F-OT-07: Histopathology Specimen Form | دليل السياسات والإجراءات في غرفة العمليات

Patient Name

MRN

DOB / Age

Gender

Ward / Clinic

Name of Operation

1. Sending Information (Operating Theatre)

Treating Physician (Name/ID)

Stamp / Signature

Date of Operation

Time

Sample Sent By (Nurse Name/ID)

Stamp / Signature

Date Sent

Time Sent

Nature / Type of Specimen

Specimen Site / Laterality

2. Clinical Details (To be completed by Physician)

Brief Clinical History & Findings

Clinical / Pre-operative Diagnosis

Post-operative Diagnosis

Relevant Operative / Endoscopic Findings

Relevant Radiological Findings

Relevant Laboratory Investigations

Previous Histopathology / Cytology Report No. & Date

3. Laboratory Receiving Log

Sample Received By

Sign / Stamp

Date Received

Time Received

4. Pathology Report (Laboratory Use Only)

Histo/Cyto-path No.

Date Logged

Alternative Date (Optional)

Performed By (Pathologist)

Technician

Gross Features

No. of Sections/Smears

No. of Blocks

Macroscopic Comments

Microscopic Findings

Date of Findings

Impression / Diagnosis

Final Comment

Date of Release

Sign / Stamp (Histo-pathologist)