into the record book or computer file of the autopsy gross tissue laboratory. On completion of the final autopsy diagnosis, designated gross specimens are sent to the tissue registry for permanent storage.

We keep specimens for microscopic examination in "stock bottles" with formalin solution. These bottles contain fragments of all organs, tissues, and lesions. The case number is inscribed on a plastic tag inside the jar and on a label on the outside. Tis sues requiring special identification or fixatives are kept in separate jars. After material for histologic study has been selected, the remaining tissues in the stock bottles are trimmed and transferred to Sealac bags with fresh formalin solution (see below: "The Institutional Tissue Registry: Storage Methods"). In institutions with appropriate recording and storage facilities (tissue registries), bottles or bags with fixed tissue samples can be saved permanently. If, in such a setting, a pathologist desires to review an old specimen or needs old blocks or slides, a request card, fax, or E-mail message is sent to the autopsy tissue laboratory where the records are kept. A computerized list will reveal whether the specimen is still available. In institutions with a properly run tissue registry, the list will state where stored specimens, blocks, or slides can be found. After the review is completed, the material is returned and the computer records are updated.

For further details about autopsy documents, see Chapters 17 and 18.

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