UW Medicine Anatomic Pathology Specimen Collection Manual...Anatomic Pathology Specimen Collection Manual . UW Medicine Pathology Mission Statement The Division of Anatomic Pathology

UW Medicine Anatomic Pathology Specimen Collection Manual

UW Medicine Pathology Mission Statement The Division of Anatomic Pathology is committed to excellence in the diagnosis of human disease. Our department and team members are committed to:

• Delivering timely and accurate diagnoses that support outstanding patient care and inform effective and appropriate treatment options for patients.

• Providing fellows, residents and medical school students with exceptional education and experience, creating leaders within pathology and within healthcare.

• Striving to provide educational services within UWMC that enhance the clinical expertise of our medical colleagues and promote the advancement of medical knowledge through basic and clinical research.

• Employing compassion throughout all diagnostic services. • Focusing on patient and employee safety and on quality.

UW Medicine Pathology Vision Statement The Division of Anatomic Pathology is a recognized leader in quality diagnostic services, state of the art research, comprehensive teaching and is engaged in continually evolving methods to offer excellent and meaningful diagnoses.

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Contents General Information ................................................................................................................1-1

1.1 Laboratory Contact Information ................................................................................................ 1-1

1.2 Specimen Labeling and Submission ........................................................................................... 1-2

1.3 Specimen Rejection .................................................................................................................... 1-3

Gynecological Cytology Service ................................................................................................2-1

2.1 Gynecological ThinPrep Pap Test ............................................................................................... 2-1

Non-Gyn Cytology Services ......................................................................................................3-1

3.1 Bladder Washing ........................................................................................................................ 3-1

3.2 Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.) ...................................... 3-2

3.3 Bronchial Brushing ..................................................................................................................... 3-3

3.4 Bronchial Washing ..................................................................................................................... 3-4

3.5 Cerebrospinal Fluid (CSF) ........................................................................................................... 3-5

3.6 Fine Needle Aspiration (FNA) ..................................................................................................... 3-6

3.7 Miscellaneous Aspiration (Cysts, Joints, Etc) ............................................................................. 3-7

3.8 Miscellaneous Brushing (Renal, Gastric, Common Bile Duct, Endocervical Cytobrush, Etc) ..... 3-8

3.9 Sputum ....................................................................................................................................... 3-9

3.10 Sputum for PCP ........................................................................................................................ 3-10

3.11 Thyroid Aspirate ....................................................................................................................... 3-11

3.12 Urine – Voided ......................................................................................................................... 3-12

3.13 Urine – Catheterized ................................................................................................................ 3-13

Molecular Diagnostics Services ................................................................................................4-1

4.1 Human Papilloma Virus (GYN in ThinPrep Pap Test Media) ...................................................... 4-1

4.1.1 GYN in SurePath Media .............................................................................................................. 4-2

4.1.2 GYN in Qiagen Specimen Transport Media (STM) ..................................................................... 4-3

4.1.3 Anal in Qiagen Specimen Transport Media (STM) ..................................................................... 4-4

4.1.4 Anal in ThinPrep Media ............................................................................................................. 4-5

Histology Services ....................................................................................................................5-1

5.1 Frozen Sections UWMC-MT ....................................................................................................... 5-1

5.2 Frozen Sections UWMC-NW ...................................................................................................... 5-2

5.3 Frozen Sections HMC ................................................................................................................. 5-3

5.4 Gross Examination ..................................................................................................................... 5-4

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5.5 Bone Marrow Biopsy Specimens ............................................................................................... 5-5

5.6 Renal Biopsy Specimens ............................................................................................................. 5-6

5.7 Surgical Tissue Specimens .......................................................................................................... 5-7

5.8 Tissue Biopsy Specimens ............................................................................................................ 5-8

Neuropathology Services .........................................................................................................6-1

6.1 Brain/Spine Biopsy Specimens ................................................................................................... 6-1

6.2 Brain Tumor Specimen for Fluorescent In Situ Hybridization (FISH) ......................................... 6-2

6.3 Muscle Specimens ...................................................................................................................... 6-3

6.4 Nerve Specimens........................................................................................................................ 6-4

6.5 Ocular Biopsy Specimens ........................................................................................................... 6-5

Immunofluorescence ...............................................................................................................7-1

7.1 Direct Immunofluorescence ...................................................................................................... 7-1

7.1.1 Oral Biopsy Specimens ............................................................................................................... 7-1

7.1.2 Skin Specimens ........................................................................................................................... 7-2

7.2 In-Direct Immunofluorescence .................................................................................................. 7-3

7.2.1 Serum Specimen ......................................................................................................................... 7-3

Cytogenetics Services...............................................................................................................8-1

8.1 Amniotic Fluid ............................................................................................................................ 8-1

8.2 Bone Marrow / Oncology Blood ................................................................................................ 8-2

8.3 Chorionic Villi ............................................................................................................................. 8-3

8.4 DNA Samples .............................................................................................................................. 8-4

8.5 Peripheral Blood ........................................................................................................................ 8-5

8.6 Solid Tissue (including Products of Conception, Skin Biopsies, Stillbirths) ................................ 8-6

8.7 Urine........................................................................................................................................... 8-7

8.8 Biliary Duct Brushing .................................................................................................................. 8-8

Additional Testing Services ......................................................................................................9-1

9.1 Electron Microscopy Services: ................................................................................................... 9-1

9.2 DNA Flow Cytometry .................................................................................................................. 9-2

Outside Slides/Block Review Services ..................................................................................... 10-1

10.1 Slide Reviews (UW Medicine Patients) .................................................................................... 10-1

Slide Consults (External consultation with UW Medicine Pathologists) .................................. 10-1

Requisitions/Forms................................................................................................................ 11-1

1-1

General Information 1.1 Laboratory Contact Information

Harborview Medical Center Ninth and Jefferson Building – 2nd Floor (2NJB-244) Telephone: (206) 744-3145 Fax: (206) 744-8240

University of Washington Medical Center – Montlake 2nd Floor (BB220) Telephone: (206) 598-6400 Fax: (206) 598-5068

University of Washington Medical Center – NW 1550 N 115th St, #A-220 Telephone: (206) 668-1779 Fax: (206) 668-1163

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1.2 Specimen Labeling and Submission The College of American Pathologists (CAP) and other accrediting agencies require strict adherence to specimen labeling and specimen submission guidelines. In order to avoid delays in testing, diagnosis and to prevent specimen rejection, the following requisition and specimen container requirements must be followed.

Requisition:

Patient’s First Name Patient’s Last Name Patient’s Middle Initial (if applicable) Patient’s Medical Record Number Patient’s Date of Birth Date of Specimen Collection Time of Specimen Collection Referring Providers Name Clinical Data including history, planned procedures and differential diagnosis (if applicable) Exact anatomical source/site, whenever possible Name and Contact Phone Number of Person Completing the Form

Specimen Container:

Patient’s First Name Patient’s Last Name Patient’s Middle Initial (if applicable) Patient Medical Record Number and/or Patient Date of Birth Exact anatomical source/site whenever possible

For Cytopathology:

Each prepared slide must be labeled separately and any specimen containers with patient materials must also be labeled correctly

For ALL specimens submitted to Anatomic Pathology:

All containers must be sealed appropriately to prevent loss of specimens and to reduce employee exposure to chemicals. Specimen containers must be completely sealed in order to ensure that specimens or collection media does not leak.

A common reason for specimen rejection is the incomplete or improper closure of caps on specimen collection containers, causing container leaks. This can result in loss of irretrievable specimens or unreadable specimen labels due to leaked fluid or collection media. Please double-check specimen collection containers in order to ensure containers are closed properly. Additionally, all specimen containers must be placed in a biohazard bag of appropriate size and a complete seal attained.

A report within the Patient Safety Network System (PSN) and/or the Laboratory Event Management System (LEMS), will be submitted for documentation, if insufficient specimen submission practices occur.

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1.3 Specimen Rejection All specimens must be properly labeled in order to ensure patient safety and to prevent errors in diagnosis and treatment. Anatomic Pathology does not accept unlabeled and/or mislabeled specimens.

Definitions of Unlabeled and Mislabeled Specimens:

Unlabeled Specimen:

Specimen with no patient identifiers (i.e. patient name, patient medical record number)/specimen that has not been labeled.

Mislabeled Specimen:

Specimen that has not been labeled with two patient identifiers.

Specimen labeled with a patient name and/or medical record number that are different from that on the accompanying laboratory request form.

Specimen retrieved from correct patient but labeled with a wrong name and/or medical record number/date of birth.

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Gynecological Cytology Service 2.1 Gynecological ThinPrep Pap Test

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 5 Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt)

• Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Cytology Requisition

For Conventional Smear: • Glass Slide • 95% Ethanol Fixative • Specimen Collection Container

Specimen Collection: Label vial with two patient identifiers. Obtain adequate sample from ectocervix and endocervical canal using plastic spatula and endocervical brush. Immediately rinse vigorously 10 times in solution to remove any residual sample from spatula and brush. Discard the collection device. Tighten cap and place vial and requisition in bag for transport to laboratory. If conventional smear is desired, label glass slide and immediately place into 95% Ethanol fixative. Label fixative container, mark appropriate boxes on requisition, and place both in bag for transportation to laboratory.

Specimen Handling: Room Temperature Specimen Requirements: • Label with two (2) patient identifiers

• Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

Do not use formalin as a fixative

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled / Mislabeled Specimen • Specimen received in inappropriate fixative • Specimen received with collection device still in vial

Retention Time of Specimen: Six (6) Weeks After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview ** Turnaround times vary depending on multiple specimen and laboratory factors.

3-1

Non-Gyn Cytology Services 3.1 Bladder Washing

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag If delay is anticipated to be longer than 24 hours for delivery:

• CytoLyt or 50% Ethanol Specimen Collection: Collect specimen and deliver fresh specimen to laboratory

immediately. If a delay of more than 24 hours to deliver is anticipated, add equal volume CytoLyt or 50% ethanol.

Specimen Handling: Room Temperature if specimen is delivered upon collection.* *If slight delivery delay is anticipated, refrigerate *If a longer delivery delay is anticipated, add equal volume

CytoLyt or 50% ethanol Specimen Requirements: • Label with two (2) patient identifiers


Bladder washing is a valuable addition to cystoscopy in symptomatic patients. Typically it is performed prior to cystoscopy with the injection of 50-75ml of physiological saline through a catheter or the cystoscope. Bladder visualization is performed by injecting water to dilate the bladder. Cystoscopic examination should be performed after the irrigation for cytology, because water causes cellular degeneration. Highly cellular specimens are obtained in this manner.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use

formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology – Harborview

** Turnaround times vary depending on multiple specimen and laboratory factors.

3-2

3.2 Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00pm Turnaround Time**: 5 business days Specimen Collection Supplies: • EDTA or Sodium Heparin

• Specimen Collection Container • Biohazard Safety Bag

Specimen Collection: Optimum volume is 100-300ml (more if available). For bloody specimens, add 0.5 EDTA or Sodium Heparin for every 100ml collected into a clean container.

Specimen Handling: Room temperature if specimen is delivered upon collection*

*If delivery delay is anticipated, refrigerate Specimen Requirements: • Labeled with two (2) patient identifiers


Do not use formalin as a fixative


formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview

**Turnaround times vary depending on multiple specimen and laboratory factors.

3-3

3.3 Bronchial Brushing Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Bronchial Brush

• Specimen Collection Container • CytoLyt Solution • Biohazard Safety Bag

Specimen Collection: 1. Label specimen container with 2 patient identifiers 2. Collect specimen on brush. 3. Cut off brush end and immediately submerge brush in CytoLyt

to avoid air-drying effects Specimen Handling: Room temperature if specimen is delivered upon collection*

*If delivery delay is unavoidable, refrigerate

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition

Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

• Do not fix brush in formalin or let dry. • Do not fix slides in formalin or let dry • CytoLyt solution can be obtained from Cytology at HMC or the

Pathology Gross Room at UWMC Rejection Criteria: • Inadequate Information/missing requisition

• Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use

formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology – Harborview


3-4

3.4 Bronchial Washing Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag Specimen Specimen Collection: During a bronchoscopy, washings are obtained after the insertion

of about 10 ml of physiological saline. This is instilled in small portions of 2-3ml at a time and collected in a tube connected as a trap in the vacuum line, via the bronchoscope while the patient coughs. The flexible tip of the scope may be directed towards the opening of the smaller bronchioles and several areas sampled. Additional material may be obtained by rinsing the bronchoscope after withdrawal. In order to localize the lesion, separate bronchoscopes must be used for each lobe in question. The diluted lavage or wash is sent immediately to the lab for processing, in the capped collection tube.

Specimen Handling: Room temperature if specimen is delivered upon collection* (up to four [4] hours) *If delivery delay is anticipated, refrigerate to prevent bacterial

growth. *If delay is longer than overnight, add equal amount of CytoLyt or

50% ethanol for proper fixation. Specimen Requirements: • Labeled with two (2) patient identifiers


• If specimen is too large for an equal volume of fixative in the collection tube, divide in between two containers and add an equal volume of CytoLyt or 50% ethanol to each

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative

Retention Time of Specimen: One (1) Week After Final Report is Issued Contact Information: Cytopathology - Harborview


3-5

3.5 Cerebrospinal Fluid (CSF) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag If delay is anticipated to be longer than 24 hours for delivery: • CytoLyt solution

Specimen Collection: 1. Discard the first drops from the tap. 2. Obtain as much spinal fluid as clinical judgment allows. 3. Place a screw-top tube supplied by the floor. Prioritize the necessary lab tests, i.e. microbiology, hematology, cytology.

Specimen Handling: Room temperature if specimen is delivered upon collection.* *If slight delivery delay is anticipated, refrigerate *If a longer delivery delay is anticipated (more than 24hours),

record the volume of the specimen and deposit the specimen in CytoLyt solution.


Transportation: Immediately deliver/send to laboratory Comments / Special Instructions:

CSF is a highly perishable specimen; if specimen is to be obtained in the afternoon notify the laboratory. CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC For Lymphoma/Leukemia send directly to Hematopathology in SCCA (206-288-7060) Do not fix in formalin

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative • CSF that has been frozen or spun

Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview


3-6

3.6 Fine Needle Aspiration (FNA) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Slides

• Pap fixative (95% Ethanol) • Needle • Syringe • Physiological Saline • Biohazard Safety Bag If Delayed: • 50% Ethanol or, • CytoLyt Solution

Specimen Collection: 1. Label slides with at least 2 patient identifiers 2. Express one drop of aspirated material on a labeled slide. The

needle tip should be brought close to the slide with the beveled edge of the tip facing down towards the slide.

3. Touch the drop of material with another clean labeled slide and apply gentle pressure to procedure a monolayer of cells on both slides.

4. Immediately drop the two slides back to back into pap fixative (95% ethanol).

5. Rinse the needle by drawing saline into the syringe and expel back into the saline container.

If slides and pap fixative are not available, deposit and rinse the entire sample in CytoLyt solution

Specimen Handling: Room temperature if specimen is delivered upon collection.* *Refrigerate if delay is anticipated *If more than a 24 hour delay is anticipated, express the sample into CytoLyt solution.


Transportation: Immediately deliver/send to laboratory Comments / Special Instructions:

To request a fine needle aspirate (performed by a Cytopathologist) call Harborview Pathology to schedule assistance. CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC Do not fix in formalin




3-7

3.7 Miscellaneous Aspiration (Cysts, Joints, Etc) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Needles

• Syringe • Specimen Collection Container • CytoLyt Solution • Biohazard Safety Bag

Specimen Collection: 1. Collect fluid in syringe. 2. Transfer fluid into a clean labeled container.

Or remove the needle, cap off the syringe and submit the specimen in the syringe.

3. Label the syringe or container with patient identifiers. For small volume of fluids (less than 5ml) and/or if delivery delay is anticipated, deposit the fluid in CytoLyt solution.

Specimen Handling: • Fresh unfixed specimen • Room temperature if specimen is delivered upon collection.* *Refrigerate if delay is anticipated *If delivery is delayed by more than 24 hours, deposit in

CytoLyt solution. Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special Instructions:

Do not use formalin as a fixative CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative


**Turnaround times vary depending on multiple specimen and laboratory factors

3-8

3.8 Miscellaneous Brushing (Renal, Gastric, Common Bile Duct, Endocervical Cytobrush, Etc)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Brush

• CytoLyt Solution • Specimen Container • Biohazard Safety Bag

Specimen Collection: 1. Obtain specimen on brush by brushing lesion. For endocervical brushings, the cytobrush is passed into the endocervical canal and rotated 360° five times.

2. Cut off brush end and place in CytoLyt solution immediately. Specimen Handling: Room temperature if specimen is delivered upon collection. Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special Instructions:

Do not fix specimen in formalin or let dry. CytoLyt Solution can be obtained from Cytology at Harborview or UWMC Pathology Gross Room

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled Specimen • Specimen received in inappropriate fixative



3-9

3.9 Sputum Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Ba Specimen Collection: Early morning spontaneous deep cough technique is appropriate

for symptomatic patients with pulmonary disease and free airways. The patient should be given three, wide mouth, disposable, labeled containers and instructed as follows: 1. For three successive mornings, upon waking, clear throat of

any material that accumulated overnight and discard. 2. Rinse mouth out with water several times. 3. Cough deeply several times during the waking hour each

morning. 4. Spit whatever rises with the coughs into the specimen

collection cup, using different cups each morning. 5. Refrigerate containers until delivered to laboratory.

Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

Three consecutive early morning specimen's increase they yield of malignant cells. Do not use formalin as a fixative




3-10

3.10 Sputum for PCP Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag Specimen Collection: Collect fresh unfixed induced specimen. Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed cytology specimen requisition, include r/o PCP request


Sputum induction is intended primarily for the detection of early lung carcinoma in asymptomatic persons who have too little sputum to be raised naturally. It is also used for the detection of PCP. Non-induced specimen will not be processed for PCP. Do not use formalin as a fixative

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative • Non-induced specimen


**Turnaround times varies depending on multiple specimen and laboratory factors

3-11

3.11 Thyroid Aspirate Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Slides

• Pap Fixative (95% ETOH) • CytoLyt Fixative • Biohazard Safety Bag

Specimen Collection: 1. Label each slide with patient's name. 2. Once aspiration is obtained, express one drop of aspirated

material on a labeled slide with the beveled edge on tip facing down towards the slide.

3. Touch the drop of material with another clean labeled slide and apply gentle pressure to procedure a monolayer of cells on both slides.

4. Immediately drop the two slides back to back into pap fixative (95% ethanol).

5. Rinse the needle by drawing CytoLyt or saline solution into the syringe and expel back into the vial for each pass.

If slides and pap fixative are not available, deposit and rinse the entire sample of CytoLyt or saline solution.

Specimen Handling: Room temperature if specimen is delivered upon collection Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible

Comments / Special Instructions:

CytoLyt can be obtained from Cytology at HMC or the Gross Room at UWMC Do not fix in formalin




3-12

3.12 Urine – Voided Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag If long delay is anticipated for delivery: • CytoLyt or 50% Ethanol

Specimen Collection: Optimum volume is 100ml. 50-100ml is adequate. Specimen Handling: Room temperature if specimen is delivered upon collection*

*If overnight or weekend delay is anticipated, refrigerate *If a longer delivery delay is unavoidable, add equal volume of CytoLyt or 50% ethanol

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition


Optimal sample should be obtained after hydration and exercise. Clean-catch, midstream urine is recommended. Pooled 24 hour and/or concentrated early morning specimens are not recommended due to an increased chance of cellular deterioration and accumulation of salts


formalin as a fixative. • First morning urine specimens



3-13

3.13 Urine – Catheterized Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container

• Biohazard Safety Bag If long delay is anticipated for delivery: • CytoLyt or 50% Ethanol

Specimen Collection: Optimum volume is 100ml. 50-100ml is adequate. Specimen Handling: Room temperature if specimen is delivered upon collection*

*If overnight or weekend delay is anticipated, refrigerate *If a longer delivery delay is unavoidable, add equal volume of

CytoLyt or 50% ethanol Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

Catheterized urine is preferred for the lack of contamination and greater content of transitional cells. If there are questions of low-grade transitional carcinoma, prior to insertion of catheter, it is helpful to collect voided baseline urine for comparison to the catheterized specimen. Excessive lubricant should be avoided as it may obscure the cells. Do not send first morning urine.


formalin as a fixative. • First morning urine specimens



4-1

Molecular Diagnostics Services 4.1 Human Papilloma Virus (GYN in ThinPrep Pap Test Media)

Day(s) / Time (s) Performed: Variable Depending on Workload Tests Run 2-3 Times per Week

Turnaround Time**: Four (4) Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt)

• Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Requisition

Specimen Collection: 1. Label vial with two patient identifiers. 2. Obtain adequate sample from endocervix and endocervical

canal using plastic spatula and endocervical brush. 3. Rinse vigorously 10 times in solution to remove any residual

sample from spatula and brush. 4. Tighten cap and place vial and requisition in bag for transport

to laboratory Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

• Ordered as Co-Test, Reflexive to Pap results or • HPV with Reflexive Pap (Primary HPV) • HPV Screen with Genotype1 (16, 18, and Other 12 High Risk types)

Rejection Criteria: • Incorrect information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media

Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic - Harborview

1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-2

4.1.1 GYN in SurePath Media Day(s) / Time (s) Performed: Variable depending on Workload

Tests run 2-3 times per week Turnaround Time**: Four (4) business days Specimen Collection Supplies: • SurePathTM preservative vial

• Broom Collection Device with Detachable Head • Combination Cytobrush/plastic Spatula with detachable

heads • Biohazard Safety Bag

Specimen Collection: 1. Label SurePathTM preservative vial with a minimum of patient's name and birthdate or requisition label

2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc) on the test requisition

3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from cervix.

4. A. Insert broom device into endocervical canal and rotate 5 times clockwise. Detach head of broom and place in vial.

4 B. Insert contoured end of plastic spatula into endocervical canal and rotate 360 degrees. Detach head and place in vial. Insert Cytobrush into endocervical canal and slowly rotate 1/4 to 1/2 turn in one direction. Detach head and place in vial

Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers


HPV Screen with Genotype 1 (16, 18, and Other 12 High Risk types)

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media

Retention Time of Specimen: Three (3) Month Laboratory Subsection: Molecular Diagnostic - Harborview


4-3

4.1.2 GYN in Qiagen Specimen Transport Media (STM) Day(s) / Time (s) Performed: Variable depending on Workload

Tests run 2-3 times per week Turnaround Time**: Four (4) business days Specimen Collection Supplies: • Qiagen STM collection kit (Tube with 1ml STM and pre-scored

Dacron Swab) • Optional: Cytobrush • Biohazard Safety Bag

Specimen Collection: 1. Label Qiagen STM tube with a minimum of patient's name and date of birth or requisition label.


3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from cervix.

4. A. Insert Cytobrush into endocervical canal and rotate 3 times. Place brush in STM tube and break off shaft of brush.

4 B. Insert Dacron Swab into endocervical canal and rotate in alternating directions 5 times. Place brush in STM tube and break off shaft of brush

Specimen Handling: Room Temperature Note: Can be stored at room temperature for up to two (2) weeks. After two weeks, needs to be stored at 2-8oC

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition


HPV Screen with Genotype 1 (16, 18, and Other 12 High Risk types)

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media



4-4

4.1.3 Anal in Qiagen Specimen Transport Media (STM) Day(s) / Time (s) Performed: Variable depending on Workload

Tests run 2-3 times per week Turnaround Time **: Four (4) business days Specimen Collection Supplies: • Qiagen STM collection kit (Tube with 1ml STM and pre-

scored Dacron Swab) • Optional: Cytobrush • Biohazard Safety Bag

Specimen Collection: 1. Label Qiagen STM tube with a minimum of patient's name and date of birth or requisition label.


3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from area of interest.

4. A. Insert Cytobrush into area of interest and rotate 3 times. Place brush in STM tube and break off shaft of brush.

4 B. Insert Dacron Swab into area of interest and rotate in alternating directions 5 times. Place brush in STM tube and break off shaft of brush

Specimen Handling: Room Temperature Note: Can be stored at room temperature for up to two (2) weeks. After two weeks, needs to be stored at 2-8oC

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition


HPV Screen with Genotype1 (16, 18, and Other 12 High Risk types)

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media



4-5

4.1.4 Anal in ThinPrep Media Day(s) / Time (s) Performed: Variable Depending on Workload

Tests Run 2-3 Times per Week Turnaround Time **: Four (4) Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt)

• Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Requisition

Specimen Collection: 1. Label ThinPrep vial with a minimum of patient's name and date of birth or requisition label.

2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc.) on the test requisition

3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from area of interest.

4. A. Insert Cytobrush into area of interest and rotate 3 times. Place brush in ThinPrep vial and break off shaft of brush.

5. B. Insert Dacron Swab into area of interest and rotate in alternating directions 5 times. Place brush in ThinPrep vial and break off shaft of brush



Ordered as Co-Test or Reflexive to Pap results. HPV Screen with Genotype1 (16, 18 and Other 12 High Risk types)

Rejection Criteria: • Incorrect information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media

Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic – Harborview


5-1

Histology Services 5.1 Frozen Sections UWMC-MT

Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8am – 5pm Turnaround Time **: Single Requests - 20 minutes

Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag/sterile container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature

• Sent STAT • Call/Page appropriately

o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if a

regular courier pick-up is required CALL 206/598-0330 to request an intraoperative consultation from 8am – 5pm Page the on-call pathology resident to request an intraoperative consultation from 5pm – 8am the following day.

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue

Transportation: Surgical Pavilion: HA Immediate Delivery Main OR: Pathology resident pick-up after notification by OR


For proper specimen management, specimens must be fresh and sent immediately. Frozen section requests are NOT to be used as a courier service without intraoperative consultation work.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in Formalin

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - UWMC-MT


5-2

5.2 Frozen Sections UWMC-NW Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes

Multiple/Weekend/Off-Hour Requests – Variable

Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container

Specimen Collection: Fresh Tissue

Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately

o Provide OR# and Surgeons name requesting frozen CALL the OPERATOR 206/668-4556 to page the daytime/afterhours on-call Pathologist for an intraoperative consultation from 8am – 5pm


Transportation: Surgical Pavilion: HA Immediate Delivery

Main OR: Pathology resident pick-up after notification by OR

Comments / Special Instructions


Rejection Criteria: • Inadequate information / missing requisition • Unlabeled / Mislabeled Specimen • Specimen Submitted in Formalin

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued

Laboratory Testing Performed: Gross Room / Histology - UWMC-NW


5-3

5.3 Frozen Sections HMC Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes

Multiple/Weekend/Off-Hour Requests – Variable

Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container

Specimen Collection: Fresh Tissue

Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately

o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if a

regular courier pick-up is required. CALL 206/744-3145 to request an intraoperative consultation from 8:30am – 4:50pm CALL the OPERATOR 206/744-3000 afterhours from 4:50pm – 8:29am the following day and request the on-call Pathologist.


Transportation: During regular business hours a Pathology technician will pick-up

the frozen specimen from the specific OR requesting one. After-hours the on-call Pathologist will pick the frozen specimen up from the main OR desk.

Comments / Special Instructions



Retention Time of Specimen: Two (2) Weeks After Final Report is Issued

Laboratory Testing Performed: Gross Room / Histology - HMC


5-4

5.4 Gross Examination Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes

Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature

• Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen CALL the OPERATOR 206/668-4556 to page the daytime/afterhours on-call Pathologist for an intraoperative consultation from 8am – 5pm


Transportation: Surgical Pavilion: HA Immediate Delivery Main OR: Pathology resident pick-up after notification by OR




Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - UWMC-NW


5-5

5.5 Bone Marrow Biopsy Specimens Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes

Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature

• Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if

a regular courier pick-up is required. CALL 206/744-3145 to request an intraoperative consultation from 8:30am – 5pm CALL the OPERATOR 206/744-3000 afterhours from 5pm – 8am the following day and request the on-call Pathologist.


Transportation: During regular business hours a Pathology technician will pick-up the frozen specimen from the specific OR requesting one. After-hours the on-call Pathologist will pick the frozen specimen up from the main OR desk.



Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/Mislabeled Specimen • Specimen Submitted in Formalin

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - HMC


5-6

5.6 Renal Biopsy Specimens Day(s) / Time (s) Performed: Monday – Friday 8am - 5pm Turnaround Time: 6 business days Specimen Collection Supplies: • EM Fixative

• Michel's IF Media • Formalin • At HMC, all the above fixatives can be obtained as a kit from

HMC Gross Room refrigerator (2NJ274). • Biohazard Safety Bag

Specimen Collection: • Tissue Core Biopsies Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Surgical Specimen Requisition Transportation: As soon as possible deliver/send to Gross Room Refrigerator.

Deliver to NW211 Monday-Friday if STAT. Comments / Special Instructions:

Fixatives can be obtained from HMC Gross room refrigerator (2NJ274) or UWMC Gross Room refrigerator (NW211B). Access code required. • For UWMC-Renal kit/Fixative is available in NW211. • For HMC-Renal kit is available in 2NJ274 Gross room fridge. • For facilities outside of UWMC system- renal kits are shipped

upon request. Rejection Criteria: • Inadequate information/missing requisition

• Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred

preservative for required testing method. Retention Time of Specimen: Two (2) weeks after final report is issued. Laboratory Subsection: Gross Room/Histology-UWMC


5-7

5.7 Surgical Tissue Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time **: 24 - 72 Hour Specimen Collection Supplies: • 10% Neutral Buffered Formalin (NBF) - if fixation is necessary

• Sterile Specimen Collection Container - if appropriate for size • Biohazard Safety Bag

Specimen Collection: • As deemed appropriate by physician/surgeon Specimen Handling: • Room temperature if delivered immediately or fixed in10%

Neutral Buffered Formalin • Refrigerated if delayed delivery is anticipated and specimen

is fresh Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Surgical Specimen Requisition Transportation: As soon as possible deliver/send to Gross Room Refrigerator or

Pathology Specimen Refrigerator, as applicable Comments / Special Instructions:

For proper specimen management, specimens should be received in pathology as soon as possible

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred

preservative for required testing method. Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview, UWMC-MT, and UWMC-NW


5-8

5.8 Tissue Biopsy Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 24 - 72 Hours Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is

requested (i.e., flow cytometry) • Biohazard Safety Bag

Specimen Collection: • As deemed appropriate by physician/surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible

or fixed in 10% Neutral Buffered Formalin • Refrigerated - if submitted fresh and delay is anticipated.

Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition

Transportation: As soon as possible deliver/send to Gross Room Refrigerator or Pathology specimen refrigerator, as applicable


For proper specimen management, fresh tissue specimens should be received in pathology as soon as possible.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred

preservative for required testing method. Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview, UWMC-MT, UWMC-NW


6-1

Neuropathology Services 6.1 Brain/Spine Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 48 - 120 hours Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is


Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible

• Refrigerated - if delay is anticipated Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Surgical Specimen Requisition Transportation: Immediately deliver to Gross Room Refrigerator at UWMC-MT

(EC239), UWMC-NW (A265), or HMC (2NJ274) Comments / Special Instructions:


Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview


6-2

6.2 Brain Tumor Specimen for Fluorescent In Situ Hybridization (FISH)

Day(s) / Time (s) Performed: Mondays and Thursdays 8:00 am - 5:00 pm Turnaround Time**: 10 Business Days Specimen Collection Supplies: • Sterile Specimen Collection Container

• Biohazard Safety Bag Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible

• Refrigerated - if delay is anticipated Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Molecular Specimen Requisition Transportation: Immediately deliver to Gross Room Refrigerator at UWMC-MT,

UWMC-NW, or HMC Comments / Special Instructions:


Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Molecular Diagnostic Laboratory – Harborview


6-3

6.3 Muscle Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00pm Turnaround Time**: 10 Business Days Specimen Collection Supplies: • Tongue Blade or Stiff Paper

• Saline • Telfa or Gauze • Sterile Specimen Container/Petri Dish • Biohazard Safety Bag Wet Ice

Specimen Collection: 1. Obtain a longitudinal muscle biopsy, 0.8 to 1.0 cm in diameter and at least 3 cm in length. If the initial sample is too small, additional sample should be taken.

2. Place the specimen on a tongue blade or stiff paper and cover the muscle with Telfa or gauze moistened with saline.

3. Place the specimen in a container (Petri dish or Specimen Jar) with wet ice and place in a biohazard bag. Do not immerse the specimen in saline. Do not use muscle clamps unless surgeon requires their use.

Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Neuropathology Specimen Requisition Transportation: Immediately deliver to Gross Room at HMC (2NJ274), UWMC-MT

(EC239), or UWMC-NW (A265) Comments / Special Instructions:

For proper specimen management, muscle biopsies should be delivered immediately to the Gross Room.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Muscle Immersed in Saline or improper fixative used.

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview


6-4

6.4 Nerve Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 10 Business Days Specimen Collection Supplies: • Tongue Blade or Stiff Paper

• Saline • Telfa or Gauze • Sterile Specimen Container / Petri Dish • Biohazard Safety Bag

Specimen Collection: 1. Obtain specimen at least 3 cm long. 2. Place specimen on a tongue blade or stiff paper and cover the

nerve with Telfa or gauze moistened in saline. 3. Place specimen in specimen container

Do not immerse specimen in saline

Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Neuropathology Specimen Requisition Transportation: Immediately Deliver to Gross Room at HMC (2NJ274), UWMC-MT


For proper specimen management, nerve biopsies should be delivered immediately to the gross room.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Nerve immersed in saline or improper fixative used

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology – Harborview


6-5

6.5 Ocular Biopsy Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 2-5 Business Days (except Eye Globes) Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is


Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Neuropathology Specimen Requisition Transportation: Immediately deliver to gross room at HMC (2NJ274), UWMC-MT


For proper specimen management, ocular biopsies should be delivered immediately to the gross room.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Improper fixation method used

Retention Time of Specimen: Two (2) weeks after Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview


7-1

Immunofluorescence 7.1 Direct Immunofluorescence

7.1.1 Oral Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Biohazard Safety Bag

• IF Transport Media ONLY Specimen Collection: • As deemed appropriate by surgeon

• 4mm punch biopsy • 5mm punch biopsy, if biopsy is to be divided

Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Specimen Requisition Transportation: As soon as possible deliver/send to Pathology Comments / Special Instructions:

Immunofluorescence panel includes: IgG, IgA, IgM, C3 & Fibrinogen. IF Transport Media may be obtained from Gross Room refrigerator (NW211B) at UWMC. Access code required.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Specimen submitted in preservative not preferred for

required testing methodology • Specimen received in formalin • Specimen received in saline

Retention Time of Specimen: 6 Months After Final Report is Issued - Specimen is Frozen Laboratory Subsection: Immunohistochemistry (IHC) – UWMC


7-2

7.1.2 Skin Specimens Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Sterile Specimen Collection Container

• IF Transport Media • Michels • Biohazard Safety Bag

Specimen Collection: • As deemed appropriate by surgeon • 4mm punch biopsy • 5mm punch biopsy, if biopsy is to be divided

Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Specimen Requisition Transportation: Deliver/send to pathology as soon as possible Comments / Special Instructions:

Immunofluorescence panel includes: IgG, IgA, IgM, C3 & Albumin, C1q, H&E. Include all relevant clinical history; e.g. sun exposure, involvement of specimen IF Transport Media may be obtained from Gross Room refrigerator (NW211B) at UWMC. Access code required.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Specimen submitted in preservative not preferred for

required testing methodology • Specimen received in formalin

Retention Time of Specimen: 6 months After Final Report is Issued - Specimen is Frozen Laboratory Subsection: Immunohistochemistry (IHC) – UWMC


7-3

7.2 In-Direct Immunofluorescence

7.2.1 Serum Specimen Day(s) / Time (s) Performed: Monday – Friday 8:00 am 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Capped Test Tube / Vial

• Red Top Tube for Peripheral Blood • Biohazard Safety Bag

Specimen Collection: • 2 ml Serum (preferred) • 7 ml Peripheral Blood - use Red Top Tube for blood

Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Specimen Requisition to include collection time. Differential Diagnosis request required.

• Peripheral Blood must be received within 2 hours of blood draw

• Notify lab ahead of sending specimen by calling 206-598-4028 or 206-598-6400

Transportation: As soon as possible deliver/send to Pathology BB220 Monday through Friday. Send on ice packets - do not freeze blood


Serial dilution performed on serum applied different substrate tissue dependent on the differential diagnosis • Centrifuge blood ASAP to separate serum

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative not preferred for

required testing methodology • Blood is frozen

Retention Time of Specimen: 6 months After Final Report is Issued Laboratory Subsection: Immunohistochemistry (IHC) - UWMC


8-1

Cytogenetics Services 8.1 Amniotic Fluid

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm

Turnaround Time**: • Chromosome Analysis: 7-14 days • Prenatal Aneuploidy FISH Panel: Preliminary 1-3 days • Prenatal Array CHG:10-14 days

Specimen Collection Supplies: Corning tissue culture tubes or tubes from a Baxter Amniocentesis tray kit Biohazard Safety Bag

Specimen Collection: Collect 15-30ml of fluid obtained under sterile conditions. Place the fluid into the Corning tissue culture tubes or tubes from the amniocentesis tray kit. Discard the first 1ml of fluid or use for AFP testing. *For Array CGH: Collect 15-20ml of amniotic fluid or two T-25 flasks that are 90-100% confluent.

Specimen Handling: Room Temperature Specimen Requirements: • Specimen container labeled with two (2) patient identifiers

• Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Instructions:

n/a

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen

Retention Time of Specimen: Two (2) weeks after Final Report is Issued Laboratory Subsection: Cytogenetics- UWMC

**Turnaround times are averaged; some cases may be delayed due to slower than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-2

8.2 Bone Marrow / Oncology Blood Day(s) / Time (s) Performed: Monday - Friday 8:00 am 5:00 pm

Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm

Turnaround Time**: • Chromosome Analysis: 5-10 days • STAT Chromosome Analysis: Preliminary 1-3 days Final 2-4 days • Neoplasia FISH Study: 2-5 days • Additional FISH Study: 1-3 days • STAT FISH Analysis Preliminary 24 hours/Final 1-3 days

Specimen Collection Supplies: Preservative-Free Sodium Heparin Green Top Vacutainer or a Sterile Heparinized Syringe Biohazard Safety Bag

Specimen Collection: Collect 3-5ml of bone marrow or 5-10ml of blood in a preservative-free sodium heparin (green top vacutainer) or in a sterile heparinized syringe.

Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers


n/a

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Improper fixation of specimen

Retention Time of Specimen: 2 Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC


8-3

8.3 Chorionic Villi Day(s) / Time (s) Performed: Monday - Thursday 8:00 am - 5:00 pm Turnaround Time**: • Chromosome Analysis: 7-14 days

• Prenatal Aneuploidy FISH Panel: Preliminary 1-3 days • Prenatal Array CGH: 10-14 days

Specimen Collection Supplies: Sterile Flask or tube with sterile tissue culture media Biohazard Safety Bag

Specimen Collection: Collect 15-50mg chorionic villi in a sterile flask or tube with sterile tissue culture media. *For Array CGH: Collect two T-25 flasks that are 90% to 100% confluent

Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers


n/a

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC

**Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-4

8.4 DNA Samples Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm


Turnaround Time**: • Prenatal Array CGH:10-14 days • Routine Array CGH:14-21 days

Specimen Collection Supplies: TE-Buffer Biohazard Bag

Specimen Collection: Obtain 20-30mg of DNA suspended in TE-buffer Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers


n/a


Retention Time of Specimen: Indefinitely Laboratory Subsection: Cytogenetics – UWMC


8-5

8.5 Peripheral Blood Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm


Turnaround Time**: • Routine Chromosome Analysis: 10-14 days • Metaphase FISH Study: 7-10 days • Mosaicism Study:14 days • Family Chromosome Follow-up Study: 3-14 days • Newborn Chromosome Study: Preliminary 2-3 days / Final 2-7

days • STAT FISH to rule out Aneuploidy: Preliminary 1-3 days / Final

1-3 days • Routine Array – CGH: 14-21 days

Specimen Collection Supplies: Adult: Preservative-free sodium heparin Green Top Vacutainer Infants: Preservative-free sodium heparin Green Top Vacutainer or Sterile Heparinized Syringe Array CGH: 1 EDTA Purple Top Vacutainer and 1 Preservative-free sodium heparin Green Top Vacutainer Y-PCR for Male Infertility: EDTA Purple top Vacutainer Biohazard Safety Bag

Specimen Collection: Adults: 5-10ml whole blood preservative-free sodium heparin Infants: 1-3ml whole blood preservative-free sodium heparin Array CGH: (2 tubes of blood REQUIRED) 3-5ml whole blood in EDTA and 3-5ml whole blood in sodium heparin Y-PCR for Male Infertility: 5ml whole blood in EDTA


• Completed Cytogenetics Specimen Requisition Transportation: Deliver/send as soon as possible to laboratory Comments / Special Instructions:

n/a


Retention Time of Specimen: 2 Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC


8-6

8.6 Solid Tissue (including Products of Conception, Skin Biopsies, Stillbirths)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm

Turnaround Time**: • Solid Tumor Chromosome Analysis: 8-28 days • Paraffin Embedded Tissue FISH: 3-8 days • Products of Conception Chromosome Analysis: 9-21 days • Tissue Chromosome Analysis: 9-21 days • Routine Array CGH:14-21 days

Specimen Collection Supplies: Sterile tube with sterile tissue culture media Biohazard Safety Bag

Specimen Collection: Obtain sample under sterile conditions. If there is identifiable tissue in a POC, send chorionic villi. Stillbirth-if possible send fascia lata, lung, or kidney. Use separate containers with sterile media and label the material. If material is small and unidentifiable, send entire sample. Note: Do Not Send Entire Fetus Note: Do Not Place Sample in Formalin, Formaldehyde, or Alcohol *For Array CGH: collect 15-20mg of tissue in sterile media or 2 T-25 flasks that are 90%-100% confluent

Specimen Handling: Refrigerated – send sample in a cooler Specimen Requirements: • Labeled with two (2) patient identifiers


n/a


Retention Time of Specimen: 2 weeks after final report is issued Laboratory Subsection: Cytogenetics - UWMC


8-7

8.7 Urine Day(s) / Time (s) Performed: Monday- Friday 8:00 am - 5:00 pm


Turnaround Time**: • Urovysion FISH: 8-10 days Specimen Collection Supplies: ThinPrep Cytolyt Collection Cup or Sterile Jar

Biohazard Safety Bag Specimen Collection: Obtain 40-100 cc of urine in a sterile Collection Cup or a Sterile Jar.

Transfer to a Thinprep Cytolyt collection cup Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers


n/a

Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen

Retention Time of Specimen: 2 weeks after final report issued Laboratory Subsection: Cytogenetics- UWMC


8-8

8.8 Biliary Duct Brushing Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: • FISH: 7-10 days Specimen Collection Supplies: ThinPrep vial containing 20ml PreservCyt or Cytolyt solution

Biohazard Safety Bag Specimen Collection: Minimum 20ml Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers

• Completed Mayo Clinic Specimen Requisition Transportation: Deliver/send to Cytogenetics Laboratory as soon as possible Comments / Special Instructions:

This test is sent out to the Mayo Clinic. Deliver specimens directly to the UWMC Cytogenetics Laboratory for coordinating appropriate send out protocol

Rejection Criteria: • Specimen quantity below 20ml • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen

Retention Time of Specimen: Retained at Mayo Clinic until FISH test is reported Laboratory Subsection: Mayo Clinic


9-1

Additional Testing Services 9.1 Electron Microscopy Services: Specimen for Electron Microscopy (Primary Cilia, Skin, Renal, Muscle, Nerve and Lung)

Day(s) / Time (s) Performed: Monday - Friday 7:00 am –5:00 pm Turnaround Time**: Three (3) days Specimen Collection Supplies: • EM fixative (Half-Strength Karnovsky's Fixative or 3%

Glutaraldehyde) • Blue Top Tissue Collection Vial • Blade • Dental Wax Plate • Nasal Brush (same type used for cervical brush) for cilia case. • Biohazard Safety Bag

Specimen Collection: Immediately after the biopsy is obtained, place the specimen into a vial of EM fixative and send it to the EM Lab. The specimen should be free of blood or extra connective tissue. For Cilia brushing, put the entire brush in the vial containing EM fixative. *When cutting the tissue into smaller pieces, avoid crushing.

Specimen Handling: Refrigerate Specimen Requirements: • Smaller pieces, 1-2 mm in one side

• Specimen must be in EM fixative • Cannot be dried out • Specimen Container labeled with two (2) patient identifiers • Completed Specimen Requisition

Transportation: Keep refrigerated before and during shipping (e.g. ship in crushing ice in a Styrofoam container). Do not freeze the tissue.


• Specimen should be free of blood or extra connective tissue. EM fixative can be obtained from the EM lab at UWMC.

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation method used • Tissue is dried out

Retention Time of Specimen: Two (2) Months After Final Report is Issued Laboratory Subsection: Electron Microscope – UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

9-2

9.2 DNA Flow Cytometry Specimens for DNA Flow Cytometry (Tumor/Tissue Biopsies):

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm

For questions regarding submission of specimens for DNA Flow Cytometry, please contact Montlake Front Office at 206-598-6400.

10-1

Outside Slides/Block Review Services 10.1 Slide Reviews (UW Medicine Patients)

Slide Consults (External consultation with UW Medicine Pathologists) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 2-4 working days Specimen Collection Supplies: n/a Specimen Collection: As appropriate, the following specimens are submitted:

• Paraffin tissue blocks • Slides

Specimen Handling: Room Temperature Specimen Requirements: • Pathology Service Request Form completed by requesting

service • Pathology Report and/or Gross Description from outside

facility that include patient’s name, date of birth, and the outside facility accession number

• Materials labeled with two patient identifiers. Transportation: Transport via trackable method of transport, such as Federal

Express. Comments / Special Instructions:

n/a

Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Demographic information/outside reports do not match

patient information on requisition • Materials received are damaged and unable to be repaired

Retention Time of Specimen: 45 Days Laboratory Subsection: Pathology Accessioner Office


11-1

Requisitions/Forms

Form Name Applicable Section(s) UH 0070 – Cytology & Molecular Specimen Requisition Forms Cytology, Molecular UH 0657 – Histology Services Specimen Collection Forms Histology DNA Flow Cytometry Specimen Requisition Forms DNA Flow Cytometry Neuropathology Service Form - Neuro Referral Neuropathology Clinical_Cytogenomics_Lab_Requisition_Constitutional Cytogenetics Clinical_Cytogenomics_Lab_Requisition_Neoplasia Cytogenetics Cytogenetics_and_Genomics_Research_Service_Request_Form Cytogenetics Neoplasia_IFISH_Supplemental_Request_Form_10-24-19 Cytogenetics General Pathology Consult Review Request Form PSR General 1_7_13

Outside Slide Reviews / Consultations General Consults / Reviews Breast & Gynecological Pathology Bone & Soft Tissue Cardiac Tissue Cytology and Cervical Dermatopathology Electron Microscopy Gastrointestinal (GI) Pathology Genitourinary (GU) Pathology

Pathology IHC & Molecular - IHCMOL_PSR_2019 Immunohistochemistry (IHC) and Immunofluoresence (IF)

Renal Transplant Biopsy Requisition Form Renal Pathology Native Kidney Biopsy Requisition Form Renal Pathology

CYTOLOGY REQUEST (*SEE REVERSE FOR SPECIMEN COLLECTION TECHNIQUES/ADD’L INFO) ACCESSION NO.

HISTORY AGE LMP Birth Control Pills Previous Irradiation

Intrauterine Device Chemotherapy DES Exposure Clinical Cancer Estrogen Therapy Previous Abnormal Cytology

HPV Vaccination Previous HPV-HR Positive

MENOPAUSAL PREGNANT NOW? Trimester #___ POST-PARTUM?

PERTINENT CLINICAL DATA DATE/TIME COLLECTED

SPECIMEN SOURCE Endocervical Sputum Peritoneal Wash Needle Aspirate: Site: Ectocervical Bronchial Wash Pericardial Fluid Vaginal Pool Bronchial Brush Urine (Voided) Vaginal Wall Esophageal Brush Urine (Cath) Other: Site:

Pleural Fluid Bladder Wash Ascitic Fluid CSF (Cerebrospinal fluid) NOT for lymphoma/leukemia evaluation - See reverse page for instructions.

GYN TEST REQUESTS FROM LIQUID PAP MEDIA MARK ALL THAT APPLY

DIAGNOSIS CODE REQUIRED: [ONLY MOST COMMON LISTED. Write in code(s) if not listed below]

PAP TEST – SCREENING (LOW RISK): Z01.411 Routine gynecologic examination with abnormal findings Z01.419 Routine gynecologic examination without abnormal findings Z12.4 Screening for malignant cervical neoplasia Z12.72 Screening for malignant vaginal neoplasia Z12.89 Screening for malignant neoplasms (total hysterectomy)

PAP TEST – SCREENING (HIGH RISK): Z77.9 Other (suspected) exposures to hazards to health

Z92.89 Personal history of other medical treatment DIAGNOSTIC:

Z85.41 Personal history of malignant neoplasm of cervix uteri C53.9 Malignant neoplasm of cervix uteri, unspecified C54.1 Malignant neoplasm of endometrium D06.9 Carcinoma in situ of the cervix, unspecified N87.9 Dysplasia of cervix (excludes CIS and CIN III) N92.6 Irregular menstruation, unspecified N93.9 Abnormal uterine and vaginal bleeding, unspecified R87.610 ASC-US Pap R87.611 ASC-H Pap R87.612 LGSIL Pap R87.613 HGSIL Pap R87.810 Positive High Risk HPV R87.615 Unsatisfactory Pap Test

Other:

CYTOLOGY SCREENING / PAP

HPV TESTING HPV SCREENING1 (Reflex if ASC-US) HPV SCREENING1 (Co-Test)

1 High Risk HPV types included are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 & 68. Genotyping for HPVs 16 and 18 is integrated into testing and reporting.

CHLAMYDIA / GONORRHEA CHLAMYDIA GONORRHEA

CHLAMYDIA / GONORRHEA DIAGNOSIS CODE (REQUIRED): Z01.411 Routine gynecologic examination with abnormal findings Z01.419 Routine gynecologic examination without abnormal findings Z11.3 Screen for Venereal Disease N76.0 Acute vaginitis N76.1 Subacute and chronic vaginitis

_____ Other ______________________________________

ATTENDING PHYSICIAN UWP # AT (SERVICE) M.D. PHONE #

FOR USE BY CYTOLOGY ONLY SATISFACTORY CYTOTECHNOLOGIST COMMENTS SPECIMEN DESCRIPTION

UNSATISFACTORY

NEGATIVE

ABNORMAL:

PATHOLOGIST COMMENTS CYTOPREPARATION

Endocervicals/Metaplastics SMEARS CCF THIN PREP

PRESENT ATROPHIC CELL BLOCK SPECIAL STAIN

ABSENT NOT APPLICABLE

CYTOTECHNOLOGIST DATE PATHOLOGIST DATE

PLACE PATIENT LABEL HERE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington

CYTOLOGY REQUEST

DO NOT SCAN OR UPLOAD TO THE MEDICAL RECORD

UH0070 REV JAN 20 HMC PMM# 1667

Cytology Lab Use Only

Specimen Collection for Cytology Harborview Medical Center

(206) 744-0355, 744-4635, or 744-4279

To facilitate optimal preparation and speed results, please bring specimens to Cytology Laboratory at HMC (NJB Bldg. Room 2NJ244) or Pathology Office (Room BB220) at University of Washington Medical Center by 3:45 p.m. Monday – Friday.

To request a fine needle aspirate (performed by a Cytopathologist), please call (206) 744-3145.

SPECIMENS must be properly labeled with patient name and hospital number and sent in biological safety bags. They must be accompanied by a completed requisition with name, date of birth, hospital number, referring provider, appropriate boxes checked, and clinical information provided. FORMALIN IS NEVER AN APPROPRIATE CYTOLOGY FIXATIVE. See below for directions.

GYN Label PreservCyt vial with patient’s name and hospital number. Obtain adequate sample from ectocervix and endocervical canal using plastic spatula and endocervical brush. Rinse vigorously 10 times in solution to remove any residual sample from spatula and brush. Discard collection device(s). Tighten cap and place vial and requisition in bag for transport to laboratory.

If conventional smear is desired, label glass slide and immediately place into 95% ethanol fixative. Label fixative container, mark appropriate boxes on requisition, and place both in bag for transportation to laboratory.

Sputum Send fresh unfixed early morning deep cough specimen as soon as possible. Three consecutive early morning specimens increase the yield of malignant cells. If a delay is anticipated, please refrigerate.

Sputum for PCP Send only induced specimens, non-induced specimens will not be processed for PCP.

Bronchial Washings Send fresh, unfixed specimens to laboratory immediately. Refrigerate if delay in transport is anticipated.

Bronchial Brushing Cut off brush end and send in physiological saline ASAP to the laboratory. Refrigerate if delay is unavoidable.

Body Cavity Fluids (peritoneal wash, pleural, ascites, pericardial, etc.)

Add 0.5 ml EDTA to clean container for each 100 mls collected. Optimum volume is at least 100-300 mL (up to 1 liter if available). Send to laboratory immediately. Refrigerate if delay in transport is anticipated

Urine (voided) Please send “clean catch” specimen. Do Not send first morning void. Optimum volume is 100 mls. Send specimen immediately to laboratory or refrigerate if slight delay is unavoidable. If a delay of 24 hours or more is anticipated, add equal volume 50% ethanol.

Urine (catheterized) Send fresh specimen to laboratory or refrigerate if slight delay is anticipated. If longer delay is anticipated, add equal volume 50% ethanol.

Bladder Washings Send fresh specimen immediately to laboratory. Refrigerate if delay is necessary. Add equal volume 50% ethanol if delay is more than 24 hours.

CSF Cerebrospinal fluid is a highly perishable specimen; notify laboratory if specimen is to be obtained in the afternoon. Minimum volume necessary for processing is one ml. Send to laboratory immediately. Refrigerate if delay is unavoidable. If long delay is anticipated (e.g. over the weekend), record the volume and deposit the specimen in CytoLyt solution, which can be obtained from the Cytology Laboratory (744-4279) or the UWMC Pathology Gross Room (NW211). *Send CSF for lymphoma/leukemia evaluation directly to Hematopathology (206)288-7060.

Fine Needle Aspiration

Fix slides immediately in 95% ethanol (ETOH). Rinse needle in physiological saline and transport immediately to laboratory. If delay is required add equal volume 50% ethanol. You may also deposit and rinse entire sample in CytoLyt solution. CytoLyt solution can be obtained from Cytology Laboratory (744-4279) or the UWMC Pathology Gross Room (NW211). If FNA assistance is required, call Pathology (744-3145) or Cytology (744-4635).

Thyroid Aspirates Fix slides immediately in 95% ethanol (ETOH). If the aspirate is markedly bloody, deposit and rinse entire sample in CytoRich Red Collection fluid. If assistance is needed, please call Pathology (744-3145) or Cytology (744-4635).

Misc. Aspirations (cysts, joint, etc)

Send fresh unfixed specimen to laboratory as soon as possible. Refrigerate if delay is anticipated.

Misc. Brushings (renal, gastric, bile duct, endocervical cytobrush, etc.)

Cut off brush end and place in CytoLyt solution immediately. CytoLyt solution can be obtained from Cytology Laboratory (744-4279) or UWMC Pathology Gross Room (NW211).

Misc. Smears Fix smears immediately in 95% ethanol.

ABN (Advanced Beneficiary Notice): For Medicare patient(s), please check that ABN has been signed to facilitate patient billing if Medicare does not cover procedure (Medicare may cover only one low-risk screening pap every 2 years). ABN must be signed in order to bill patient.

Diagnosis/ICD-10 Code: Specify the diagnosis code to indicate medical necessity. (Rev. JAN 20)

ANATOMIC PATHOLOGY CONSULT REQUEST ALL FIELDS ON THIS FORM ARE MANDATORY

Specimen Originated at:

HMC SCCA UWMC - NW UWMC - MTL

Outpatient

Inpatient

Accession No. (For Pathology Use Only)

Operating Room # Date & Time Specimen Removed: AM PM

HSCT Patient (Send to SCCA) Form Prepared By: Phone #: (Please Print Clearly)

Requesting Provider & Others Needing Pathology Report NPI # Department Pager Telephone #

1.

2.

3. MANDATORY: CLINICAL HISTORY, PLANNED PROCEDURE(S), DIFFERENTIAL DIAGNOSIS: (Include ICD code if known)

Hold for Risk Management:

Previous surgery: Chemo or radiation therapy: Transplant (type & date): Last menstrual period (date): Other:

SPECIMEN: Specify EXACT Anatomical Source Improperly labeled specimens may not be accepted as per APOP HMC 65.1/UWMC 65.2, 65.3

Liver Biopsy Liver transplant biopsy Liver diagnostic biopsy Liver metastatic disease biopsy

Liver Enzymes Billirubin Alk Phos GGT AST ALT Flow Cytometry Studies

Hematopatholgy Flow Cytometry

DNA Flow Cytometry

A.

B.

C.

D.

E.

Intraoperative Consultation: (For Pathology Use Only) SEE FINAL REPORT Frozen Section Gross Only Imprint/Smear

Tissue Saved for: ( ) IHC FLOW FROZEN HEME CYTOGEN EM (Designate Specimen A, B, C, etc.) Fixative

RESIDENT SIGNATURE PRINT NAME FELLOW’S SIGNATURE PRINT NAME

I reviewed the specimen(s) and the interpretation was made by me. I reviewed the specimen(s) and agree with the resident’s interpretation.

PHYSICIAN SIGNATURE PRINT NAME PAGER NPI DATE TIME


UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington ANATOMIC PATHOLOGY CONSULT REQUEST ORDER Page 1 of 2

*U0657**U0657*

UH0657 REV JAN 20

SPECIMEN (SPECIFY EXACT ANATOMICAL SOURCE) Improperly labeled specimens may not be accepted as per APOP HMC 65.1/UWMC 65.2, 65.3

F.

G.

H.

I.

J.

K.

L.

M.

N.

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Q.

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X. FOR ADDITIONAL LINES, USE ANOTHER FORM

METHOD OF SUBMITTING SPECIMEN All tissue specimens should be submitted using appropriate procedure as stated in the Specimen Handling Manual.

Fresh, unfixed tissue should be delivered immediately to the Pathology Department.

Pathology Consultations, Frozen Sections, & Flow Cytometry, Call Pathology:

HMC – 206-731-3145 SCCA – 206-288-1355 UWMC- MTL – 206-598-6400 UWMC – NW - 206-368-1779

NOTE: Improperly Labeled Specimens Will Not Be Processed Until Corrected Label must include: Name, Patient Number, Age, Date, and Specimen Source

PHYSICIAN SIGNATURE PRINT NAME PAGER NPI DATE TIME


UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington ANATOMIC PATHOLOGY CONSULT REQUEST ORDER Page 2 of 2

*U0657**U0657*

UH0657 REV JAN 20

1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 | Fax: 206-598-8049

UWPathology.org

For UW Pathology use MRN: Accession #

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Patient Phone # Outside Facility Patient ID # Phone Fax

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Requesting Physician (primary): Phone Fax NPI #

Referring Physician/Surgeon: Phone Fax NPI #

Referring Pathologist: Phone Fax NPI #

Additional reports to: Phone Fax NPI #

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Payment Options:

Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client) *Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients. These tech charges will be billed to the requesting institution.

Primary Insurance Secondary Insurance

ID/Policy # Group # ID/Policy # Group #

Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip

Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

Note: For Fresh or Frozen tissue, refer to shipping kit materials and or UWPathology.org for DNA Flow Cytometry preparation and shipping instructions.

Specimen Information Attach: Report

Medium: # Outside Accession/Case #: Specify Biopsy Location or Tissue Source: Collect Date

Fresh, Frozen,

Paraffin Blocks

Patient Information:

UC Crohn's Colitis IBD Barrett's Esophagus POC Other (please specify):

Fresh, Frozen,

Paraffin Blocks

Fresh, Frozen,

Paraffin Blocks

Fresh, Frozen,

Paraffin Blocks

Fresh, Frozen,

Paraffin Blocks

If you run out of room, please use a second form and attach

Additional Patient History (eg: Disease Process) :

Physician Signature Required Accessioned By: Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at

http://pathology.washington.edu/clinical/servicerequest

Signature: Date:

DNA FLOW – 1/7/14

908 Jefferson St, Room 2NJ244, Seattle, WA 98104 Phone: 206-744-3145 | Fax: 206-744-8240 | UWPathology.org


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Note: For Fresh or Frozen tissue refer to shipping kit materials and or UWPathology.org for preparation and shipping instructions. Specimen Information

Transport Medium: Quantity Outside Accession/Case #: Specimen Source (be specific ex: R/L Sural Nerve, R/L Occipital Lobe, etc): Collection Date: Slides Fixed Fixed for EM

Blocks Fresh (on wet ice) Frozen (on dry ice)

Slides Fixed Fixed for EM






FISH/IHC Testing (optional): Additional Comments or Related History (Not required): FISH:

1p/19q Deletion PTEN Deletion EGFR Amplification

IHC (write in):

Physician Signature Required For UW Pathology Use Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest

Accessioned by: Time Stamp:

Signature: Date:

Neuro Referral PSR 1/7/14

1959 NE Pacific St, Room NW-125, Seattle, WA 98195Phone: 206-598-4488 | Fax: 206-598-2610

UWPathology.org/clinical/cytogenetics


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Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client)*Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients. These tech charges will be billed to the requesting institution.






Note: For sample collection requirements see http://www.UWPathology.org/clinical/cytogenetics Specimen Type Date Obtained:Prenatal

Amniotic FluidChorionic VilliPrenatal Cord BloodProducts of Conception

Please Complete for Prenatal Specimens:

Gestational Age:By Dates:By Ultrasound:

Tissue-FetalFetal Sex: Male Female Site: _________________________________

PostnatalBlood Postnatal Cord Blood Skin Biopsy + Site: ___________________

In Heparin in EDTA (for PCR or Microarray)

NeoplasiaBone MarrowBone Core BiopsyLeukemic Blood

TumorParaffin Blocks/Slides (FFPE)Urine

Other:

Tests STAT ROUTINEChromosomal Microarray Analysis (CMA) (CGH/SNP)

Constitutional Targeted Microarray (CTM)Constitutional High-density Microarray (CHM)Neoplasia Genomic Microarray (NGM)

Reflex to Karyotype

Reflex to FISH or IFISH

Chromosome AnalysisRoutine Karyotyping Family Follow-up Mosaicism for: ____________________

Reflex to MicroarrayCTM CHM NGM

FISH and IFISH- Please see Neoplasia IFISH Supplemental Request Form or call for probe availability

IFISH for Aneuploidy (13,18,21,X,Y)FISH or IFISH for: _______________________________________________Neoplasia IFISH: Complete the Neoplasia IFISH Supplemental Request Form

OtherY-PCR for Male Infertility Breakage Study (Control Required)

Other: _______________________________________________________

Clinical Diagnosis/IndicationsClinical History: Diagnosis:

Physician Signature RequiredSubmitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest

Signature: Date:

PSR CYTOGEN- 1/7/14

Clear FormCONSTITUTIONAL TEST

REQUEST FORM

Specimen Type Diagnosis or Indication for Testing

Peripheral Blood

Amniotic Fluid (Gestational Age: )

Chorionic Villi (Gestational Age: )

Products of Conception (Gestational Age: )

Fetal Tissue (Site: )

Umbilical Cord Blood

Skin Biopsy (Site: )

Saliva

Paraffin Blocks/Slides (Site: )

DNA

Please attach copy of pedigree if indication is Family History of…

ICD-10 Code:

This is a family follow-up study

(Name of proband: )

Date obtained:

Note: For sample collection requirements see www.pathology.washington.edu/patient-care/cytogenetics-collection

*** SEE PAGE 2 FOR TESTS ***

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Ordering Provider Signature Required

Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest

Signature Date

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Requesting Physician (primary): Phone Fax NPI#

Referring Physician/Surgeon: Phone Fax NPI#

Referring Pathologist: Phone Fax NPI#

Additional reports to: Phone Fax NPI#

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Payment Options:

Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client)

*Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients. These tech charges will be billed to the requesting institution.





Insured’s Name DOB Relation to Pt: Insured’s Name DOB Relation to Pt:

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Patient Phone # Outside Facility Patient ID



For UW Pathology useMRN: Accession #

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Reflex to Karyotype







Other: _______________________________________________________



Signature: Date:

PSR CYTOGEN- 1/7/14

Clear Form

1959 NE Pacific St, Room NW-125, Seattle, WA 98195Phone: 206-598-4488 | Fax: 206-598-2610 UWPathology.org/clinical/cytogenetics

1 of 2

07.05.2018

Test(s) Requested

Interphase FISH for common aneuploidies (13, 18, 21, X, Y)

Interphase FISH after pregnancy loss (13, 15, 16, 18, 21, 22, X, Y)

Metaphase FISH for:

1p36.1 deletion

15q11-q13 duplication (autism)

22q11.2 deletion (VCFS/DiGeorge)

22q11.2 duplication

Angelman syndrome (15q11.2 deletion)

Cri du Chat syndrome (5p deletion)

Kallmann syndrome

Langer-Giedion (8q24 deletion)

Miller-Diecker syndrome (17p13.3 deletion)

Pallister-Killian syndrome (iso12p mosaicism)

Potocki-Lupski syndrome (17p11.2 duplication)

Prader-Willi syndrome (15q11.2 deletion)

SHOX-related haploinsufficiency

Smith-Magenis syndrome (17p11.2 deletion)

Sotos syndrome (5q35 deletion)

SRY (46,XX testicular DSD/46,XY DSD/46,XY CGD)

Subtelomeres (Specify: )

Williams syndrome (7q11.23 deletion)

Williams-Beuren region duplication (7q11.23 duplication)

Wolf-Hirschhorn (4p deletion)

X-linked ichthyosis (STS deletion)

Other (Specify: )

Cytogenomic Microarray Analysis (CMA/CGH/CGAT/SNP Array)

Report all findings

Do not report variants of uncertain clinical significance

ddPCR (droplet digital PCR) for deletion or duplication (Specify: )

Routine G-banded chromosome analysis and karyotyping

Mosaicism study by chromosome analysis and karyotyping

Mosaicism for:

Limited parental follow-up study by chromosome analysis and karyotyping

Y chromosome deletions by PCR for male infertility

Grow cell cultures for sendout

Sendout instructions:

STAT ROUTINE 7

2 of 2

Reflex Testing

If is Normal then reflex to

Abnormal

If is Normal then reflex to

Abnormal

Patient Insurance Billing Consent

I authorize the Clinical Cytogenomics Laboratory (CCL) to release to my designated insurance carrier, health plan, or third party administrator the information on this form and any other information provided by my health care provider necessary for reimbursement. I assign and authorize insurance payments to CCL. I understand my insurance carrier may not approve and reimburse my medical genetic services in full due to usual and customary rate limits, benefit exclusions, coverage limits, lack of authorization, medical necessity, or otherwise. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles except where my liability is limited by contract or State or Federal law. A duplicate or faxed copy of this authorization is considered the same as the original document.

Patient Signature Date




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Reflex to Karyotype







Other: _______________________________________________________



Signature: Date:

PSR CYTOGEN- 1/7/14

Clear Form

01.25.2016

NEOPLASIA TEST REQUEST FORM

Specimen Type Diagnosis or Indication for Testing

Bone Marrow

Bone Core Biopsy

Leukemic Blood

Fresh or Frozen Tumor (Site: )

Paraffin Blocks/Slides (Site: )

Urine

Other:

ICD-10 Code:

Disease Phase: Pre-treatment or Relapse

Post-treatment

Post-transplant

Test(s) Requested

G-banded chromosome analysis and karyotyping

Neoplasia Cytogenomic Microarray Analysis ( CMA / CGH / CGAT / SNP Array )

Single Neoplasia IFISH (specify locus or gene) If: Normal

Abnormal reflex to

Neoplasia IFISH Panel (check one) See http://www.pathology.washington.edu/clinical/cytogenetics/ for loci included in panels.

AML Eosinophilia T-cell ALL Bladder CancerMDS / MPD (or CMML) CLL or SLL Adult B-cell ALL GlioblastomaB-cell Lymphoma Multiple Myeloma Childhood ALL Other:

STAT ROUTINE

Date obtained:

Note: For sample collection requirements see http://www.UWPathology.org/clinical/cytogenetics

6

Ordering Provider Signature Required

Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest

Signature Date

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Requesting Physician (primary): Phone Fax NPI#

Referring Physician/Surgeon: Phone Fax NPI#

Referring Pathologist: Phone Fax NPI#

Additional reports to: Phone Fax NPI#

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Payment Options:

Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client)

*Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients. These tech charges will be billed to the requesting institution.





Insured’s Name DOB Relation to Pt: Insured’s Name DOB Relation to Pt:

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Patient Address

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Patient Phone # Outside Facility Patient ID



For UW Pathology useMRN: Accession #

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Reflex to Karyotype







Other: _______________________________________________________



Signature: Date:

PSR CYTOGEN- 1/7/14

Clear Form

1959 NE Pacific St, Room NW-125, Seattle, WA 98195Phone: 206-598-4488 | Fax: 206-598-2610 UWPathology.org/clinical/cytogenetics

CYTOGENETICS and GENOMICS RESEARCH SERVICE REQUEST FORM: USE FOR RESEARCH / NONCLINICAL CYTOGENETICS AND GENOMICS STUDIES

Please contact us for pricing

TEST SAMPLE TYPE

complete G-banding karyotype analysis (20 cells) established cell line

abbreviated G-banding karyotype analysis (5 cells) cell line ready to harvest

extended G-banding karyotype analysis (50 or more cells) slides ready for analysis

specimen, blood or solid tissue, for setup/culture/harvest

FISH or IFISH ___________________________________ other (specify)__________________________________

Microarray analysis (human)

male female

human

mouse other__________________

IDENTIFYING INFORMATION (CELL LINE NAME, Passage etc.): ___________________________________________________

REASON FOR TESTING: ________________________________________________________________________________

RULE OUT: ___________________________________________________________________________________________

TEST ORDERED BY: ________________________________________________________________________

Phone #:________________________________________________________________________________

Email:_____________________________________________________________________________________

DATE: ____________________________________________________________________________________

TEST NUMBER: ____________________________________________________________________________

PRICE QUOTED: ___________________________________________________________________________

CHARGE: Send bill to:________________________________________________________________________

Grant name:_____________________________________________________________________________

Grant #:________________________________________________________________________________

EMAIL REPORT TO: _____________________________________________________________________

MAIL REPORT TO: Name:_________________________________________________________________

Department:___________________________________________ Box #:____________________________

Address:_____________________________________________________________________________

FAX REPORT TO: ______________________________________________________________________

Cytogenetics and Genomics Research Service Request Form 3 18 2013

Cytogenetics and Genomics Laboratory Box 356100, 1959 NE Pacific St, Room NW125 University of Washington Medical Center Phone: 206-598-4488 FAX: 206-598-2610

NEOPLASIA IFISH SUPPLEMENTAL REQUEST FORM Please CHECK the appropriate box, SIGN below and FAX to 206-598-2610

Requesting Physician:_________________________________ Referring institution:_____________________________________ Printed

Requesting Physician:_________________________________ Copy Report to:_________________________________________ Signature

Neoplasia IFISH Supplemental Request Form 10-24-19

Cytogenetics and Genomics Laboratory Room NW125 University of Washington Medical Center Phone: 206-598-4488 FAX: 206-598-2610

Patient Name:______________________________ Accession Number:____________________ Block:________ Collection date:________________

Patient DOB: ______________ Sex:__________ Indication:__________________________________ Specimen Source:_________________________

Disease Chromosome abnormality

Gene Disease Chromosome abnormality

Gene

AML

□ Panel

□ t(8;21) □ t(15;17)□ inv(16)* □ rea(11q23)* □ -5 or del(5q) □ -7 or del(7q) □ t(6;9) □ inv(3) □ +8 □ t(9;22) □ -17 or del(17p) □ del(17p)

□ RUNX1T1/RUNX1□ PML/RARA□ CBFB* □ MLL* □ EGR1/D5S23□ D7S486/CEN7 □ DEK/NUP214 □ MECOM □ CEN +8 □ BCR/ABL1/ASS1 □ TP53

Eosinophilia

□ Panel

□ rea(4q12)

□ rea(5q32) * □ rea(8p12)* □ inv(16)*

□ SCFD2/LNX/ PDGFRA/KIT

□ PDGFRB* □ FGFR1* □ CBFB*

T-cell ALL

□ Panel

□ rea(7q34)* □ rea(14q11)* □ del(9p) □ rea(11q23)*

□ TRB* □ TRA and TRD* □ CDKN2A/CEN9 □ MLL*

MDS/MPD (and CMML)

□ Panel

□ inv(3) □ -5 or del(5q) □ -7 or del(7q) □ +8□ -13 or del(13q) □ del(20q) □ -17 or del(17p)

□ MECOM□ EGR1/D5S23□ D7S486/CEN7□ CEN8□ D13S319/13q34□ D20S108□ TP53

Adult B-cell ALL

□ Panel

□ del(9p) □ t(9;22) □ rea(14q32)* □ -17 or del(17p) □ t(1;19) □ rea(11q23)*

□ CDKN2A/CEN9 □ BCR/ABL1/ASS1 □ IGH* □ TP53 □ PBX1/TCF3 □ MLL*

B-cell Lymphoma

□ Panel

□ MYC ReflexTesting

High Grade □ Panel

□ rea(3q27)* □ rea(8q24) * □ t(11;14)* □ t(11;18) * □ t(14;18) * □ t(8;14) * □ t(14;18) (MALT) □ rea(14q32)* □ rea(18q21)* □ abn(1p/1q)

□ BCL6* □ MYC * □ CCND1/IGH * □ BIRC3/MALT1 * □ IGH/BCL2 * □ MYC/IGH* □ IGH/MALT1 □ IGH* □ BCL2* □ CDKN2C/CKS1B

Childhood ALL

□ Panel

□ t(1;19) □ t(9;22) □ rea(11q23)* □ t(12;21) □ rea(12p13)* □ +4 □ +10

□ PBX1/TCF3 □ BCR/ABL1 □ MLL* □ ETV6/RUNX1 □ ETV6* □ CEN4 □ CEN10

Renal cell carcinoma □ rea(Xp11)* □ TFE3*

□ If MYC abnormal, reflex to t(14;18) IGH/BCL2 & 3q27 BCL6 Breast cancer □ 17q ampli* □ ERBB2*

□ rea(3q27)* □ rea(8q24) * □ t(8;14) * □ t(14;18) *

□ BCL6* □ MYC* □ MYC/IGH* □ IGH/BCL2 *

Lung cancer □ rea(2p23)* □ rea(6q22)* □ rea(7p12)*

□ ALK* □ ROS1* □ EGFR*

T-cell Lymphoma

Hepatosplenic T-cell PLL

□ rea(7q34)* □ rea(14q11)* □ i(7q) □ rea(14q32)

□ TRB* □ TRA and TRD* □ D7S486/CEN7 □ TCL1A

Sarcoma (Ewing) Sarcoma (synovial) Sarcoma (osteo; soft tissue) Rhabdomyosarcoma Myxoid liposarcoma Myxoid & RC Liposarcoma EMC

□ rea(22q12)* □ rea(18q11)* □ 12q14.5-q15 ampli* □ rea(13q14)* □ rea(16p11)* □ rea(12q13)* □ rea(9q22.33q31.1)*

□ EWSR1* □ SS18* □ MDM2* □ FOXO1* □ FUS* □ DDIT3* □ NR4A3* CLL (or SLL)

□ Panel

□ del(6q) □ del(11q) □ t(11;14)* □ +12 □ -13 or del(13q) □ -17 or del(17p)

□ MYB □ ATM □ CCND1/IGH* □ CEN12 □ D13S319/13q34 □ TP53

Bladder cancer □ Extra copies of 3, 7, 17; del(9p21)

□ CEN3, CEN7, CEN17, CDNK2A

Multiple Myeloma

□ Panel

□ abn(1p/1q) □ t(4;14) □ t(11;14)* □ t(14;16) □ -13 or del(13q) □ -17 or del(17p)

Reflex Testing if indicated: □ rea(14q32)*

□ CDKN2C/CKS1B □ FGFR3/IGH □ CCND1/ IGH* □ IGH/MAF □ D13S319/13q34 □ TP53/CEN17

□ IGH*

Glioblastoma

□ Panel

□ del(1p)(19q)* □ del(10q23)* □ 7p12 ampli* □ 8q24 ampli*

□ 1p19q deletion* □ PTEN* □ EGFR* □ MYC*

ABC & NF □ rea(17p13)* □ USP6*

Other □ □

* Indicates probe is validated on paraffin tissue (FFPE) and suspension cells

1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 | Fax: 206-598-8049

www.uwpathrequest.org/patient-care/servicerequest


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Note: For neuropathology services please use the form located at http://pathology.washington.edu/clinical/servicerequest/

Specimen Information Attach: Report Demographics

Medium: # Outside Accession/Case #: Specimen Source (ex: R/L calf skin, etc): Collect Date Case Type:

Slides, Blocks Slide Review (UW/HMC/SCCA Patient)

Dr: ____________________________

Clinic: __________________________

Appt Date: ______________________

Slide Consult (Non UW/HMC/SCCA Pt.) ---------------------------------------------------------------------------------------------------------------------------------------

Breast/Gyn Pathology Bone/Soft Tissue Cardiac Cytology & Cervical Biopsies Dermatopathology Electron Microscopy GI Pathology GU Pathology Immunohistochemistry (IHC) Immunofluorescence Renal Other

Slides, Blocks

Slides, Blocks

Slides, Blocks

Slides, Blocks

Wet Tissue

If you run out of room, please use a second form and attach

Additional Comments or Related History (Not required):

Physician Signature Required Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest

Signature: Date:

PSR GENERAL- 1/7/13

First Name Last Name MI

1959 NE Pacific St, Room BB220, Seattle, WA 98195Phone: 206-598-6400 | UWPathology.orgFax: 206-598-8049 or 206-598-4928 with Accession #

Accession # (if filled, fax to 206-598-4928)

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Specimen Information Tissue Media Accession Number Block ID Slide ID Specimen Description Collection Date

Prognostic Testing

FISH Breast GI Lung Solid Tumor IHC Breast GI Lung Solid Tumor

HER2neu HER2neu

ALK/EGFR MSI

Required if clinical not provided Hold for Risk Management

Previous Surgery: Last Menstrual Period:

Chemo/Radiation Therapy: Other/Comments:

Transplant (type/date):

Physician Signature Required For UW Pathology Use Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at

http://pathology.washington.edu/clinical/servicerequest Accessioned by: Time Stamp:

Signature: Date:

IHCMOL PSR 1/7/14

Renal Transplant Biopsy Requisition Form Anatomic Pathology, Box 356100 Room BB220D Seattle, WA 98195-6100 Phone: (206) 598-6400 Supplies, Fax: (206) 598-8049

1) TODAY’S DATE: _____________

2) PREVIOUS BIOPSY: YES / NO (If YES, date of previous biopsy: ____________)

3) TRANSPLANT DETAILS: Transplant date:___________________

TYPE: K alone, KP, other_________________________

4) ORIGINAL CAUSE OF RENAL FAILURE: _______________________________________________________

5) INDICATION FOR Bx: Protocol biopsy or Clinical / Follow-up___________________________________

____________________________________________________________________________________________

6) LABORATORY INVESTIGATION:

Serum creatinine _______mg/dl acute rise, chronic rise, failure to decline

Proteinuria YES / NO __________________________________________________ Donor specific antibodies YES / NO _______________________________________

7)

8) CURRENT IMMUNOSUPRESSION

Medication Dose / Level Medication Dose / Level

Prednisone Azathioprine

Mycophenolate (MMF) Cytoxan

FK506 Leflunomide

Cyclosporine Other

Sirolimus

Requesting Physician: __________________________ Pager, cell: __________________________

Clinical Impression Definite Suspected Comments

Acute Rejection

Acute Tubular Necrosis

Chronic Rejection

Calcineurin inhibitor toxicity

BK polyomavirus infection Request SV40

Recurrent GN

Severe Hypertension

Other

UWMC PATIENT NO. UWMC ACCESSION NO.

PATIENT NAME DATE OF BIRTH

AGE WEIGHT SEX HEIGHT

Native Kidney Biopsy Requisition FormAnatomic Pathology, Box 356100 Room BB220D Seattle, WA 98195-6100 Phone: (206) 598-6400 Supplies, Fax: (206) 598-8049

1) TODAY’S DATE: _________________

2) PREVIOUS BIOPSY: YES / NO (If YES, date of previous biopsy: ____________)

3) CLINICAL DIAGNOSIS/ CONCERNS: _____________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

4) RENAL DISEASE:

- ARF or CKD Known duration: _________________________________________

5) MEDICAL HISTORY-Hypertension YES / NO_________________BP: Systolic: ______/ Diastolic: _____________-Diabetes YES / NO________________________________________________________ -Family history YES / NO ________________________________________________________

6) TREATMENT: (If YES, please specify which drugs and dosage)

7) LABORATORY DATA:

Requesting Physician: __________________________ Pager, cell: ______________________________

Antibiotics Yes / No

Antihypertensive Agents Yes / No

Immunosuppressants Yes / No

Other Medications Yes / No

Creatinine _____ mg/dl

Creatinine Clearance _____ml/min.

Proteinuria _______________gm/24h

or (circle one) 0 1+ 2+ 3+ 4+

Urine Culture:

Urine sediment

RBC

WBC

casts

SEROLOGY

ANA + / - titer ___________

Anti-ds DNA + / - titer ____________

ANCA + / - titer ____________

Anti-GBM + / - titer _____________

Complement: C3________C4_______

HIV + / - HepB + / - HepC + / -

Other _________________________________

UWMC PATIENT NO. UWMC ACCESSION NO.

PATIENT NAME DATE OF BIRTH

AGE WEIGHT SEX HEIGHT

Documents

UW Medicine Anatomic Pathology Specimen Collection Manual...Anatomic Pathology Specimen Collection Manual . UW Medicine Pathology Mission Statement The Division of Anatomic Pathology