INDEX: MS3-3

EFFECTIVE: 04/02/15

Page 1 of 2

SUPERSEDES: 08/31/12

SUBJECT: Pathological Examinations of Surgical Specimens

POLICY STATEMENT: All specimens and tissues surgically removed are sent to Pathology for examination and documentation.

RULES:

1. Exceptions to this policy are:

A. Specimens or foreign bodies that, by their nature or condition, do not permit productive examination, such as a cataracts, orthopedic appliances, foreign bodies, or portions of rib removed only to enhance operative exposure;

B. Therapeutic radioactive sources, the removal of which is guided by radiation safety monitoring requirements;

C. Traumatically injured members that have been amputated and for which examination for either medical or legal reasons is not deemed necessary;

D. Foreign bodies (e.g., bullets) that, for legal reasons, are given directly in the chain of evidence to law enforcement representatives;

E. Foreskin from the circumcision of a newborn infant;

F. Placentas that are grossly normal and have been removed in the course of clinically uncomplicated deliveries;

G. Teeth, provided the anatomic name or anatomic number of each tooth or fragment of each tooth, are recorded in the medical record;

H. Pacemakers;

I. Tonsils and adenoids of patients under thirteen (13) years of age, which will be sent to Pathology at the discretion of the surgeon; and

J. Material removed from routine disc surgeries will be sent to Pathology at the discretion of the surgeon.

K. Arthritic material from routine knee replacement procedures will be sent to Pathology at the discretion of the surgeon. Surgeons should document appropriately in the patient’s record if such material is not sent to Pathology.

2. For patients thirteen (13) and older, all tonsil and adenoid tissue will be sent to Pathology for microscopic examination.

3. Routine osteoarthritis specimens removed during total hip procedures are to be sent to Pathology for gross examination.

4. Medical Staff members are urged to send specimens for gross examination. The above exceptions apply only to specimens where examination is deemed unnecessary by the surgeon. The surgeon will be medically and legally responsible for any specimens not submitted for pathologic examination. Any specimen sent to Pathology will be the responsibility of that department and a report will be generated. Should there be any uncertainty about documentation of removal of a specimen or if there are any unusual circumstances that would warrant extra care with additional documentation, the specimen should be sent to Pathology for examination.

5. All other specimens (i.e., specimens not specifically listed above) will have gross and microscopic examination. Any specimen that is grossly examined by the Pathologist is subject to microscopic examination if the Pathologist deems it necessary.

6. No routine frozen sections will be performed after 5 p.m.

Recommended by Medical Executive Committee: 02/27/15

Approved by the Board of Trustees: 04/02/15

Initially Approved: 07/25/03

Reviewed: 08/31/12

Amended:

12/16/04 04/01/05 02/28/07 10/07/10 02/09/12 04/05/12