There are several requirements pertaining to surgical pathology reports including gross description in CAP's anatomical pathology checklist regarding to surgical pathology and autopsy service:
- GEN.40491 “Primary Specimen Container Labeling”
- All primary specimen containers are labeled with at least two patient-specific identifiers.
- The laboratory has a written policy with criteria for acceptable labeling of primary specimen containers AND
- Specimen collection procedures with defined labeling specifications OR
- Records of audits for compliance with specimen labeling policies and procedures.
- ANP.11670 “Specimen - Gross Examination”
- Written instructions or guidelines are readily available in the laboratory for the proper dissection, description, and histologic sampling of various specimen types (e.g. mastectomy, colectomy, hysterectomy, renal biopsy, etc.).
- ANP.11610 “Gross Examination Qualifications”
- If individuals other than a pathologist or pathology resident assist in gross examinations, such individuals must qualify as high complexity testing personnel. Grossing is defined as a tissue examination requiring judgment and knowledge of anatomy. This includes the dissection of the specimen, selection of tissue, and any level of examination / description of the tissue, including color, weight, measurement, or other characteristics of the tissue. The laboratory director may delegate the dissection of specimens to non-pathologist individuals; these individuals must be qualified as high complexity testing personnel under the CLIA regulations.
- ANP.12350 “Cancer Protocols”
- Reports must include the required data elements from the current edition of the CAP Cancer Protocols. The laboratory has up to eight months from the posting date of the CAP Cancer Protocol to implement data element changes.
- ANP.12385 “Synoptic Reporting”
- Data elements required by applicable CAP Cancer Protocols are reported using a synoptic format in at least 90% of the eligible surgical pathology reports.
- This checklist item indicates that paired required data element: response format is required.
- For example, required data element “tumor size” must be indicated followed by the response (tumor size: 7.5 cm).
- Outline format without the paired required data element: response format is not considered synoptic.
- Attention must be paid to formatting as some reports may be difficult to read. In fact, the checklist item ANP.12385 allows the use of additional methods to enhance or achieve visual separation such as the use of headers, indentations, bolding, or font variations.
- ANP.33200 “Gross and Microscopic Descriptions”
- Gross descriptions are clear and pertinent findings are adequately described. If microscopy is performed, microscopic descriptions are included in the report and a key of block and/or slide designations is included to identify the source of specific microscopic sections.
