ANATOMIC PATHOLOGY
VistA® COMPUTER SYSTEM.
DRAFT COPY ONLY.
(Procedure 7).
G. William Moore, MD, PhD.
Chief, Quality Assurance Section.
Chief, Autopsy Section
Lawrence A. Brown, MD.
Chief, Chemistry Section.
Automated Data Processing
Application Coordinator.
http://www.netautopsy.org/axsop/axsop007.htm
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United States Government Work, uncopyrighted, public-domain,
DRAFT COPY ONLY. This document does not necessarily represent the views
or policies of any United States Government agency.
This document is provided "as is", without warranty of any kind,
express or implied, including but not limited to the warranties
of merchantability, fitness for a particular purpose and
non-infringement. In no event shall the authors be liable
for any claim, damages or other liability, whether in an
action of contract, tort or otherwise, arising from, out of,
or in connection with the document or the use or other dealings
made with the document.
See also: Main objectives: 1.
Receipt of Specimens: 2,
3.
Specimen Accessioning: 4,
5, 6.
VistA® Computer: 1.
PRINCIPLE OF THE TEST.
Surgical Pathology and autopsy pathology specimens are received
in the Histology Laboratory from different areas of the hospital,
and must be entered into the computer, for proper organization
and tracking of specimen information. This procedure covers
the major functions of the anatomic pathology VistA® computer system,
including: general login;;
login to CPRS;
login to VistA®;
case login, edit, and delete;
case entry;
case lookup;
collective review of previous
anatomic pathology records;
disclaimers and sendouts;
enter provisional/final autopsy report;
administrative functions (backup, work-requests,
referrals, leave);
email and notifications; and
anatomic pathology searches and templates..
SPECIMEN REQUIRED.
All human tissue excised at surgery, outpatient clinics, fresh
or in fixative, along with a filled-out Tissue Examination Form
(U. S. Standard Form 515, USSF515).
REAGENTS, INSTRUMENTATION.
Any computer terminal in the hospital which is networked to CPRS
(Computer Patient Record System) and to the VistA®
(Veterans-health Information Systems and Technology Architecture)
computer system (formerly, DHCP).
STEP-BY-STEP DESCRIPTION.
0. TABLE OF CONTENTS.
1. General login to network and VistA®/CPRS.
1.1. Surgical pathology and autopsy pathology specimens received.
1.2. Sign onto Baltimore VAMHCS computer.
1.3. Confidentiality of signon/password codes.
1.4. Sign onto the network.
1.4.1 Sign off the network.
1.4.2 Cleaning up the computer's internal workspace.
1.4.3 Information Resources Management Help Desk 410-642-2411, x1115.
1.5. User should see: Internet explorer icon, CPRS icon, VistA® icon.
1.6. Baltimore VAMHCS intranet homepage.
2. Login to CPRS.
2.7. CPRS is the hospitalwide patient-based computer system.
2.8. Dermatology note from CPRS.
2.9. ENT surgery, GYN surgery, surgery H&P, oncology notes.
2.10. Endoscopy report note.
2.11. Radiology report note.
2.12. Graph laboratory values.
2.12.1 Display Surgical Path/cytopath/autopsy results.
3. Login to VistA®.
3.13. Login to VistA®
3.14. Click on the VistA® icon.
4. Case login, edit, and delete.
4.15. VistA® Surgical pathology case login.
4.16. VistA® Surgical pathology case edit, delete.
4.17. VistA® Cytology case login.
4.18. VistA® Cytology case edit, delete.
4.19. VistA® Autopsy case login.
4.19.1 VistA® SNOMED code delete.
5. Case entry.
5.20. Surgical pathology case entry, clin history and gross.
5.21. Surgical pathology case entry, gross and micro.
6. Case lookup.
6.22. VistA® Surgical pathology lookup.
6.23. VistA® Cytology lookup.
6.24. VistA® Autopsy lookup.
7. Review of previous anatomic pathology records.
7.25. VistA® Surgical pathology preliminary report.
7.26. VistA® Surgical pathology report by accession number.
7.27. VistA® Surgical operation schedule.
7.28. VistA® Surgical pathology print logbook.
7.29. VistA® Cytology print logbook.
7.30. VistA® Autopsy print logbook.
8. Disclaimers and sendouts.
8.31. VistA® Gynecologic pathology disclaimers.
8.32. Dermatopathology disclaimers.
8.33. VistA® Obtain interim reports on HPV sendouts.
8.34. VistA® Obtain interim reports on DIF sendouts.
8.35. VistA® Show list of sendouts.
8.36. Look up ASCUS/HPV test.
9. Enter provisional/final autopsy report.
9.37. Enter provisional autopsy report.
9.38. Enter final autopsy report.
10. Administrative functions (backup, work-requests, referrals, leave).
10.39. Manual paper backup of anatomic pathology reports.
10.40. Weekly disk backup of anatomic pathology reports.
10.41. Issuing a VistA® work request.
10.42. Login a referral specimen, not a veteran.
10.43. Request for employee annual leave, sick leave.
10.44. Change user toolbox characteristics (password, name,...).
10.44.1 VistA® screen-based word processor.
10.45. U. S. Government electronic signature.
11. Email and Notifications.
11.46. Edit VistA® mailgroup.
11.47. Email transaction summary.
11.48. Print unresponded-to VistA® emails.
11.48.1 Response to VistA® Alert.
12. Anatomic pathology searches and templates.
12.49. SNOMED search.
12.50. SNOMED search for AFIP consultations.
12.51. Gross template: Autopsy.
12.52. Gross template: Leg amputation.
12.53. Gross template: Outside consultation.
12.54. Gross template: Skin resection.
12.55. Gross template: Prostatectomy.
12.56. Gross template: Laryngectomy.
12.57. Gross template: Colectomy.
12.58. Gross template: Partial gastrectomy.
12.59. Gross template: Lung wedge resection.
12.60. Gross template: Lung lobectomy.
12.61. Gross template: Hysterectomy
12.62. Gross template: Mastectomy.
12.63. Gross template: Thyroidectomy.
12.64. Gross template: Nephrectomy.
12.65. Gross template: Radical cystoprostatectomy.
12.66. Gross template: Whipple pancreatectomy.
12.67. Gross template: Parotidectomy.
12.68. Gross template: Lymph node specimen.
12.69. Gross template: Radical neck dissection specimen.
12.70. Gross template: Tooth.
12.71. VistA® JUMP-TO OPTIONS.
1. GENERAL LOGIN TO NETWORK AND VistA®/CPRS.
1.1. SURGICAL PATHOLOGY AND AUTOPSY PATHOLOGY SPECIMENS
are received in the Histology Laboratory from different areas
of the hospital, and must be entered into the computer,
for proper organization and tracking of specimen information.
This procedure covers the major functions of the
anatomic pathology VistA® computer system, including:
general login; case login, edit, and delete; case entry;
case lookup; collective review of previous anatomic pathology records;
disclaimers and sendouts; enter provisional/final autopsy report;
administrative functions (backup, work-requests, referrals, leave);
email and notifications; and anatomic pathology searches and templates.
1.2. To sign onto the Baltimore VAMHCS computer,
you must have a NETWORK USER NAME and PASSWORD, and
NETWORK LOG ONTO DOMAIN; and a CPRS/VistA® ACCESS CODE
and VERIFY CODE. Your network user name is vhabalsssssg,
where sssss is the first five letters of your surname (last name),
and g is the first initial of your given name (first name).
For example, the network user name for Joseph Pathologist is:
vhabalpathoj;
the network user name for William Kim is: vhabalkimw.
Your network log onto domain name is: VHA05. If you do not have
the other codes that you need, or if your codes have expired,
then you should contact: Chief,
Automated Data Processing Section or
Chief, Quality Assurance Section.
If you are outside the Pathology and Laboratory Medicine Service,
then you should contact your departmental administrator.
1.3. Every person entitled to examine
Baltimore VAMHCS records has signon/password codes,
and they should be kept confidential in the same manner
that you would keep confidential your personal identification number (PIN)
to your bank account or credit card. The U. S. Federal Government
is allowed to examine all transactions carried out on your computer account,
and you are held responsible for them. You should not divulge
these code even to your supervisor. If the supervisor has need
to examine your computer account in your absence, then this is done
by changing your password through administrative channels,
and informing you when you return to work.
1.4. To SIGN ONTO the network, press CONTROL-ALT-DELETE
(together), and enter your NETWORK USER NAME and
NETWORK PASSWORD. The LOG ONTO DOMAIN at the Baltimore VAMHCS
is VHA05. If somebody else is signed onto the computer
in front of you, then signoff, and sign on under your own identifiers.
You should not use somebody else's open network connection.
1.4.1 To SIGN OFF the network,
click on START (bottom left)
then click on SHUTDOWN... (bottom menu selection).
You will be given several options, including
LOGOFF, RESTART, SHUT_DOWN.
Whenever you leave your computer workstation, you should sign off using
one of these options.
The fastest option is
LOGOFF.
The problem with
LOGOFF is that this option doesn't really
clean up your computer's memory (see below).
Once every day or two, you should sign off your computer using the
RESTART option.
This option cleans up the computer's internal workspace,
but it requires several minutes to carry out.
In general, you should leave your computer powered on when
you leave at the end of the day, since the central computer
staff may wish to install software updates in your absence.
The slowest option is SHUT_DOWN, which causes the computer
to power down, usually after some disaster has occurred in the computer.
The SHUT_DOWN option should be used only rarely.
1.4.2 CLEANING UP THE COMPUTER'S INTERNAL WORKSPACE.
Your computer workstation has an internal OPERATING SYSTEM,
which manages all the low-level functions of the computer,
such as receiving input from the keyboard or network line,
displaying information on the computer screen, and managing
the random-access-memory (RAM) and the hard-disk-drive.
The operating system, in turn, consists of a
CENTRAL PROCESSING UNIT (CPU), or calculating device,
and MEMORY, or system of electronic cubbyholes.
The CPU can be envisioned as a device that receives information
(numbers, characters) from the keyboard or a network line,
calls up information from the memory, adds the numbers,
and then stores the solution back into the memory.
In principle, the computer is nothing more than a large,
very fast electronic system with this design and purpose.
Computer memory is organized in contiguous chunks of transistors, or
MEMORY-BLOCKS. As the operating system performs its functions,
memory-blocks are filled up with information, and later on,
the information must be ERASED. In order to save time,
the computer operating system doesn't really erase obsolete memory-blocks
right away. Instead, the computer has an arrow, or POINTER,
that points to each memory-block. When the memory-block is no longer needed,
the pointer is cut. During high workload periods, the computer
operating-system may fill up with unused memory-blocks.
During low workload periods, the computer operating-system repatriates
these blocks so that they can be used again as active memory.
This so-called GARBAGE COLLECTION FUNCTION
of a computer operating system isn't very glamorous,
but computer companies that have ignored this function have gone
bankrupt, and hospital adminstrators and pathologists who had a hand
in purchasing these systems have been fired.
The paradigm is:
if it takes 25 hours to process a day's worth of data,
then your system will eventually run out of memory.
There are two styles of operating system: the
TIDY HUSBAND OPERATING SYSTEM
and the
SLOPPY HUSBAND OPERATING SYSTEM.
When a tidy husband comes home from work, he takes off his socks
and immediately deposits them into the dirty-clothes hamper.
When a sloppy husband comes home from work,
he takes off his socks and throws them onto the living room floor.
At some point, the wife either picks up the socks
or nags the sloppy husband into picking up the socks,
or else the living room would eventually be overrun by dirty socks.
The MUMPS and UNIX/LINUX operating systems
are examples of tidy-husband operating-systems.
Whenever a memory-block becomes free,
the operating-system repatriates the memory-block.
This tidyness tends to slow down the operating-system,
but the operating-system never crashes.
Microsoft® operating systems are examples of sloppy-husband
operating-systems. When a memory-block becomes free,
the operating-system may repatriate it
at some time in the future, maybe never.
Since a Microsoft® operating system
is always doing something (refreshing the computer screen,
watching the keyboard for new keystrokes, etc.),
a Microsoft® operating system will eventually crash
(the so-called blue screen of death),
even if it is performing no work.
Turn on your computer, and a few days later, the computer will have crashed.
This never happens with MUMPS and UNIX/LINUX operating systems,
unless they are shut down abnormally (e.g., a sudden power failure).
This sloppiness of Microsoft® operating systems allows faster processing.
Rumor has it that sloppy Microsoft® operating systems
were more attractive to executives playing video games, who were
the eventual purchasers of these systems.
To repeat, once every day or two, you should sign off your computer,
using the RESTART option. This option cleans up
the computer's internal workspace, but it requires several minutes
to carry out.
If you don't do this, you will find that your computer becomes
increasingly slower, and becomes forgetful, such as forgetting
where the printer is, or ignoring some of the keys on your keyboard.
If you notice your computer workstation acting bizarrely, then you
should RESTART the computer before calling for help.
1.4.3 INFORMATION RESOURCES
MANAGEMENT HELP DESK 410-642-2411, X1115.
If you have any problems with your computer workstation,
you may call the IRM help desk, which is manned 24 hours a day,
at 410-642-2411, ext 1115.
1.5. After you sign onto the network, your computer desktop
should have: an INTERNET EXPLORER ICON, a CPRS ICON,
and a VistA® ICON.
If you do not have these icons, then you should contact:
Chief, Automated Data Processing Section
or Chief, Quality Assurance Section.
1.6. Click on the INTERNET EXPLORER ICON. You may reach the
BALTIMORE VAMHCS INTRANET at URL:
http://vaww.vamhcs.med.va.gov
Click on PATHOLOGY AND LABORATORY SERVICE
Under ANATOMIC PATHOLOGY PROCEDURE MANUAL,
click on ANATOMIC PATHOLOGY SEARCH.
Enter keywords, and click on START SEARCH,
for example: VistA® COMPUTER SYSTEM
2. LOGIN TO CPRS.
Return to top of page.
2.7. CPRS (Computer Patient Record System)
is the hospitalwide patient-based computer system available
to all authorized personnel at the Baltimore VAMHCS.
Click on the
CPRS ICON
on your desktop. The necessary
ACCESS CODE and VERIFY CODE are the same as for
VistA®. Enter the patient-name in the PATIENT SELECTION BOX
that appears automatically when you bring up CPRS. On CPRS, you must
always select a patient before you begin, even if you are not performing
a patient-related function. If the system does not allow you to select
a patient, then the system is down, and you should contact
Chief, Automated Data Processing.
Click on FILE (upper right corner).
Click on SELECT NEW PATIENT.
2.8. DERMATOLOGY NOTE from CPRS.
In many pathology cases, the CPRS clinical information is valuable
in obtaining a high-quality final pathology report.
Click on the NOTES tab at the bottom of the CPRS screen.
If the notes do not go back far enough:
Click on VIEW (upper toolbar).
Click on SIGNED NOTES BY DATE RANGE.
Enter the BEGINNING DATE.
Click on OK.
Click on DERMATOLOGY NOTE on the upper left frame.
To print, click on FILE in the UPPER RIGHT CORNER.
Then click on PRINT.
2.9. OTHER NOTES from CPRS.
ENT SURGERY NOTE
GYN SURGERY NOTE
SURGERY HISTORY AND PHYSICAL EXAMINATION
ONCOLOGY/HEMATOLOGY NOTE
AJCC CANCER STAGING NOTE
2.10. ENDOSCOPY REPORT NOTE from CPRS.
Click on the REPORTS tab at the bottom of the
CPRS screen. Click on PROCEDURES (LOCAL ONLY) on the upper left
frame. Select the desired endoscopy procedure on the upper right frame.
To print, click on FILE in the UPPER RIGHT CORNER.
Then click on PRINT.
2.11. RADIOLOGY REPORT NOTE
from CPRS.
Click on the REPORTS tab at the bottom of the CPRS screen.
Click on IMAGES (LOCAL ONLY) on the upper left frame.
To print, click on FILE in the UPPER RIGHT CORNER.
Then click on PRINT.
2.12. GRAPH LABORATORY VALUES
from CPRS.
Click on the LABS tab at the bottom of the CPRS screen.
Click on GRAPH on the upper left frame.
Under LABORATORY TEST in the middle of the screen,
enter PSA, or some other suitable laboratory test to graph.
Under DATE RANGE,
select ALL VALUES, unless a shorter range is desired.
To print, click on FILE in the UPPER RIGHT CORNER.
Then click on PRINT.
2.12.1 DISPLAY SURGICAL
PATH/CYTOPATH/AUTOPSY RESULTS from CPRS.
Click on the LABS tab at the bottom of the CPRS screen.
Click on ANATOMIC PATHOLOGY on the upper left frame.
Click on SURGICAL PATHOLOGY or CYTOLOGY or AUTOPSY
on the lower left frame.
3. LOGIN TO VistA®.
Return to top of page.
3.13. The VistA® Computer System
Anatomic Pathology package is available to all Baltimore VAMHCS
departments that are part of the VistA® system. Different positions
have different levels of read-or-write access, and only persons
within the pathology department may create or alter pathology records.
All problems related to data processing are directed to the laboratory
Chief, Automated Data Processing,
or to Information Resource Management (IRM).
3.14. When you click on the VistA® icon,
you will be prompted as follows:
Username: dhcp
**************************************************************************
*****WARNING WARNING WARNING*****
ALERT: Some portions of these files are still in paper form.
This U.S. Government computer system is for official use only. The files
on this system include Federal records that contain sensitive information.
All activities on this system may be monitored to measure network
performance and resource utilization...............
ACCESS CODE:
VERIFY CODE:
You must enter your confidential ACCESS CODE
and VERIFY CODE. You should be promped with:
Select LABORATORY MENU Option:
If you are not in the LABORATORY MENU option, then enter ^LAB:
1 Lab accession and test counts [LRUPAC]
2 Lab add test(s) to an existing order [LRADDTST]
3 LAB CPT BILLING [LRCAPES]
4 Lab Label Zebra Configuration [APALRBA]
5 Lab orders by collection type [LRRP5]
6 Lab Shipping Menu [LA7S MAIN MENU]
7 Lab test order [LROW]
8 Lab Test Results [CCZPROF2 LRZ OUT]
9 Laboratory DHCP Menu [LRMENU]
10 LABORATORY MENU [LRZCLASSI] (LABORATORY MENU)
11 Laboratory Reports [CCZPROF2 CCZLAB]
Type '^' to stop, or choose a number from 1 to 11 :10 LABORATORY MENU
If you don't know what to do next, then type ? for a list of options.
4. CASE LOGIN, EDIT, AND DELETE.
Return to top of page.
4.15. VistA® SURGICAL PATHOLOGY CASE LOGIN:
Ordinarily, a new surgical pathology case login is performed by
histotechnologists. However, in extraordinary circumstances,
such as replacement of an erroneous record, login, edit, and delete
is conducted by, or supervised by, an attending pathologist.
In the case of case deletion, the
Chief, Anatomic Pathology Section,
is informed.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: LI Log-in, anat path
Select ANATOMIC PATHOLOGY section: BSP
Log-In for 2003 ? YES// (YES)
Select Patient Name: VETERAN,JOHN Q 11-11-11 123456789
VETERAN,JOHN Q ID: 123-45-6789 Physician: DOCTOR,JANE Q
AGE: 87 DATE OF BIRTH: NOV 11,1911
PATIENT LOCATION: 1 CYSTO//
Assign BA-SURGICAL PATHLOGY accession #: 111 ? YES// (YES)
Date/time Specimen taken: TODAY// (JAN 1, 2004)
PHYSICIAN: PATHOLOGIST,JOHN Q MD JQP 113 PATHOLOGIST
SPECIMEN SUBMITTED BY: JOHN Q PATHOLOGIST MD //
Comment:
4.16. VistA® SURGICAL PATHOLOGY CASE EDIT, DELETE:
Edit a surgical pathology case as follows:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: E Edit/modify data, anat path
Select Edit/modify data, anat path Option: ?
LI Edit log-in & clinical hx, anat path
MM Modify anat path gross/micro/dx/frozen section
SC Edit anat path comments
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Edit/modify data, anat path Option: MM Modify anat path
gross/micro/dx/frozen section
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Modify data for 2004 ? YES// (YES)
Select Accession Number/Pt name: 1234..........
Delete a surgical pathology case as follows:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: D Delete accession #, anat path
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Delete an Accession Number
Accession number date: 3/30/2003 (MAR 30, 2003)
Select Accession # : 1234
VETERAN,JOHN Q ID: 123456789 DOB: Jul 29, 1960
ACC # 1234
Case Deleted!
Sometimes you will get an ERROR MESSAGE
for the delete function, as follows.
If you get this error message, then you must go into
SURGICAL PATHOLOGY CASE ENTRY (OPTIONS GD AND GS)
and delete the contents of the entire case.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: D Delete accession #, anat path
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Delete an Accession Number
Accession number date: 3/30/2003 (MAR 30, 2003)
Select Accession # : 1234
VETERAN,JOHN Q ID: 123456789 DOB: Jul 29, 1960
ACC # 1234
Report completed &/or released, deletion not allowed.
4.17. VistA® CYTOLOGY LOGIN:
Ordinarily, a new surgical pathology case login is performed by
cytotechnologists. However, in extraordinary circumstances,
such as replacement of an erroneous record, login, edit, and delete
is conducted by, or supervised by, an attending pathologist.
In the case of case deletion, the
Chief, Anatomic Pathology Section,
is informed.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: LI Log-in, anat path
Select ANATOMIC PATHOLOGY section: BCY
Log-In for 2003 ? YES// (YES)
Select Patient Name: VETERAN,JOHN Q 11-11-11 123456789
VETERAN,JOHN Q ID: 123-45-6789 Physician: DOCTOR,JANE Q
AGE: 87 DATE OF BIRTH: NOV 11,1911
PATIENT LOCATION: 1 CYSTO//
Assign BA-CYTOPATHOLOGY accession #: 222 ? YES// (YES)
Date/time Specimen taken: TODAY// (JAN 1, 2004)
PHYSICIAN: PATHOLOGIST,JOHN Q MD JQP 113 PATHOLOGIST
SPECIMEN SUBMITTED BY: JOHN Q PATHOLOGIST MD //
Comment:
4.18.
VistA® CYTOPATHOLOGY CASE EDIT, DELETE:
Edit a cytopathology case as follows:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: E Edit/modify data, anat path
Select Edit/modify data, anat path Option: ?
LI Edit log-in & clinical hx, anat path
MM Modify anat path gross/micro/dx/frozen section
SC Edit anat path comments
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Edit/modify data, anat path Option: MM Modify anat path
gross/micro/dx/frozen section
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOLOGY
Modify data for 2004 ? YES// (YES)
Select Accession Number/Pt name: 1234..........
Delete a cytopathology case as follows:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: D Delete accession #, anat path
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOLOGY
Delete an Accession Number
Accession number date: 3/30/2003 (MAR 30, 2003)
Select Accession # : 1234
VETERAN,JOHN Q ID: 123456789 DOB: Jul 29, 1960
ACC # 1234
Case Deleted!
Sometimes you will get an ERROR MESSAGE
for the delete function, as follows.
If you get this error message, then you must go into
CYTOPATHOLOGY CASE ENTRY (OPTIONS GD AND GS)
and delete the contents of the entire case.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: D Delete accession #, anat path
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOLOGY
Delete an Accession Number
Accession number date: 3/30/2003 (MAR 30, 2003)
Select Accession # : 1234
VETERAN,JOHN Q ID: 123456789 DOB: Jul 29, 1960
ACC # 1234
Report completed &/or released, deletion not allowed.
4.19. VistA® AUTOPSY LOGIN:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: L Log-in menu, anat path
Select Log-in menu, anat path Option: LI Log-in, anat path
Select ANATOMIC PATHOLOGY section: BAU
Log-In for 2003 ? YES// (YES)
Select Patient Name: VETERAN,JOHN Q 11-11-11 123456789
VETERAN,JOHN Q ID: 123-45-6789 Physician: DOCTOR,JANE Q
AGE: 87 DATE OF BIRTH: NOV 11,1911
PATIENT LOCATION: 1 CYSTO//
Assign BA-CYTOPATH0LOGY accession #: 33 ? YES// (YES)
Date/time Specimen taken: TODAY// (JAN 1, 2004)
PHYSICIAN: PATHOLOGIST,JOHN Q MD JQP 113 PATHOLOGIST
SPECIMEN SUBMITTED BY: JOHN Q PATHOLOGIST MD //
Comment:
4.19.1 VistA® SNOMED
CODE DELETE:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: D Data entry, anat path
Select Data entry, anat path Option: CO Coding, anat path
Select Coding, anat path Option: SN SNOMED coding, anat path
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOPATHOLOGY
BA-CYTOPATHOLOGY (BCY)
Enter Etiology, Function, Procedure & Disease ? NO// Y (YES)
Data entry for 2004 ? YES// (YES)
Select Accession Number/Pt name: 1234 for 2003
VETERAN,JANE Q ID: 123-45-6789
Specimen(s):
CERVICAL/VAGINAL-LIQUID BASE
DATE REPORT COMPLETED: APR 29,2003//
Select CYTOPATH ORGAN/TISSUE: VAGINA AND CERVIX, CS //
CYTOPATH ORGAN/TISSUE: VAGINA AND CERVIX, CS//
Select MORPHOLOGY: NEGATIVE FOR MALIGNANT CELLS //
MORPHOLOGY: NEGATIVE FOR MALIGNANT CELLS//
MORPHOLOGY: NEGATIVE FOR MALIGNANT CELLS//
Select ETIOLOGY:
Select MORPHOLOGY:
Select FUNCTION: CLINICAL XYZ// @
SURE YOU WANT TO DELETE? Y (Yes)
Select FUNCTION:
Select PROCEDURE:
Select DISEASE:
Select CYTOPATH ORGAN/TISSUE:
5. CASE ENTRY.
Return to top of page.
5.20.
VistA® SURGICAL PATHOLOGY CASE ENTRY:
1. ENTER CLINICAL HISTORY AND GROSS DESCRIPTION. OPTION GD.
Select Data entry, anat path Option: GD Clinical Hx/Gross Description/FS
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY (BSP)
Data entry for 2003 ? YES// (YES)
Select Accession Number/Pt name: 1234 for 2003
VETERAN,JOHN Q ID: 123-45-6789
Specimen(s):
1. RIGHT CERVICAL LYMPH NODE.
Select SPECIMEN: 1. RIGHT CERVICAL LYMPH NODE.//
SPECIMEN: 1. RIGHT CERVICAL LYMPH NODE.//
Select SPECIMEN:
BRIEF CLINICAL HISTORY:
1> CHRONIC LYMPHOCYTIC LEUKEMIA.
PREOPERATIVE DIAGNOSIS:
1> CHRONIC LYMPHOCYTIC LEUKEMIA.
OPERATIVE FINDINGS:
1> SAME.
POSTOPERATIVE DIAGNOSIS:
1> SAME.
RESIDENT PATHOLOGIST: EAGER,JANE R
GROSS DESCRIPTION:
1> PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
2>
3> 1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
4> IDENTIFICATION AND "RIGHT CERVICAL LYMPH NODE". IT CONSISTS OF TWO
5> OVOID TAN-GRAY LYMPH NODES, ONE BISECTED IN THE OPERATING ROOM,
6> MEASURING 4.9 X 2.1 X 1.1 AND 3.2 X 1.9 X 0.9 CM. THE CUT SURFACES ARE
7> HOMOGENEOUS, LIGHT TAN, AND PINK. THE SPECIMEN IS SERIALLY SECTIONED
8> AND SUBMITTED IN TOTO.
9>
10> SUMMARY OF SECTIONS:
11>
12> 1-1, LARGER LYMPH NODE, 2 PIECES.
13>
14> 1-2, LARGER LYMPH NODE, 3 PIECES.
15>
16> 1-3 AND 1-4, LARGER LYMPH NODE, 2 PIECES EACH.
17>
18> 1-5 AND 1-6, SMALLER LYMPH NODE, 4 PIECES EACH.
Select Accession Number/Pt name:
5.21.
VistA® SURGICAL PATHOLOGY CASE ENTRY:
ENTER GROSS AND MICROSCOPIC DESCRIPTIONS. OPTION GS.
Select Anatomic pathology Option: D Data entry, anat path
Select Data entry, anat path Option: GS FS/Gross/Micro/Dx/SNOMED Coding
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY (BSP)
Enter Etiology, Function, Procedure & Disease ? NO// (NO)
Data entry for 2003 ? YES// (YES)
Select Accession Number/Pt name: 1234 for 2003
VETERAN,JOHN Q ID: 123-45-6789
Specimen(s):
1. RIGHT CERVICAL LYMPH NODE.
GROSS DESCRIPTION:
1> PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
2>
3> 1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
4> IDENTIFICATION AND "RIGHT CERVICAL LYMPH NODE". IT CONSISTS OF TWO
5> OVOID TAN-GRAY LYMPH NODES, ONE BISECTED IN THE OPERATING ROOM,
6> MEASURING 4.9 X 2.1 X 1.1 AND 3.2 X 1.9 X 0.9 CM. THE CUT SURFACES ARE
7> HOMOGENEOUS, LIGHT TAN, AND PINK. THE SPECIMEN IS SERIALLY SECTIONED
8> AND SUBMITTED IN TOTO.
9>
10> SUMMARY OF SECTIONS:
11>
12> 1-1, LARGER LYMPH NODE, 2 PIECES.
13>
14> 1-2, LARGER LYMPH NODE, 3 PIECES.
15>
16> 1-3 AND 1-4, LARGER LYMPH NODE, 2 PIECES EACH.
17>
18> 1-5 AND 1-6, SMALLER LYMPH NODE, 4 PIECES EACH.
MICROSCOPIC DESCRIPTION:
1> MALIGNANT LYMPHOMA, DIFFUSE LARGE B-CELL TYPE, PROBABLY TRANSFORMED
2> FROM SMALL LYMPHOCYTIC LYMPHOMA/CHRONIC LYMPHOCYTIC LEUKEMIA.
PATHOLOGIST: PATHOLOGIST,JOHN Q
DATE REPORT COMPLETED: APR 1,2003//
Select ORGAN/TISSUE: LYMPH NODE
1 LYMPH NODE 08000
2 LYMPH NODE OF ABDOMEN 08400
3 LYMPH NODE OF CLOQUET 08840
4 LYMPH NODE OF GREATER CURVATURE OF STOMACH 08456
5 LYMPH NODE OF HEAD 08100
Press to see more, '^' to exit this list, OR
CHOOSE 1-5: 1 LYMPH NODE 08000
ORGAN/TISSUE NUMBER: 1//
WEIGHT (gm):
Select MORPHOLOGY: MALIGNANT LYMPHOMA
1 MALIGNANT LYMPHOMA 95903
2 MALIGNANT LYMPHOMA, B-CELL TYPE 95933
3 MALIGNANT LYMPHOMA, CENTROBLASTIC-CENTROCYTIC, DIFFUSE 96143
4 MALIGNANT LYMPHOMA, CENTROBLASTIC TYPE 96323
5 MALIGNANT LYMPHOMA, CENTROBLASTIC-CENTROCYTIC, FOLLICULAR 96923
Press to see more, '^' to exit this list, OR
CHOOSE 1-5: 1 MALIGNANT LYMPHOMA 95903
Select MORPHOLOGY:
Select ORGAN/TISSUE:
Select Accession Number/Pt name:
6. CASE LOOKUP.
Return to top of page.
6.22.
VistA® SURGICAL PATHOLOGY LOOKUP.
Select Anatomic pathology Option: I Inquiries, anat path
Select Inquiries, anat path Option: DS Display surg path reports for a patient
SURGICAL PATHOLOGY PATIENT REPORT(S) DISPLAY
Select Patient Name: J6789 JONES,SAMUEL 7-29-33 123456789
NO NSC VETERAN B/ JACKSON,JACK BT TEAM OPAL
Enrollment Priority: Category: IN PROCESS End Date:
Is this the patient ? YES// (YES)
Date Spec taken: Aug 21, 2003 Pathologist: BILL PATHOLOGIST
Date Spec rec'd: Aug 21, 2003 15:16 Resident: JOAN RESIDENT
Date completed: Aug 24, 2003 Accession #: BSP 03 1234
Submitted by: JOE UROLOGIST Practitioner: JOE UROLOGIST
-----------------------------------------------------------------------------
Specimen:
1. RIGHT PELVIC LYMPH NODE (FS)
2. LEFT PELVIC LYMPH NODE (FS) LEFT PELVIC LYMPH NODE (FS)
3. BIOPSY OF BLADDER NECK
4. PROSTATE GLAND
Brief Clinical History:
71 Y.O. MAN WITH 4+3=7 PSA: 13.
Preoperative Diagnosis:
prostate cancer.
Operative Findings:
PROSTATE CA.
Postoperative Diagnosis:
prostate cancer.
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND FOUR CONTAINERS.
1. SPECIMEN #1 IS RECEIVED FRESH LABELED WITH THE PATIENT'S NAME, AND
"RIGHT PELVIC LYMPH NODE (FS)", AND CONSISTS OF A RED-TAN PIECE OF.......
6.23.
VistA® CYTOLOGY LOOKUP.
Select Anatomic pathology Option: I Inquiries, anat path
Select Inquiries, anat path Option: DC Display cytology reports for a patient
CYTOLOGY PATIENT REPORT(S) DISPLAY.......
6.24. VistA® AUTOPSY PRINTOUT.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PS Print single report only
Select ANATOMIC PATHOLOGY SECTION: BAU BA-AUTOPSY
1. Autopsy protocols
2. Autopsy supplementary reports
Select 1 or 2: 1
BA-AUTOPSY Autopsy Protocols
Select Patient Name: V6789
1 V6789 VETERAN,JOHN Q 3-12-49 123456789 NO NSC VETERAN B/
2 V6789 VETERAN,JANE R 11-22-58 987654321 NO NSC VETERAN B/
CHOOSE 1-2: 1 V6789 VETERAN,JOHN Q 3-12-49 123456789 NO NSC VETERAN B/
Enrollment Priority: Category: NOT ENROLLED End Date:
VETERAN,JOHN Q ID: 123-45-6789 Physician: PHYSICIAN, MARY Y
DIED Sep 25, 2002 08:52
Autopsy performed: Sep 26, 2002 Acc # BAU 02 20
(D)ouble or (S)ingle spacing of report(s): S
Print weights, measures and coding (if present): ? YES// (YES)
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
Requested Start Time: NOW// (JAN 14, 2004@16:28:13)
Report Queued to device LABSCOPE$PRT
Select Print, anat path Option:
VistA® SCREEN-BASED WORD PROCESSOR.
7. REVIEW OF PREVIOUS ANATOMIC PATHOLOGY RECORDS.
Return to top of page.
7.25.
VistA® SURGICAL PATHOLOGY PRELIMINARY REPORT PRINTOUT.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PS Print single report only
Select ANATOMIC PATHOLOGY SECTION: BS P BA-SURGICAL PATHLOGY
1. Preliminary reports
2. Final reports
Select 1 or 2 : 1
Preliminary reports for BA-SURGICAL PATHLOGY
Select Patient Name: S6789 SMITH,HOWARD A 2-24-32 123456789 NO
NSC VETERAN B/ JONES,JACK LR TEAM
Enrollment Priority: GROUP 5 Category: IN PROCESS End Date:
SMITH,HOWARD A ID: 123-45-6789 Physician: JONES,JACK
AGE: 91 DATE OF BIRTH: FEB 24,1932
Specimen(s) Count # Accession # Date Obtained
( 1) BSP 03 1234 Aug 15, 2003
1. LEFT NASAL ALAR LESION
( 2) BSP 03 1230 Aug 15, 2003
1. LEFT SUPERIOR HELIX LESION.
( 3) BSP 03 1100 Jul 12, 2003
1. SKIN BX-LEFT EAR
Choose Count #(1-3): 1
Accession #: BSP 03 1234 Date Obtained: Aug 05, 2003
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
Requested Start Time: NOW// (JAN 03, 2004@13:22:16)
Report Queued to device LABSCOPE$PRT
7.26. VistA® SURGICAL PATHOLOGY PRINT REPORT BY ACCESSION NUMBER.
To print a consecutive set of reports by accession number from the
ANATOMIC PATHOLOGY MENU. For example, reports BSP 03-1000 through
BSP 03-1010:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PA Print final path reports by accession #
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Select Accession YEAR: 2003 (2003)
Start with accession #: 1000
Go to accession #: 1010
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1
7.27. VistA® SURGICAL OPERATION SCHEDULE.
Select LABORATORY MENU Option: SCHEDule of Operations
Select Division: BALTIMORE, MD MD VAMC 512
Print Schedule of Operations for which date ? T+1 (JAN 04, 2003)
Do you want to print the schedule at all locations ? NO//
This report is designed to use a 132 column format.
Print the Report on which Device: HOME//<ENTER>
MARYLAND HCS PAGE 1
SURGICAL SERVICE
SCHEDULE OF OPERATIONS
SIGNATURE OF CHIEF: OR COORD BEEP 5641
PRINTED: JAN 03, 2003 13:20 FOR: JAN 04, 2003
PATIENT DISPOSITION PREOPERATIVE DIAGNOSIS
REQ ANESTHESIA SURGEON
ID# AGE START TIME OPERATION(S)
ANESTHESIOLOGIST FIRST ASST.
WARD END TIME
PRIN. ANESTHETIST ATT SURGEON
OPERATING ROOM: 5 OR
VETERAN, JOHN Q PACU (RECOVERY l hip djd
CHOICE ORTHOPOD,JACK
123-45-6789 55 09:00 left total hip arthroplasty
VETERAN,JOHN Q
OUTPATIENT 11:30
RESIDENT,JOSHI SURGEON,JANE
Case # 654321 REQUESTED BLOOD COMPONENTS: TYPE & CROSSMATCH
RBC,AS-1 RED BLOOD CELLS LEUKODEPLETED - 2 UNITS (P.A.T.)
7.28. VISTA SURGICAL PATHOLOGY PRINT LOGBOOK.
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: ?
PQ Print all reports on queue
DQ Delete report print queue
LQ List pathology reports in print queue
PS Print single report only
AD Add patient(s) to report print queue
AU Autopsy administrative reports ...
AR Anat path accession reports ...
CS Cum path data summaries
LA Anatomic pathology labels ...
LT Edit/print/display preselected lab tests ...
PB Print log book
PA Print final path reports by accession #
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Print, anat path Option: PB Print log book
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY LOG BOOK
Print SNOMED codes if entered ? NO// Y (YES)
Print only Topography and Morphology codes ? NO// Y (YES)
Log book year: 2003 OK ? YES// (YES)
Start with Acc #: 1
Go to Acc #: LAST //
DEVICE: HOME// VIRTUAL TERMINAL
Sep 04, 2003 17:37 MARYLAND HCS Pg: 1
BA-SURGICAL PATHLOGY (BSP) LOG BOOK for 2003
# =Demographic data in file other than PATIENT file
Date Num Patient ID LOC PHYSICIAN PATHOLOGIST
-----------------------------------------------------------------------------
1/02 1 SMITH,JOHN 6789 OR9 SURGEON,JACK PATHOLOGIST,JOE
SSN: 123-45-6789
OutPatient
Date specimen taken:12/31/2002 Entered by:TECHNOLOGIST,SALLY
Released by:PATHOLOGIST,JOE
1. HEPATITIS C FOR STAGING.
SNOMED codes:
T-56000 LIVER
M-43000 CHRONIC INFLAMMATION
-----------------------------------------------------------------------------
1/02 1 JONES,HARVEY 6789 OR6 UROLOGIST,JACK PATHOLOGIST,JOE
...................
7.29. VISTA CYTOLOGY PRINT LOGBOOK.
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PB Print log book
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOLOGY
BA-CYTOLOGY LOG BOOK
Print SNOMED codes if entered ? NO// Y (YES)
Print only Topography and Morphology codes ? NO// Y (YES)
Log book year: 2003 OK ? YES// (YES)
Start with Acc #: 1
Go to Acc #: LAST //
DEVICE: HOME// VIRTUAL TERMINAL
Sep 04, 2003 17:37 MARYLAND HCS Pg: 1
BA-CYTOLOGY (BCY) LOG BOOK for 2003
# =Demographic data in file other than PATIENT file
Date Num Patient ID LOC PHYSICIAN PATHOLOGIST
-----------------------------------------------------------------------------
1/02 1 SMITH,JOHN 6789 OR9 SURGEON,JACK PATHOLOGIST,JOE
SSN: 123-45-6789
OutPatient
Date specimen taken:12/31/2002 Entered by:TECHNOLOGIST,SALLY
Released by:PATHOLOGIST,JOE
1. HEPATITIS C FOR STAGING.
SNOMED codes:
T-56000 LIVER
M-43000 CHRONIC INFLAMMATION
-----------------------------------------------------------------------------
1/02 1 JONES,HARVEY 6789 OR6 UROLOGIST,JACK PATHOLOGIST,JOE
7.30. VistA® AUTOPSY PRINT LOGBOOK.
Select Anatomic pathology Option: P Print, anat path
text.
Select Print, anat path Option: PB Print log book
Select ANATOMIC PATHOLOGY SECTION: BAU BA-AUTOPSY
BA-AUTOPSY LOG BOOK
Print SNOMED codes if entered ? NO// Y (YES)
Print only Topography and Morphology codes ? NO// Y (YES)
Log book year: 2003 OK ? YES// (YES)
Start with Acc #: 1
Go to Acc #: LAST //
DEVICE: HOME// VIRTUAL TERMINAL
Sep 04, 2003 17:37 MARYLAND HCS Pg: 1
BA-SURGICAL PATHLOGY (BSP) LOG BOOK for 2003
# =Demographic data in file other than PATIENT file
Date Num Patient ID LOC PHYSICIAN PATHOLOGIST
-----------------------------------------------------------------------------
1/02 1 SMITH,JOHN 6789 OR9 SURGEON,JACK PATHOLOGIST,JOE
SSN: 123-45-6789
Date specimen taken:12/31/2002 Entered by:TECHNOLOGIST,SALLY
Released by:PATHOLOGIST,JOE
OutPatient
Date died: Jan 01, 2003 04:15 Path resident: RES,JACK
Entered by: PATHOLOGIST,JOE
SNOMED codes:
T-43000 CORONARY ARTERY
M-52140 ATHEROMATOUS PLAQUE, COMPLICATED
T-28000 LUNG
M-41000 ACUTE INFLAMMATION
M-36500 EDEMA
M-32800 EMPHYSEMA
M-43000 CHRONIC INFLAMMATION
8. DISCLAIMERS AND SENDOUTS.
Return to top of page.
Disclaimers are included in all gynecologic pathology reports
and to selected dermatopathology reports.
8.31. VistA® GYN DISCLAIMERS.
ALL GYNECOLOGIC CYTOPATHOLOGY REPORTS have the following format.
SPECIMEN ADEQUACY: SATISFACTORY FOR EVALUATION.
ENDOCERVICAL CELLS PRESENT.
INTERPRETATION: NEGATIVE FOR INTRA-EPITHELIAL LESION OR MALIGNANCY.
FINDINGS:
COMMENT:
THE GYNECOLOGIC CYTOLOGY TEST IS A SCREENING PROCEDURE,
SUBJECT TO BOTH RARE FALSE POSITIVE AND UP TO 6% FALSE NEGATIVE
RESULTS. THE TEST IS MOST RELIABLE WHEN A SATISFACTORY SAMPLE
IS OBTAINED ON A REGULAR, REPETITIVE BASIS. RESULTS MUST BE
INTERPRETED IN THE CONTEXT OF HISTORICAL AND CURRENT
CLINICAL INFORMATION.
If the specimen is inadequate, then the report should read:
UNSATISFACTORY FOR EVALUATION. LIMITED BY....
If the specimen contains no endocervical cells, then the report should read:
NO ENDOCERVICAL CELLS PRESENT.
FINDINGS
may include such information as:
BENIGN REACTIVE CELLULAR CHANGES;
SQUAMOUS METAPLASIA;
ATROPHIC SMEAR;
YEAST AND HYPHAL FORMS PRESENT MORPHOLOGICALLY CONSISTENT WITH CANDIDA;
TRICHOMONAS;
SHIFT IN VAGINAL FLORA, CONSISTENT WITH BACTERIAL VAGINOSIS.
For HPV_DNA testing on cases with a gynecologic cytolopathology
INTERPRETATION of Atypical Squamous Cells
of Undetermined Significance (ASCUS), the suggested disclaimer is:
COMMENT: A SUPPLEMENTARY REPORT WILL BE ISSUED PENDING DNA
HIGH-RISK HPV TYPING. CONFIRM/PRIORITY EMAIL SENT TO
Chief, Womens' Clinic
ON xx/xx/2005.
8.32. DERMATOPATHOLOGY DISCLAIMERS.
8.32.1 The anatomic pathologist is trained to diagnose,
name, and describe pathologic lesions, and to understand
the natural history of these lesions. Incomplete excision
of benign lesions that have a propensity toward local regrowth,
or malignant neoplasms, either in-situ or invasive,
should have an additional COMMENT. For example:
(1) The lesion may be incompletely diagnosed,
and there may be a more serious, underlying process,
based upon the available material.
Then the comment might read:
The lesion has been transected at its base, and an underlying ...
[e.g., invasive squamous cell carcinoma]
in the unexamined tissue cannot be excluded.
(2) Alternatively, the lesion may, or will certainly, recur.
Then the comment might read:
The usual biologic behavior of this lesion is that it will recur/regrow
if incompletely excised. If the clinical setting is appropriate,
then the lesion should be completely excised
[, with conservative/wide margins].
8.32.2. Comments such as these should supplement, not replace,
any required notification of the primary caregiver by email,
and any direct or telephone communication with the primary caregiver
for clarification or discussion. The date of communication
and name of discussant should be documented in the pathology report,
and SNOMED-coded as EMAIL or CONSULTATION, BY TELEPHONE,
as appropriate.
8.32.3. In some pathology cases, it is necessary to issue an additional report,
after the case has been initially signed out by the attending pathologist.
The initial report should contain a COMMENT such as the following,
which notifies the clinician that a supplementary report will follow:
Additional tissue sections/special stains/etc.
will be examined, and a supplementary report will be issued.
The banner on the supplementary report reads: *** MODIFIED REPORT ***.
This unfortunate choice of words, mandated by the VA Central Office,
and under protest by our department, suggests that the sense of the
original report has been changed. This misimpression may be counteracted
by the following disclaimer:
This supplementary report provides additional information for this case,
and does not change the meaning of the original report.
8.33. VistA® OBTAIN INTERIM REPORTS ON HPV SENDOUTS.
Interim-report for cases with
HPV (human papilloma virus)
for sendout.
If there is an empty printout, then no sendouts have been performed
for this patient for the past year.
Perform 34. VistA® SHOW LIST OF SENDOUTS, to determine whether
the HPV specimen has been sent out in the past year.
Select LABORATORY MENU Option: ^INTERIM
1 Interim report by provider [LRRD]
2 Interim report for chosen tests [LRRP3]
3 Interim report for selected tests as ordered [LRRSP]
4 Interim report [LRRP2]
5 Interim reports for 1 location (manual queue) [LRRS BY LOC]
Type '^' to stop, or choose a number from 1 to 5 :2 Interim report for chosen tests
Select HOSPITAL LOCATION NAME: BALTIMORE
GENERAL LAB DATA DISPLAY
Select Patient Name: V6789
1 VETERAN,JANE R FEMALE 09/10/1955 987654321
2 VETERAN,JOHN Q MALE 09/16/1964 123456789
CHOOSE 1-2: 2 VETERAN,JANE R FEMALE 09/16/1964 123456789
VETERAN, JANE R ID: 123-45-6789
AGE: 39 DATE OF BIRTH: Sep 16, 1924
Enrollment Priority: GROUP 8a Category: ENROLLED End Date:
Select LABORATORY TEST NAME: HPV DNA - HIGH RISK
Select LABORATORY TEST NAME:
Date to START with: TODAY//T-9999 (JUL 05, 1976)
Date to END with: T-7//T (NOV 20, 2003)
Print address page? NO//
DEVICE: HOME// VIRTUAL TERMINAL
Printed at: page 1
MARYLAND HEALTH CARE SYSTEM - BALTIMORE DIVISION (512) 10 N. GREENE STREET
VETERAN,JANE R Report date: 11/20/2003 2:22 pm
SSN: 123-45-6789 SEX: F DOB: Mar 25, 1968 LOC: 2B GEN
Provider: NURSE,SALLY S
Specimen: CERVICAL SECRETION
Accession [UID]: BSO 03 1234 [1234567890]
Specimen Collection Date: 08/34/2003
Test name Result units Ref. range Site Code
HPV DNA - HIGH RISK NEG neg [512]
Eval: HPV subtypes examined: 16,18,31,33,35,39,45,51,52,56,58, or 68
Eval: HPV DNA assayed by QUEST, Arbutus MD (021230)
Eval:
Eval: If NEG for HPV-DNA high risk subtypes,
Eval: then consider routine follow-up.
Eval:
Eval: If ***POS for HPV-DNA high risk subtypes,
Eval: then risk of HSIL or CERVICAL CARCINOMA is present.
VETERAN,JANE R 123-45-6789 11/20/2003 2:22 pm PRESS '^' TO STOP
Printed at: page 2
MARYLAND HEALTH CARE SYSTEM - BALTIMORE DIVISION (512) 10 N. GREENE STREET
VETERAN,JANE R Report date: 11/20/2003 2:22 pm
SSN: 123-45-6789 SEX: F DOB: Mar 25, 1964 LOC: 2B GEN
Eval: Consider colposcopy and/or biopsy.
=============================================================================
KEY: "L"=Abnormal low, "H"=Abnormal high, "*"=Critical value
VETERAN,JANE R 123-45-6789 11/20/2003 2:22 pm PRESS '^' TO STOP
8.34. VistA® OBTAIN INTERIM REPORTS ON DIF SENDOUTS.
Interim-report for
DIF (direct immunofluorescence, fresh skin biopsy)
for sendout.
If there is an empty printout, then no sendouts have been performed
for this patient for the past year.
Perform 34. VistA® SHOW LIST OF SENDOUTS, to determine whether
the DIF specimen has been sent out in the past year.
Select LABORATORY MENU Option: ^INTERIM
1 Interim report by provider [LRRD]
2 Interim report for chosen tests [LRRP3]
3 Interim report for selected tests as ordered [LRRSP]
4 Interim report [LRRP2]
5 Interim reports for 1 location (manual queue) [LRRS BY LOC]
Type '^' to stop, or choose a number from 1 to 5 :2 Interim report for chosen tests
Select HOSPITAL LOCATION NAME: BALTIMORE
GENERAL LAB DATA DISPLAY
Select Patient Name: V6789
1 VETERAN,JANE R FEMALE 09/10/1955 987654321
2 VETERAN,JOHN Q MALE 09/16/1964 123456789
CHOOSE 1-2: 2 VETERAN,JANE R FEMALE 09/16/1964 123456789
VETERAN, JANE R ID: 123-45-6789
AGE: 39 DATE OF BIRTH: Sep 16, 1924
Enrollment Priority: GROUP 8a Category: ENROLLED End Date:
Select LABORATORY TEST NAME: DIF
Select LABORATORY TEST NAME:
Date to START with: TODAY//T-9999 (JUL 05, 1976)
Date to END with: T-7//T (NOV 20, 2003)
Print address page? NO//
DEVICE: HOME// VIRTUAL TERMINAL
Printed at: page 1
MARYLAND HEALTH CARE SYSTEM - BALTIMORE DIVISION (512) 10 N. GREENE STREET
VETERAN,JANE R Report date: 11/20/2003 2:22 pm
SSN: 123-45-6789 SEX: F DOB: Mar 25, 1968 LOC: 2B GEN
Provider: NURSE,SALLY S
Specimen: .........
.....................
VETERAN,JANE R 123-45-6789 11/20/2003 2:22 pm PRESS '^' TO STOP
8.35. VistA® SHOW LIST OF SENDOUTS, to determine whether
the specimen (HPV, DIF) has been sent out in the past year.
Select LABORATORY MENU Option: ^SHOW
Select Anatomic pathology Option: ^SHOW
1 Show Current Patient List [ORLP LIST]
2 Show list of accessions for a patient [LRUPT]
3 Show Me the Notifications I Can Receive [ORB3 REC RECIP NOTIFICATIONS]
4 Show Me the Order Checks I Can Receive [ORK REC RECIP ORDER CHECKS]
5 Show Progress Notes Across Patients [TIU REVIEW PN CLINICIAN]
6 Show all options in a Menu Template [XQTLIST]
Type '^' to stop, or choose a number from 1 to 6 :2
Show list of accessions for a patient
Select ACCESSION AREA: BSO BA-SENDOUT
Select Patient Name: V6789
1 VETERAN,JANE R FEMALE 09/10/1955 987654321
2 VETERAN,JOHN Q MALE 09/16/1924 123456789
CHOOSE 1-2: 2 VETERAN,JANE R FEMALE 09/16/1964 123456789
VETERAN, JANE R ID: 123-45-6789
AGE: 39 DATE OF BIRTH: Sep 16, 1964
Ward on Adm: LR1INT Service: INTER MEDICINE LTC
Adm Date: FEB 4,2002@12:05:26 Adm DX: Hospice Care
Present Ward: LR1INT Primary MD: PRACTITIONER,J
Attending MD: PRACTITIONER,J
PATIENT LOCATION: ABCDE// ABCDE
Is this the patient ? YES// (YES)
BA-SENDOUT VETERAN,JOHN Q MALE 09/16/1964 123456789 TESTS ORDERED
Spec Date/time Acc # Site/specimen Tests
02/04/2002 14:31 BSO 02 654 SERUM 1)MYOGLOBIN
UID: 1234566789
8.36. HOW TO LOOK UP AN ASCUS/HPV TEST. The attending pathologist who sends out HPV_DNA on an ASCUS case
is responsible for following up whether the HPV_DNA test is actually
sent out, and is actually reported back to VistA®, within the next month.
Select LABORATORY MENU Option: ^GEN
1 General MailMan Information [XMHELPALL]
2 General report for selected tests [LRGEN]
3 Generate Survey Statistics [QAP GENERATE SURVEY STATISTICS]
Type '^' to stop, or choose a number from 1 to 3 :2 General report for selected tests
Select HOSPITAL LOCATION NAME: BALTIMORE
GENERAL LAB DATA DISPLAY
Select Patient Name: V6789
1 D6789 VETERAN,JANE R 7-22-62 123456789 YES SC VETERAN B/
2 D4321 VANDECAMP,JUNE S 5-22-62 987654321 YES NSC VETERAN B/
CHOOSE 1-2: 1
1 D6789 VETERAN,JANE R 7-22-62 123456789 YES SC VETERAN B/
Enrollment Priority: GROUP 8a Category: ENROLLED End Date:
Select LABORATORY TEST NAME: HPV DNA - HIGH RISK
Select LABORATORY TEST NAME:
Specify specimen actually tested. Use BLOOD when Whole blood is tested;
use SERUM when Serum is tested; etc. In doubt press the Return key.
Select SITE/SPECIMEN: ANY//
Date to START with: TODAY//T-9999 (JUL 04, 1976)
Date to END with: T-14//T (NOV 19, 2003)
DEVICE: HOME// VIRTUAL TERMINAL Right Margin: 80//
WORK COPY: VETERAN,JANE R 123-45-6789 Age:41 Prt Date:11/19/2003@15:13
Report Range [ 11/19/2003 - 07/04/1976 ] Pg:1
SPEC HPV_DNA
=============================================================================
07/25/2003
CER NEG
-----------------------------------------------------------------------------
WORK COPY - DO NOT FILE
VETERAN,JANE R 123-45-6789
PRESS '^' TO STOP REPORT
[ *** End Of Report *** ]
9. ENTER PROVISIONAL/FINAL AUTOPSY REPORT.
Return to top of page.
9.37. VistA® ENTER PROVISIONAL ANATOMIC DIAGNOSIS
FOR AUTOPSY.
Select Anatomic pathology Option: D Data entry, anat path
Select Data entry, anat path Option: Data entry for autopsies
Select Data entry for autopsies Option: PD Provisional anatomic diagnoses
BA-AUTOPSY (BAU)
Data entry for 2003 ? YES// (YES)
Select Accession Number/Pt name: 22 for 2003
JONES,ALBERT ID: 123-45-6789
CLINICAL DIAGNOSES:. . .
. . .
transferred to the SICU for further monitoring. At the time
of transfer, the patient was stable. At approximately 10:30 AM
of the same day, the patient was found in asystole, and respiratory distress.
The ACLS protocol was initiated. Despite multiple defibrillation attempts,
the patient remained pulseless and expired at 10:42 AM.
EDIT Option:
PATHOLOGICAL DIAGNOSES:. . .
. . .
a. TWO 10 X 13 CM SQUARE THORACIC AND LEFT AXILLARY BURN SCARS,
CONSISTENT WITH DEFIBRILLATION PADS.
50>
10. CENTRAL NERVOUS SYSTEM
a. BRAIN, 1220 G, WITH NO SIGNIFICANT PATHOLOGICAL ABNORMALITY.
COMMENT:
Provisional anatomic diagnosis signed on 1/3/2003.
Final anatomic diagnosis pending examination of histologic sections.
EDIT Option:
PROVISIONAL ANAT DX DATE: JAN 3,2003//
9.38. VistA® ENTER FINAL ANATOMIC DIAGNOSIS FOR AUTOPSY.
Select Anatomic pathology Option: D Data entry, anat path
Select Data entry, anat path Option: Data entry for autopsies
Select Data entry for autopsies Option: AP AUTOPSY PROTOCOL
BA-AUTOPSY (BAU)
Data entry for 2003 ? YES// (YES)
Select Accession Number/Pt name: 22 for 2003
JONES,ALBERT ID: 123-45-6789
CLINICAL DIAGNOSES:. . .
26>transferred to the SICU for further monitoring. At the time of transfer,
27> the patient was stable.
28> At approximately 11:30 AM of the same day, the patient was found in
29> asystole,
30> and respiratory distress. The ACLS protocol was initiated. Despite
31> multiple
32> defibrillation attempts, the patient remained pulseless and expired
33> at 11:43 AM.
EDIT Option:
PATHOLOGICAL DIAGNOSES:. . .
. . .
48>a. TWO 10 X 13 CM SQUARE THORACIC AND LEFT AXILLARY BURN SCARS,
49>CONSISTENT WITH DEFIBRILLATION PADS.
50>
51>10. CENTRAL NERVOUS SYSTEM
52>a. BRAIN, 1220 G, WITH NO SIGNIFICANT PATHOLOGICAL ABNORMALITY.
53>
54>COMMENT:
55>Provisional anatomic diagnosis signed on 1/3/2003.
56>Final anatomic diagnosis pending examination of histologic sections.
EDIT Option:
PROVISIONAL ANAT DX DATE: JAN 3,2003//
10. ADMINISTRATIVE FUNCTIONS (BACKUP, WORK-REQUESTS, REFERRALS, LEAVE).
Return to top of page.
10.39. PROCEDURE FOR MANUAL PAPER BACKUP OF ANATOMIC PATHOLOGY
REPORTS WHEN VistA® COMPUTER SYSTEM IS DOWN.
When the computer is about to go down during regular
business hours, you may print out the
LAST THREE WEEKS
of surgical pathology and cytopathology reports, as shown below.
You should estimate about 100 cases (surgical pathology or cytopathology)
per week.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PA Print final path reports by accession #
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Select Accession YEAR: 2003 (2003)
Start with accession #: 1000
Go to accession #: 2000
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1
For cytology reports, as above except for:
Select ANATOMIC PATHOLOGY SECTION: BCY BA-CYTOLOGY
10.40. BIWEEKLY DISK BACKUP OF ANATOMIC PATHOLOGY REPORTS
IN CASE VistA® COMPUTER SYSTEM GOES DOWN.
Each week, the Chief, Quality Assurance
Section, Anatomic Pathology, makes a hard-disk backup of the
LAST THREE WEEKS of surgical pathology and cytopathology reports,
as shown below. This includes approximately 300 cases (surgical pathology
or cytopathology) for the three-week period. First, sign onto the VistA®
anatomic pathology system. Then go to the TOOLBAR at the top of the screen
on your computer workstation,
and click on TOOLS, then click on START CAPTURE, then save as:
c:\vistabak\surgmmdd.txt
for surgical pathology and
c:\vistabak\cytommdd.txt
for cytology.
The last four digits of the code, mmdd, stands for month/date
when the download has been performed.
For example, mmdd=1201 denotes the first of December.
Next, download the accession file to your email location as follows.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PA Print final path reports by accession #
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
Select Accession YEAR: 2003 (2003)
Start with accession #: 3700
Go to accession #: 4000
DEVICE: HOME// P-MESSAGE
1 P-MESSAGE-HFS Message Output
2 P-MESSAGE132 MAIL 132
Choose 1-2> 1 P-MESSAGE-HFS Message Output
Subject: vist1234
Select one of the following:
M Me
P Postmaster
From whom: Me//
Send mail to: PATHOLOGIST,JOHN Q// PATHOLOGIST,JOHN Q
Select basket to send to: IN// VISTABAK
And Send to:
Moving to MailMan message...........
Finished moving.
Sending [12345678]...
Sent
Select Print, anat path Option:
Select Anatomic pathology Option: MAILMan Menu
VA MailMan 8.0 service for PATHOLOGIST.JOHN_Q@BALTIMORE.MED.VA.GOV
You last used MailMan: 10/12/03@13:47
You have no new messages.
Select MailMan Menu Option: RML Read/Manage Messages
Select message reader: Classic//
Read mail in basket: IN// VISTABAK (2 messages)
Last message number: 12 Messages in basket: 12
Enter ??? for help.
VISTABAK Basket Message: 1// 12
Enter message action (in VISTABAK basket): Ignore// Print
Print recipient list? No// NO
DEVICE: HOME// 0;80;9999999 VIRTUAL TERMINAL
MailMan message for PATHOLOGIST,JOHN Q PATHOLOGIST
Printed at BALTIMORE.MED.VA.GOV 10/12/03@13:50
Subj: vist1112 [#12345678] 10/12/03@13:49 1234567 lines
From: PATHOLOGIST,JOHN Q In 'VISTABAK' basket. Page 1
-----------------------------------------------------------------------------
MEDICAL RECORD | SURGICAL PATHOLOGY Pg 1
-----------------------------------------------------------------------------
Submitted by: JANE R PODIATRIST Date obtained: Sep 28, 2003
-----------------------------------------------------------------------------
Specimen (Received Sep 28, 2003 16:09):
1. BONE LEFT FOOT
-----------------------------------------------------------------------------
Brief Clinical History:
PATIENT HAS PAINFUL LEFT BUNION & 2ND DIGIT HAMMERTOE OF MANY YEARS
DURATION. PATIENT REQUEST SURGICAL CORRECTION.
-----------------------------------------------------------------------------
Preoperative Diagnosis:
left hallux valgus
-----------------------------------------------------------------------------
Operative Findings:
left hallux valgus
-----------------------------------------------------------------------------
Postoperative Diagnosis:
left hallux valgus
Surgeon/physician: JANE R PODIATRIST
=============================================================================
PATHOLOGY REPORT
Laboratory: VA MARYLAND HCS Accession No. BSP 03 4000
-----------------------------------------------------------------------------
Pathology Resident: JOHN G RESIDENT
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION & ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
NAME, AND "BONE LEFT FOOT", AND CONSISTS OF FIVE PIECES OF TAN-WHITE TO
YELLOW BONE FRAGMENTS, MEASURING FROM 0.6 X 0.4 X 0.3 CM TO 2.2 X 1.4
X 0.4 CM. THE ARTICULAR SURFACE IS TAN-WHITE AND ROUGHENED. THE
SPECIMEN IS FOR GROSS EXAMINATION ONLY.
Microscopic exam/diagnosis:
FRAGMENTS OF BONE WITH DEGENERATIVE CHANGES (GROSS ONLY).
SNOMED code(s):
T-Y9700: foot
M-50000: degeneration
-----------------------------------------------------------------------------
(End of report)
JOHN Q PATHOLOGIST MD jqp| Date Sep 29, 2003
-----------------------------------------------------------------------------
VETERAN, WILLIAM STANDARD FORM 515
ID:123-45-6789 SEX:M DOB:07/16/1917 AGE: 86 LOC:OR
JANE Q PODIATRIST
.............
Enter message action (in VISTABAK basket): Ignore//
End reached. Begin again? No// NO
Select MailMan Menu Option:
Select Anatomic pathology Option:
Select LABORATORY MENU Option:
Do you really want to halt? YES//
Then:
1. It is convenient to place the
files
c:\vistabak\surgmmdd.txt
and
c:\vistabak\cytommdd.txt
as a shortcut on your
Microsoft® Windows® DESKTOP.
2.
Click on MYCOMPUTER on the upper left corner of your desktop.
3.
Click on C:
4.
Click on
VISTABAK
5.
Right-Click on
SURGMMDD.TXT
6.
Click on CREATE SHORTCUT.
7. Drag and Drop the file SHORTCUT TO SURGMMDD.TXT
to the desktop on your disk drive.
8. If VistA® goes down, but you have access
to your local desktop, you can print out this file on the network printer.
10.41. ISSUING A WORK REQUEST ON VistA®.
If there is a maintenance or engineering or other physical plant
problem, ordinarily this will be addressed by the
administrative staff
in the department. If it is after-hours and the problem is urgent,
then you should issue an ELECTRONIC WORK REQUEST, as follows:
Select LABORATORY MENU Option: WW Electronic Work Requests
Select Electronic Work Requests Option: ?
1 Request Electronic Work Order
2 Edit Electronic Work Order
3 Electronic Work Order Status Check
4 Incomplete Work Orders (ELECT WORK MODULE)
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Electronic Work Requests Option: 1 Request Electronic Work Order
Select ENGINEERING SECTION LIST: ?
Answer with ENGINEERING SECTION LIST, or SECTION NUMBER
Do you want the entire ENGINEERING SECTION LIST List? Y (Yes)
Choose from:
90 HOLDING AREA-BT
92 HOLDING AREA-PP
Select ENGINEERING SECTION LIST: 90 HOLDING AREA-BT
Want to enter a new work order?
Enter Yes or No: YES//
WORK ORDER #: HAB123456-789 (SEP 19, 2003@09:16)
ORIGINAL WORK ORDER #: HAB123456-789// (No Editing)
REQUEST MODE: COMPUTER// .........
10.41.1 ISSUING AN IRM WORK REQUEST ON MAGIC
.
Click on the
MAGIC
icon, which should be on every desktop.
The MAGIC dialog box will appear.
Under
PROBLEM MANAGEMENT
(upper left on screen),
click on
INCIDENT.
The
CLIENT RECORD INFORMATION
dialog box will appear.
Fill out:
COMPUTER NAME
(upper right corner of your computer desktop),
BLDG/ROOM,
and
EXT.
Under
SUBJECT DESCRIPTION,
select
HARDWARE
(if appropriate).
Under
DESCRIPTION OF PROBLEM,
write a short description of the problem,
being as specific as possible.
Don't just write:
printer doesn't work;
rather, write
paper jams repeatedly in printer.
10.42. HOW TO LOGIN A REFERRAL SPECIMEN, NOT A VETERAN.
Select LABORATORY MENU Option: anatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: log-in menu, anat path
Select Log-in menu, anat path Option: ?
LI Log-in, anat path
DA Delete accession #, anat path
PB Print log book
HW Histopathology Worksheet
RAD Select Report to Print by Patient
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Log-in menu, anat path Option: li Log-in, anat path
Select ANATOMIC PATHOLOGY SECTION: bsp BA-SURGICAL PATHLOGY
Log-In for 2003 ? YES// (YES)
Select Patient Name:
REF:VETERAN,JOHN Q
File: REFERRAL PATIENT Entry: REF:VETERAN,JOHN Q
Are you adding 'VETERAN,JOHN Q' as a new REFERRAL PATIENT? No// Y (Yes)
REFERRAL PATIENT SEX: M MALE
REFERRAL PATIENT DOB: 091624 (SEP 16, 1924)
REFERRAL PATIENT IDENTIFIER: 123456789
VETERAN, JOHN Q ID: 123-45-6789
AGE: 67 DATE OF BIRTH: Sep 14, 1924
PATIENT LOCATION: ???// LABORATORY
Assign BA-SURGICAL PATHLOGY (BSP) accession #: 1234 ? YES// (YES)
Date/time Specimen taken: TODAY// 1120 (NOV 20, 2003)
SURGEON/PHYSICIAN: PATHOLOGIST,JO
1 PATHOLOGIST,JOE S JSP 113 PATHOLOGIST
2 PATHOLOGIST,JOSEPHINE R JRP 113 PSYCHOLOGIST
CHOOSE 1-2: 1 PATHOLOGIST,JOE S JSP 113 PATHOLOGIST
SPECIMEN SUBMITTED BY: PATHOLOGIST, JOE S
Select SPECIMEN: SKIN, LEFT LOWER LIP
Select SPECIMEN:
DATE/TIME SPECIMEN RECEIVED: NOW// (NOV 19, 2003@12:59)
PATHOLOGIST: PATHOLOGIST,JO
1 PATHOLOGIST,JOE S JSP 113 PATHOLOGIST
2 PATHOLOGIST,JOSEPHINE R JRP 113 PSYCHOLOGIST
CHOOSE 1-2: 1 PATHOLOGIST,JOE S JSP 113 PATHOLOGIST
Select COMMENT:
Select Patient Name:
Select Log-in menu, anat path Option: ^GD
1 Clinical Hx/Gross Description/FS [LRAPDGD] (GD)
2 Group data review (verified & EM) [LRGVP] (GD)
Type '^' to stop, or choose a number from 1 to 2 :1 GD Clinical Hx/Gross Description/FS
ANATOMIC PATHOLOGY MENU
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY (BSP)
Data entry for 2003 ? YES// (YES)
Select Accession Number/Pt name: 4298 for 2003
VETERAN, JOHN Q ID: 123-45-6789
Specimen(s):
SKIN, LEFT LOWER LIP
Select SPECIMEN: SKIN, LEFT LOWER LIP//
SPECIMEN: SKIN, LEFT LOWER LIP Replace
Select SPECIMEN:
BRIEF CLINICAL HISTORY:
1>SLOWLY GROWING LOWER LIP LESION FOR SIX MONTHS.
2>
EDIT Option:
PREOPERATIVE DIAGNOSIS:
1>SAME.
2>
OPERATIVE FINDINGS:
1>SAME.
2>
POSTOPERATIVE DIAGNOSIS:
1>SAME.
2>
RESIDENT PATHOLOGIST:PATHOLOGIST,JOE PATHOLOGIST,JOE S JSP 113 PATHOLOGIST
GROSS DESCRIPTION:
1>RECEIVED FROM PODUNK GENERAL HOSPITAL ARE FOUR UNSTAINED SLIDES,
2>LABELED 03S1234, A1, A2.
3>
EDIT Option:
Select Anatomic pathology Option: P Print, anat path
Select Print, anat path Option: PS Print single report only
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
1. Preliminary reports
2. Final reports
Select 1 or 2 : 1
Preliminary reports for BA-SURGICAL PATHLOGY
Select Patient Name: REF:VETERAN,J
File: REFERRAL PATIENT Entry: VETERAN,J
1 VETERAN,JANE R FEMALE 09/10/1955 987654321
2 VETERAN,JOHN Q MALE 09/16/1924 123456789
CHOOSE 1-5: 2 VETERAN,JOHN Q MALE 09/16/1924 123456789
VETERAN, JOHN Q ID: 123-45-6789
AGE: 79 DATE OF BIRTH: Sep 16, 1924
Specimen(s) Count # Accession # Date Obtained
( 1) BSP 03 1234 Nov 20, 2003
SKIN, LEFT LOWER LIP
Accession #: BSP 03 4298 Date Obtained: Aug 20, 2003
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
Requested Start Time: NOW// (NOV 19, 2003@13:12:28)
Report Queued to device LABSCOPE$PRT
10.43. REQUEST FOR EMPLOYEE
ANNUAL LEAVE, SICK LEAVE, ETC.
Select LABORATORY MENU Option: 71 Employee Menu
PRIVACY ACT STATEMENT
In accordance with OPM and VA policies this information is to be furnished
for use only as authorized. It will not be reproduced or used for any other
purposes. Any output must be secured in a storage system adequate to insure
against disclosure to unauthorized parties. Disposal will be by burning,
shredding, or other treatment to destroy their legibility.
Select Employee Menu Option: 1 Leave Request
VA TIME REQUEST FOR LEAVE SYSTEM
EMPLOYEE, JOHN Q 123-45-6789
From Date: Time:
To Date: Time:
AL Annual Leave AA Authorized Absence CB Family Care
SL Sick Leave ML Military Leave AD Adoption
WP Without Pay RL Restored Annual Leave DL Donor Leave
CU Comp Time/Credit Hrs NL Non-Pay Annual Leave
Type of Leave: Number of Days:
Remarks:
_____________________________________________________________________________
COMMAND: Press H for help Insert
10.44. CHANGE USER TOOLBOX CHARACTERISTICS (PASSWORD, NAME, ETC.).
Select LABORATORY MENU Option: USER's Toolbox
Select User's Toolbox Option: EDIT User Characteristics
Select TERMINAL TYPE NAME: C-IMPC// IMAGING WORKSTATION
NAME: EMPLOYEE,JOHN Q PAGE 1 OF 1
_____________________________________________________________________________
INITIAL: PHONE: 1-999-999-9999
NICK NAME: JACK OFFICE PHONE: 1-999-999-9999
VOICE PAGER: 9999
DIGITAL PAGER:
ASK DEVICE TYPE AT SIGN-ON: DON'T ASK
AUTO MENU:
TYPE-AHEAD: ALLOWED
TEXT TERMINATOR:
PREFERRED EDITOR: LINE EDITOR - VA FILEMAN
Want to edit VERIFY CODE (Y/N):
Exit Save Refresh
Enter a command or '^' followed by a caption to jump to a specific field.
COMMAND:S Press H for help Insert
10.44.1.
VistA® SCREEN-BASED WORD PROCESSOR.
SUMMARY OF KEY SEQUENCES
Navigation
Incremental movement Arrow keys
One word left and right <CTRL-J> and <CTRL-L>
Next tab stop to the right <Tab>
Jump left and right <NUMLK><Left> and <NUMLK><Right>
Beginning and end of line <NUMLK><NUMLK><Left> and <NUMLK><NUMLK><Right>
or: <Find> and <Select>
or: <Home> and <End>
Screen up or down <NUMLK><Up> and <NUMLK><Down>
or: <Prev Scr> and <Next Scr>
or: <Page Up> and <Page Down>
Top or bottom of document <NUMLK>T and <NUMLK>B
Go to a specific location <NUMLK>G
Exiting/Saving
Exit and save text <NUMLK>E
Quit with optional save <NUMLK>Q or <CTRL-E>
Exit, save, and switch editors <NUMLK>A
Save without exiting <NUMLK>S
Enter minutes for AutoSave <NUMLK><NUMLK>S
Deleting
Character before cursor <Backspace>
Character at cursor <PF4> or <Remove> or <Delete>
From cursor to end of word <CTRL-W>
From cursor to end of line <NUMLK><PF2>
Entire line <NUMLK>D
Settings/Modes
Wrap/nowrap mode toggle <PF2>
Insert/replace mode toggle <PF3> or <Insert Here> or <Insert>
Set/clear tab stop <NUMLK><Tab>
Enter columns for tab stops <NUMLK><NUMLK><Tab>
Set left margin <NUMLK>,
Set right margin <NUMLK>.
Status line toggle <NUMLK>?
Formatting
Join current line to next line <NUMLK>J
Reformat paragraph <NUMLK>R
Finding
Find text <NUMLK>F
Find next occurence of text <NUMLK>N
Find/RePlace text <NUMLK>P
Cutting/Copying/Pasting
Select (Mark) text <NUMLK>M at beginning and end of text
Unselect (Unmark) text <NUMLK><NUMLK>M
Delete selected text <Delete> or
<Backspace> on selected text
Cut and save to buffer <NUMLK>X on selected text
Copy and save to buffer <NUMLK>C on selected text
Paste from buffer <NUMLK>V
Move text to another location <NUMLK>X at new location
Copy text to another location <NUMLK>C at new location
10.45. U. S. GOVERNMENT
ELECTRONIC SIGNATURE. Each U. S. Government worker has
an official electronic signature. You should keep your electronic signature
available to you in a safe place.
Select Accessioning menu Option: ^TBOX User's Toolbox
Select User's Toolbox Option: E
1 Edit User Characteristics
2 Electronic Signature code Edit
CHOOSE 1-2: 2 Electronic Signature code Edit
This option is designed to permit you to enter or change your Initials,
Signature Block Information, Office Phone number, and Voice and
Digital Pagers numbers.
In addition, you are permitted to enter a new Electronic Signature Code
or to change an existing code.
INITIAL: GWP
SIGNATURE BLOCK PRINTED NAME: GEORGE W PATHOLOGIST//
SIGNATURE BLOCK TITLE: Staff Pathologist//
OFFICE PHONE: 1-234-567-8901 x5678 Replace
VOICE PAGER: 5678//
DIGITAL PAGER:
Enter your Current Signature Code: callmeishmael
11. EMAIL.
Return to top of page.
11.46. VISTA® EMAIL OPTIONS.
A Answer.
B Backup.
BR Print to the Browser.
C Copy.
D Delete.
F Forward.
H Headerless Print.
HG Help:Group Information.
HU Help:User Information.
I Ignore.
L Later.
N New.
P Print.
Q Query.
Q xxx Query recipient(s) xxx.
QC Query Current.
QD Query Detailed.
QN Query Network.
QNC Query Not Current.
QT Query Terminated.
R Reply.
RI Reply and Include responses.
S Save.
T Terminate.
V Vaporize date edit.
W Write.
11.46.1 EDIT VISTA® MAILGROUP.
Email MAILGROUPs are used to send messages to groups of email recipients,
as for example, a confirm/priority email to all residents in dermatology:
Select LABORATORY MENU Option: GE Mail Group Coordinator's Edit
VA MailMan 8.0 service for MOORE.GEORGE_W@BALTIMORE.MED.VA.GOV
You last used MailMan: 11/24/03@11:42
You have no new messages.
Select MAIL GROUP NAME: LABDERMPATH
Select MEMBER: SMITH,JOAN Q//
MEMBER: SMITH,JOAN Q//
TYPE:
Select MEMBER:
Select MEMBER GROUP NAME:
Select MAIL GROUP NAME:
Select LABORATORY MENU Option:
11.47. EMAIL TRANSACTION SUMMARY.
Select LABORATORY MENU Option: MAILMAN Menu
VA MailMan 8.0 service for PATHOLOGIST.JOHN_Q@BALTIMORE.MED.VA.GOV
You last used MailMan: 01/8/04@13:10
You have no new messages.
Select MailMan Menu Option: RML Read/Manage Messages
Select message reader: Classic//
Read mail in basket: IN// (95 messages)
Last message number: 95 Messages in basket: 95
Enter ??? for help.
IN Basket Message: 11// 12345678
Subj: Staff Meeting [#12345678] 01/8/04@09:59 3 lines
From: CHAIR,THE In 'IN' basket. Page 1
----------------------------------------------------------------------------
Please note we have a staff meeting tomorrow at 1 PM.
Sincerely yours, The Chair.
Enter message action (in IN basket): Ignore// Print
Print recipient list? No// YES
Select one of the following:
D Detail
S Summary
Print Detail or Summary recipient chain: Summary// Detail
DEVICE: HOME// QUEUE TO PRINT ON
DEVICE: HOME// LABSCP
1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
2 LABSCOPE$PRT COMP (LABORATORY)-BALTIMORE,4D-139
Choose 1-2> 1 LABSCOPE$PRT (LABORATORY)-BALTIMORE,4D-139
Requested Start Time: NOW// (JAN 8, 2004@13:23:18)
Request queued. Task number: 987654
Enter message action (in IN basket): Ignore//
This message is a priority message.
Deliver future responses to this message as Priority Mail? No// NO
IN Basket Message: 93//
11.48. PRINT UNRESPONDED-TO VistA® EMAILS.
All surgical pathology and cytopathology
reports for which the pathologist issues a VistA confirm/priority email
with the subject line URGENT PATHOLOGY REPORT, which are unresponded-to
after one month. The pathologist issues such a confirm/priority email
on all new cancer cases, excluding basal cell carcinomas of the skin,
or on any other case for which there is an apparently unexpected finding,
including unexpected positive surgical margins, unexpected dysplastic
lesions, new infectious disease, or other feature of concern to the
pathologist. The fact that an email has been issued is documented in
the COMMENT section of the report, and as SNOMED code P0658,
CONSULTATION BY EMAIL. In preparation for each monthly report to the IPRC,
the CHIEF, QUALITY ASSURANCE SECTION
obtains the following listing of URGENT PATHOLOGY REPORTS
that have not be responded-to:
Select LABORATORY MENU Option: PRINT Pathology Messages not read
Enter Start Date to look at messages: 9/1/2003 (SEP 01, 2003)
Enter End Date to look at messages: 9/30/2003 (SEP 30, 2003)
DEVICE: HOME// VIRTUAL TERMINAL Right Margin: 80//
Message Subject Message # Sender
URGENT PATHOLOGY REPORT BCY 03-1234 12345678 PATHOLOGIST,JOHN Q
URGENT PATHOLOGY REPORT BCY 03-5678 90123456 PATHOLOGIST,JOHN Q
URGENT PATHOLOGY REPORT BCY 03-9012 78901234 SPECIALIST,MARY G
URGENT PATHOLOGY REPORT BCY 03-3456 56789012 SPECIALIST,MARY G
URGENT PATHOLOGY REPORT BSP 03-7890 34567890 SPECIALIST,MARY G
URGENT PATHOLOGY REPORT BSP 03-1234 12345678 SPECIALIST,MARY G
URGENT PATHOLOGY REPORT BSP 03-5678 90123456 SPECIALIST,MARY G
Select LABORATORY MENU Option:
Each patient/report is checked to determine whether some other electronic
followup has been documented, such as a CPRS note from the same
service that submitted the original report. If no such CPRS report
is apparent, then the case is reported to the IPRC.
11.48.1 RESPONSE TO A VistA® ALERT.
Attending pathologists are notified from time to time regarding
urgent patient-care results, by way of a VistA® ALERT,
issued by CPRS in response to actions taken by the clinical laboratory,
the pharmacy, or by another physician in the institution. The
attending pathologist assumes medical responsibility for the content
of these alerts. In order to view a pending VistA® ALERT,
proceed as follows:
You have PENDING ALERTS
Enter "VA to jump to VIEW ALERTS option
Select MailMan Menu Option: VA View Alerts
1.I SMITH,JANE (6789): HPV DNA - HIGH RISK Value is: NEG
Select from 1 to 1
or enter ?, A, I, D, F, S, P, M, R, or ^ to exit: A
Processed Alert Number 1
SMITH,JANE (6789): HPV DNA - HIGH RISK Value is: NEG
Continue (Y/N) or F(orward) or R(enew) YES//<ENTER>
The attending pathologist is now responsible for acting upon
the contents of that alert.
12. ANATOMIC PATHOLOGY SEARCHES AND TEMPLATES.
Return to top of page.
12.49. SNOMED SEARCH,
in order to search for cases with a particular RANGE OF SNOMED CODES
over a particular RANGE OF DATES.
The allowable range-of-dates for anatomic pathology is October 1, 1989,
through the present. Electronic anatomic pathology files are not available
before that date. As a rule, DO NOT REQUEST A LARGE RANGE OF DATES
DURING ORDINARY BUSINESS HOURS, as this heavily taxes computer resources,
and competes with routine patient-care functions in the institution.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: I Inquiries, anat path
Select Inquiries, anat path Option: SE Search options, anat path
Select Search options, anat path Option: MC MORPHOLOGY code search, SNOMED
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY search by MORPHOLOGY code
TOPOGRAPHY (Organ/Tissue)
Select 1 or more characters of the code
For all sites type 'ALL' : 67
MORPHOLOGY
For all choices type 'ALL'
Choice # 1: Select 1 or more characters of the code: 814
Choice # 2: Select 1 or more characters of the code:
Start with Date TODAY// 1/1/2003 (JAN 01, 2003)
Go to Date TODAY// 1/30/2003 (JAN 30, 2003)
DEVICE: HOME// VIRTUAL TERMINAL
Nov 20, 2003 13:57 MARYLAND HCS Pg: 1
BA-SURGICAL PATHLOGY (BSP) SEARCH(Jan 01, 2003=>Jan 30, 2003)
# = Not VA patient
SNOMED TOPOGRAPHY CODE: 67--- SNOMED MORPHOLOGY CODE: 814--
NAME ID SEX AGE ACC # ORGAN/TISSUE MORPHOLOGY
JONES,BILL 1234 M 69 BSP 03 123 COLON ADENOCARCINOMA
BAUER,BOB 5678 M 62 BSP 03 456 COLON ADENOCARCINOMA
62 BSP 03 789 COLON ADENOCARCINOMA
JACKSON,JACK 9012 M 68 BSP 03 987 COLON ADENOCARCINOMA
SMITH,SAMUEL 3456 M 61 BSP 03 654 CECUM ADENOCARCINOMA
61 BSP 03 321 COLON ADENOCARCINOMA
SMITH,JAMES M 7890 M 70 BSP 03 234 COLON ADENOCARCINOMA
Nov 20, 2003 13:57 MARYLAND HCS Pg: 2
BA-SURGICAL PATHLOGY (BSP) SEARCH(Jan 01, 2003=>Jan 30, 2003)
# = Not VA patient
SNOMED TOPOGRAPHY CODE: 67--- SNOMED MORPHOLOGY CODE: 814--
RESULT OF BA-SURGICAL PATHLOGY SEARCH:
SURGICAL PATHOLOGY PATIENTS WITHIN PERIOD SEARCHED: 352
BA-SURGICAL PATHLOGY ACCESSIONS WITHIN PERIOD SEARCHED: 355
5 OF 352 PATIENTS( 1.42%)
7 OF 56 SNOMED CODE 67 SPECIMENS(12.50%)
413 ORGAN/TISSUE SPECIMENS WITHIN PERIOD SEARCHED
(SNOMED TOPOGRAPHY CODE 67 IS 13.56%)
Popular SNOMED searches include:
COLON: SNOMED TOPOGRAPHY CODE: 8
COLON: SNOMED TOPOGRAPHY CODE: 67
PROSTATE: SNOMED TOPOGRAPHY CODE: 77
KIDNEY: SNOMED TOPOGRAPHY CODE: 71
SKIN: SNOMED TOPOGRAPHY CODE: 01
SKIN: SNOMED TOPOGRAPHY CODE: 02
BONE MARROW: SNOMED TOPOGRAPHY CODE: 06
LUNG: SNOMED TOPOGRAPHY CODE: 28
LARYNX: SNOMED TOPOGRAPHY CODE: 24
ADENOCARCINOMA: SNOMED MORPHOLOGY CODE: 814
SQUAMOUS CELL CARCINOMA: SNOMED MORPHOLOGY CODE: 807
In order to give a non-pathologist clinician/administrator access
to these files,
the CHIEF, AUTOMATED DATA PROCESSING
should issue an IRM Request, as follows:
Select MailMan Menu Option: N New Messages and Responses
Subj: IRM SUPPORT REQUEST #123456 [#98765432] 02/16/03@07:50 14 lines
From: PATHOLOGIST,JOHN Q (Baltimore Division) In 'IN' basket. Page 1 *New*
-----------------------------------------------------------------------------
PATHOLOGIST,JOHN Q (Ph: 9876) (BT) of 4D-999 has requested IRM support
on request #123456 on FEB 16,2003@07:50 with Routine priority.
DESCRIPTION:
Please add to the secondary menu of ADMINSTRATOR,LUCKY:
MULTIAXIAL CODE SEARCH, SNOMED
Option name: LRAPSEM
Synonym: AX
Anatomic pathology multiaxial SNOMED code search option.
Enter message action (in IN basket): Ignore//
12.50. SNOMED SEARCH FOR AFIP CONSULTATIONS. Search for cases with a SNOMED CODES FOR AFIP CONSULTATIONS over a particular range of dates.
Then email the search over VistA® email to yourself and
forward it to the appropriate administrator.
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: I Inquiries, anat path
Select Inquiries, anat path Option: SE Search options, anat path
Select Inquiries, anat path Option: SE Search options, anat path
Select Search options, anat path Option: PC PROCEDURE code search, SNOMED
Select ANATOMIC PATHOLOGY SECTION: BSP BA-SURGICAL PATHLOGY
BA-SURGICAL PATHLOGY search by PROCEDURE code
TOPOGRAPHY (Organ/Tissue)
Select 1 or more characters of the code
For all sites type 'ALL' : ALL
PROCEDURE
Select only procedures with results ? NO// (NO)
For all choices type 'ALL'
Choice # 1: Select 1 or more characters of the code: 030112
Choice # 2: Select 1 or more characters of the code:
Start with Date TODAY// 1/1/2003 (JAN 01, 2003)
Go to Date TODAY// 3/31/2003 (MAR 31, 2003)
DEVICE: HOME// P-MESS
1 P-MESSAGE-HFS Message Output
2 P-MESSAGE132 MAIL 132
Choose 1-2> 1 P-MESSAGE-HFS Message Output
Subject: AFIP CONSULTS 1/1-3/31/2004
Select one of the following:
M Me
P Postmaster
From whom: Me//
Send mail to: PATHOLOGIST,JOHN Q// PATHOLOGIST,JOHN Q
Select basket to send to: IN//
And Send to:
Do you want to queue this report ? NO// (NO)
Subject: AFIP CONSULTS 1/1-3/31/2004
Select one of the following:
M Me
P Postmaster
From whom: Me//
Send mail to: PATHOLOGIST,JOHN Q// PATHOLOGIST,JOHN Q
Select basket to send to: IN//
And Send to:
Moving to MailMan message...........
Finished moving.
Sending [12345678]...
Sent
The following gross templates are offered as sample dictations,
and as guidelines for preparing common, large-specimen documents
in anatomic pathology. These templates are for guidance only,
and are always superseded by the professional judgment of the
attending pathologist.
Gross dictations should represent a complete description of a specimen,
and should include dimensions in cm, anatomic features, color, consistency,
and any markings (usually sutures) placed by the surgeons, and any
inked-markings made the resident. If the specimen is unoriented,
then the dictation should state this.
In surgical pathology and autopsy pathology, it is often helpful to include
a sketch or diagram of the specimen or specific anatomy in the report,
with the understanding the report should not depend upon this sketch.
Sketches should be described in the text description with the expectation
that the paper sketch may be unavailable at some time in the future, and
the sketch could be reconstituted using the text alone. Computer texts
can be recalled instantly, and survive forever in computer archives.
12.51. GROSS TEMPLATE: AUTOPSY GROSS.
Residents should submit gross autopsy findings to the attending pathologist
organized according to the following template:
Autopsy gross template (empty).
Autopsy gross template (weight ranges).
If desired, the following text may be used and modified
for the autopsy protocol.
Input of autopsy protocol:
Select LABORATORY MENU Option: ANatomic pathology
ANATOMIC PATHOLOGY MENU
Select Anatomic pathology Option: D Data entry, anat path
Select Data entry, anat path Option: Data entry for autopsies
Select Data entry for autopsies Option: ?
PD Provisional anatomic diagnoses
AP Autopsy protocol
AS Autopsy protocol & SNOMED coding
AI Autopsy protocol & ICD9CM coding
AF Final autopsy diagnoses date
SR Autopsy supplementary report
SS Special studies, autopsy
Enter ?? for more options, ??? for brief descriptions, ?OPTION for help text.
Select Data entry for autopsies Option: AP Autopsy protocol
BA-AUTOPSY (BAU)
Data entry for 2003 ? YES// N (NO)
Select Accession Number/Pt name: 99 for 2003
VETERAN,JOHN Q ID: 123-45-6789
DATE AUTOPSY REPORT COMPLETED: NOV 22,2003//
Select AUTOPSY COMMENTS:
CLINICAL DIAGNOSES:. . .
. . .
unresponsive with a low blood pressure. The ACLS protocol was initiated,
however the patient was unable to be resuscitated. The patient died at
6:47 AM on November 21, 2003.
EDIT Option:
PATHOLOGICAL DIAGNOSES:. . .
EDIT Option: List line: 1// to: 999//
FINAL ANATOMIC DIAGNOSIS: BAU 03-99 SSN: 6789
I. CARDIOVASCULAR SYSTEM
CARDIOMEGALY...
SEROUS PERICARDIAL EFFUSION, 25 ML
PULMONIC VALVE DILATATION, 8.4 CM (7.2-7.5 CM).
MITRAL VALVE DILATATION, 11.5 CM (9.2-9.8 CM)
CORONARY ATHEROSCLEROSIS, CIRCUMFLEX CORONARY ARTERY 50%
OCCLUDED, RIGHT MAIN CORONARY ARTERY 60% OCCLUDED
MODERATE ABDOMINAL AORTIC ATHEROSCLEROSIS
II. RESPIRATORY SYSTEM
LEFT LUNG CONSOLIDATION, 720 GRAMS.
III. HEPATOBILIARY SYSTEM
CONGESTED LIVER, FOCAL MILD STEATOSIS, 2200 G (1400-1600 G).
CHOLELITHIASIS.
IV. LYMPHORETICULAR SYSTEM.
SPLENOMEGALY 370 GRAMS (45 GRAMS - 190 GRAMS)
V. GENITOURINARY SYSTEM.
BILATERAL MODERATE ARTERIONEPHROSCLEROSIS.
BILATERAL SIMPLE CORTICAL CYSTS.
MULTINODULAR PROSTATE, BENIGN GLANDULAR AND STROMAL HYPERPLASIA.
VI. GASTROINTESTINAL SYSTEM.
DIFFUSE INTRAPERITONEAL ADHESIONS.
SEROUS PERITONEAL FLUID, 95 ML.
CECAL DIVERTICULUM.
VII. ENDOCRINE SYSTEM
NONE.
VIII. MUSCULOSKELETAL SYSTEM
NONE.
IX. INTEGUMENTARY SYSTEM 24.4 CM VERTICAL ABDOMINAL SURGICAL INCISION.
COMMENT AND DISCUSSION: Autopsy showed .........
GROSS EXAMINATION.
EXTERNAL AND INTEGUMENT: Height: ... cm. Hair: Frontal alopecia.
Straight, gray. Sex: Male. Pupils: 0.3 cm,
bilaterally. Teeth: Poor dentition. A nasogastric tube is in place.
identification tags are present on the right wrist and left great toe.
RESPIRATORY SYSTEM: Right pleural fluid: 15 ml (serous). Right lung
weight: 560 g (expected 420-460 g).
Left pleural fluid: 15 ml (serous). Right lung weight: 620 g (expected
350-500 g).
Bilaterally, the lung parenchyma is tan-purple and congested.
Trachea and bronchi are unremarkable. No pulmonary thromboemboli
are present.
CARDIOVASCULAR SYSTEM: Pericardial fluid: .. ml (serous). Heart
weight: ... g (expected 350-450 g). Left ventricular myocardial
thickness: ... cm (expected 1.3-1.5 cm). Right ventricular myocardial
thickness: ... cm (expected 0.3-0.5 cm).
Tricuspid valve circumference: 11.1 cm (expected 10-12.5 cm).
Pulmonary valve circumference: 8.2 cm (expected 8.2 cm).
Mitral valve circumference: 11.3 cm (expected 8.0-10.5 cm).
Aortic valve circumference: 8.1 cm (expected 6.0-7.5 cm).
Atherosclerotic occlusion of coronary arteries: Left main: <5%; Left
anterior descending: < 5%; Left circumflex: 40%; Right main: 40%.
Atherosclerosis of abdominal aorta: Moderate.
The myocardium of the left and right atria and ventricle is unremarkable.
No evidence of myocardial infarction. Heart valves and papillary
muscles are unremarkable. No significant fibrosis or vegetations present.
GASTROINTESTINAL SYSTEM: The mucosa of the gastric antrum contains an
area of petechial hemorrhage measuring ... cm consistent with nasogastric
tube effect. There is xxx ml of serous peritoneal fluid. The distal
colon contains a circumferential sutured anastomosis. The colonic mucosa
extending xxx cm proximal to, and xxx cm distal to the anastomosis shows
dusky black discoloration. The bowel serosa overlying this area is
covered by a patchy tan-brown fibrinous exudate. The small intestine is
unremarkable.
HEPATOBILIARY SYSTEM: Liver weight: 2300 g (expeccted 1100-1800 g).
The liver parenchyma is nutmeg brown with findings grossly consistent
with steatosis. The gallbladder contains an ovoid green-tan calculus
that measures ..... cm.
LYMPHORETICULAR SYSTEM: Spleen weight: ... g (expected 120 g). The
splenic capsule shows focal white discoloration. Cut surface is maroon
without prominence of white pulp.
GENITOURINARY SYSTEM: Right kidney weight: ... g (expected 110-145 g).
Left kidney weight: ... g (expected 150-180 g). The subcapsular surface
of both kidneys is granular. The right kidney parenchyma contains a
simple cyst in the lateral superior aspect that measures ......
cm and is filled by clear serous fluid. The right cortex measures ... cm
and the right medulla measures ... cm. The left renal parenchyma
contains a simple cyst, lateral inferior aspect, measuring .... cm,
and is filled by a clear fluid. The right cortex measures
... cm and the left medulla measures ... cm. The corticomedullary
junction in each kidney is distinct. The mucosa of the bladder is
tan-pink and unremarkable. The prostate is multinodular and the testes
are unremarkable.
ENDOCRINE SYSTEM: Thyroid weight: ... g (expected 15-20 g). Pancreas
weight: ... g (expected 60-135 g). The thyroid gland, parathyroid
glands, pancreas, and adrenal glands are unremarkable.
MUSCULOSKELETAL SYSTEM: Unremarkable.
NEUROPATHOLOGY GROSS DESCRIPTION:
The scalp and skull are entered in a standard biparietal,
post-auricular manner. The dura is intact,
and the sagittal sinus is patent.
The pre-fixation brain weight is .... grams.
The cerebral and cerebellar hemispheres are symmetrical,
but there is evidence of bilateral, lateral transtentorial
herniation, as well as bilateral cerebellar tonsillar herniation.
Globally, the gyri are full and flattened in appearance.
The leptomeninges appear to be diffusely covered by
a minimal white-yellow exudate. The vessels at the
base of the brain contain a minimal amount of atherosclerosis.
There is no aneurysmal formation. The pituitary is removed
from the sella and is unremarkable. The spinal cord is removed
by an anterior approach and is unremarkable externally.
Following fixation the, cerebral hemispheres are coronally sectioned.
The cerebral parenchyma is
severely congested, with vascular prominence.
The anatomic grey and white structures are grossly identifiable.
The lateral ventricles are swollen shut, causing complete effacement
of the ventricular walls. A mid-sagittal section
of the cerebellar vermis and axial sections
of the cerebellar hemispheres are unremarkable.
Axial sections of the brainstem are unremarkable.
The sections of the spinal cord are unremarkable.
MICROSCOPIC FINDINGS:
Coronary arteries: Mild atherosclerosis.
Heart: Left ventricle with focal mild fibrosis.
Aorta: Mild complicated atherosclerosis.
Prostate: Benign glandular and stromal hyperplasia.
Thyroid, pancreas, right and left adrenal glands: No significant
pathologic abnormalities.
Liver: Mild portal fibrosis.
Stomach: Mild submucosal vascular congestion.
Spleen: Sinusoidal congestion.
Abdominal skin.
Left and right kidneys: Mild arteriosclerosis.
Right and left lung: Congestion and focal atelectasis.
Colon:
Small intestine:
Brain:
MICROSCOPIC SLIDE INDEX.
1. Coronary arteries, right ventricle, left ventricle.
2. Prostate, thyroid, liver, pancreas, stomach.
3. Aorta, spleen, serosal fibrinous material, colon.
4. Left kidney and left adrenal.
5. Right kidney and right adrenal.
6. Right lung, upper, middle and lower lobes.
7. Left lung, upper and lower lobe.
8. Small intestine, colon, esophagus.
8. Thoracic spinal cord.
9. Right midbrain.
11. Pons.
12. Medulla.
13. Vermis.
14. Right cerebellum with dentate nucleus, one
15. Right lateral geniculate nucleus.
16. Right basal ganglia.
17. Right deep gray.
18. Right middle frontal lobe.
19. Right parietal lobe.
20. Right occipital lobe.
12.52. GROSS TEMPLATE: LEG AMPUTATION.
GROSS DESCRIPTION:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH, LABELED WITH THE PATIENT'S NAME AND
"RIGHT OR LEFT AKA", AND CONSISTS OF A RIGHT LOWER EXTREMITY AMPUTATED ABOVE
THE KNEE, MEASURING ... CM FROM THE PROXIMAL BONE RESECTION MARGIN TO THE
KNEE, ... CM FROM THE KNEE TO THE HEEL, ... CM HEEL TO TOE, ... CM ACROSS
THE DORSUM OF THE FOOT, ... CM IN DIAMETER AT THE CALF, ... CM IN DIAMETER
AT THE THIGH. THE SKIN IS LIGHTLY PIGMENTED AND WRINKLED. THERE IS A
GREEN-BLACK GANGRENOUS ULCERATION ON THE DORSUM AND ANTERIOR ANKLE,
MEASURING ... CM PROXIMAL TO DISTAL, ... CM MEDIAL TO LATERAL, AND
... CM IN DEPTH. THERE ARE TWO SLOUGHED AREAS IN THE ULCER BASE A RED-PINK
AND FLESHY. THE UNDERLYING BONE IS NOT INVOLVED. THE PROXIMAL TOES HAVE
BROWN-BLACK GANGRENOUS ULCERATION. THE UNDERLYING BONE IS NOT INVOLVED.
THE TOENAILS ARE YELLOW-WHITE, THICKENED AND OTHERWISE UNREMARKABLE.
IN THE SKIN ON THE PLANTAR SURFACE OF THE FOOT IS ... THE PROXIMAL BONE
MARGIN EXTENDS ... CM FROM THE PROXIMAL RESECTION MARGIN. THE BONE MARGIN
CONSISTS OF YELLOW-WHITE VIABLE BONE AND RED SOFT MARROW.
THE SOFT TISSUE RESECTION MARGIN CONSISTS OF YELLOW LOBULATED ADIPOSE
TISSUE OVERLYING RED, HOMOGENOUS, VIABLE MUSCLE. THE SKIN AT THE SOFT
TISSUE RESECTION MARGIN IS UNREMARKABLE. THE FEMORAL ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION. THE POPLITEAL ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION. THE POSTERIOR TIBIALIS ARTERY SHOWS
ATHEROSCLEROTIC OCCLUSION. THE ANTERIOR TIBIALIS ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION.
THE SPECIMEN IS FOR GROSS EXAMINATION ONLY.
12.53. GROSS TEMPLATE: OUTSIDE CONSULTATION.
1. RECEIVED ARE SEVENTEEN SLIDES FROM GOODTIMES LABORATORY,
INC., 123 HAPPY ROAD, SUITE 456, PODUNK, MD 12345,
VOICE 123-456-7890, FAX 123-456-7891.
SLIDES ARE LABELED S2003-001234: PATIENT
IDENTIFICATION AGREES WITH REQUISITION, SLIDES,
AND THE GOODTIMES LABORATORY REPORT. THE REPORT
INDICATES THAT THE PROSTATE HAS BEEN SAMPLED FROM
THE RIGHT APEX (RA), RIGHT MIDDLE (RM), RIGHT BASE (RB),
LEFT APEX (LA), LEFT MIDDLE (LM), AND LEFT BASE (LB).
SLIDES ARE LABELED AS FOLLOWS: SIX SLIDES LABELED .....
ADENOCARCINOMA OF PROSTATE, GLEASON SCORE 3+4=7, INVOLVING
20% OF TISSUE-BLOCKS RA, RM, AND RB.
BENIGN STROMAL AND GLANDULAR HYPERPLASIA
IN TISSUE-BLOCKS LA, LM, AND LB.
COMMENT: Case discussed with Dr. Urologist on 1/17/2003.
Case reviewed in conference. The Baltimore VAMHCS
diagnosis agrees with the Goodtimes Lab diagnosis.
12.54. GROSS TEMPLATE: SKIN RESECTION SPECIMEN.
Sample dictation for unoriented skin resection specimen:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN LESION ON BACK". THE SPECIMEN CONSISTS OF AN ELLIPTICAL PIECE
OF LIGHT, TAN-WHITE SKIN, MEASURING ... X ... CM. THE SKIN SPECIMEN
HAS BEEN EXCISED TO A DEPTH OF ... CM. THE SPECIMEN IS UNORIENTED.
IN ONE-HALF THE SPECIMEN, THERE IS A LIGHT-BROWN TO DARK-GRAY-BROWN
PIGMENTED, SLIGHTLY-DEPRESSED AREA, MEASURING ... X ... CM.
THE MARGINS OF THE DEPRESSED AREA ARE ... CM AND ... CM
ALONG THE SHORT AXIS. THE LESION IS SLIGHTLY OFF-CENTER.
THE SIDE WITH THE ... CM SHORT AXIS MARGIN IS INKED BLUE,
AND THE OPPOSITE SIDE, WITH THE ... CM SHORT-AXIS MARGIN,
IS INKED YELLOW. THE SPECIMEN IS SERIALLY SECTIONED
ALONG THE SHORT AXIS, AND SUBMITTED ENTIRELY IN THREE CASSETTES.
SUMMARY OF SECTIONS:
1-1, TIP MARGIN NEAR LESION.
2-1, MIDDLE THIRD.
1-1, TIP MARGIN FAR FROM LESION.
Sample dictation for well-oriented
skin resection
specimen:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN OF LEFT KNEE". THE SPECIMEN CONSISTS OF AN ELLIPTICAL FRAGMENT
OF SKIN, WITH UNDERLYING SUBCUTANEOUS TISSUE. THERE ARE SUTURES DESIGNATING
THE LATERAL AND SUPERIOR POSITIONS, RESPECTIVELY. THE SPECIMEN
MEASURES ... CM MEDIAL TO LATERAL, ... CM SUPERIOR TO INFERIOR,
AND ... CM ANTERIOR TO POSTERIOR. THE SURFACE OF THE SKIN
IS INVOLVED BY AN ILL-DEFINED, GRANULAR DIFFUSELY ERYTHEMATOUS LESION,
MEASURING ... CM. THIS ERYTHEMATOUS REGION IS LOCATED ... CM
FROM THE CLOSEST PERIPHERAL MARGIN (INFERIOR). THE CUT SURFACE OF
THE SPECIMEN IS LIGHT TAN AND UNREMARKABLE. THE LESION IS ... CM FROM
THE CLOSEST DEEP RESECTION MARGIN. THE RESECTION MARGIN IS INKED BLACK
ON THE MEDIAL MARGIN AND BLUE ON THE LATERAL MARGIN.
THE SPECIMEN IS SERIALLY SECTIONED CONSECUTIVELY
ALONG THE SHORT AXIS, AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, SUPERIOR TIP MARGIN, SECTIONED, 4 PIECES.
1-2, SUPERIOR BELOW TIP MARGIN, SECTIONED, 3 PIECES.
1-3, SUPERIOR CENTRAL, SECTIONED, 4 PIECES.
1-4, INFERIOR CENTRAL, SECTIONED, 3 PIECES.
1-5, INFERIOR ABOVE TIP MARGIN, SECTIONED, 4 PIECES.
1-6, INFERIOR TIP MARGIN, SECTIONED, 5 PIECES.
Sample dictation for partially-oriented
skin resection
specimen.
The gross description might be corrected later,
if additional information is received.
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN OF RIGHT KNEE". THE SPECIMEN CONSISTS OF AN ELLIPTICAL PIECE
OF SKIN, WITH UNDERLYING SUBCUTANEOUS TISSUE. THERE IS A SINGLE SUTURE,
WHICH IS ARBITRARILY DESIGNATED AS 12 O'CLOCK. THE SPECIMEN MEASURES
... CM 9 O'CLOCK TO 3 O'CLOCK, ... CM 12 O'CLOCK TO 6 O'CLOCK,
AND ... CM IN DEPTH. THE SURFACE OF THE SKIN IS INVOLVED
BY AN ILL-DEFINED, GRANULAR DIFFUSELY ERYTHEMATOUS LESION,
MEASURING ... CM. THIS ERYTHEMATOUS REGION IS LOCATED ... CM
FROM THE CLOSEST PERIPHERAL MARGIN (6 O'CLOCK). THE CUT SURFACE OF
THE SPECIMEN IS LIGHT-TAN AND UNREMARKABLE. THE LESION IS ... CM FROM
THE CLOSEST DEEP RESECTION MARGIN. THE RESECTION MARGIN IS INKED BLACK
ON THE 9 O'CLOCK PERIPHERAL MARGIN, AND BLUE ON THE 3 O'CLOCK PERIPHERAL
MARGIN. THE SPECIMEN IS SERIALLY SECTIONED CLOCKWISE AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, SUPERIOR MARGIN (11 TO 1 O'CLOCK), SECTIONED, 4 PIECES.
1-2, 1 TO 3 O'CLOCK (SUPERIOR LATERAL), 3 PIECES.
1-3, 3 TO 5 O'CLOCK(INFERIOR LATERAL), 4 PIECES.
1-4, 7 TO 9 O'CLOCK (INFERIOR MEDIAL), 3 PIECES.
1-5, 9 TO 11 O'CLOCK (SUPERIOR MEDIAL), 4 PIECES.
1-6, INFERIOR MARGIN (5 TO 7 0'CLOCK), SECTIONED, 5 PIECES.
12.55. GROSS TEMPLATE: PROSTATECTOMY SPECIMEN.
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH AND IS SUBSEQUENTLY FIXED IN
FORMALIN OVERNIGHT, LABELED WITH THE PATIENT'S IDENTIFICATION AND
"PROSTATE GLAND". IT CONSISTS OF ONE INTACT PROSTATE GLAND WITH
ATTACHED BILATERAL VASA DEFERENTIA AND SEMINAL VESICLES, WEIGHING ...
GRAMS AND MEASURING ... CM FROM BASE TO APEX, ... CM FROM THE TIP OF
THE SEMINAL VESICLES TO THE APEX, ... CM LEFT TO RIGHT, AND ... CM
ANTERIOR TO POSTERIOR. THE EXTERNAL SURFACE IS DULL RED-BROWN AND
UNREMARKABLE. THE CUT SURFACE OF THE PROSTATE VARIES FROM FIRM TO
RUBBERY, AND IS NODULAR, LIGHT TAN AND YELLOW. ILL-DEFINED, DIFFUSE
YELLOW STREAKS ARE NOTED WITHIN THE PROSTATE GLAND. NO DISCRETE
MASSES OR LESIONS ARE NOTED. THE RIGHT ANTERIOR SURFACE IS INKED
BLUE, THE LEFT ANTERIOR SURFACE IS INKED BLACK, AND THE POSTERIOR
SURFACE IS INKED GREEN. THE SPECIMEN IS SERIALLY SECTIONED AND EVERY
OTHER SECTION IS SUBMITTED.
SUMMARY OF SECTION:
1-1, PROXIMAL URETHRAL MARGIN, EN FACE, 1 PIECE.
1-2, LEFT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE,
2 PIECES.
1-3, RIGHT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE,
2 PIECES.
1-4, LEFT PROSTATE AT BASE, 1 PIECE.
1-5, RIGHT PROSTATE AT BASE, 1 PIECE.
1-6, LEFT PROSTATE DISTAL TO 1-4, 1 PIECE.
1-7, POSTERIOR ONE HALF OF 1-6, 2 PIECES.
1-8, RIGHT PROSTATE DISTAL TO 1-5, 1 PIECE.
1-9, POSTERIOR ONE HALF OF 1-8, 1 PIECE.
1-10, LEFT PROSTATE DISTAL TO 1-6, 2 PIECES.
1-11, POSTERIOR ONE HALF OF 1-10, 1 PIECE.
1-12, RIGHT PROSTATE DISTAL TO 1-8, 1 PIECE.
1-13, POSTERIOR ONE HALF OF 1-12, 1 PIECE.
1-14, LEFT DISTAL URETHRAL MARGIN, SECTIONED, 3 PIECES.
1-15, LEFT DISTAL URETHRAL MARGIN, SECTIONED, 6 PIECES.
1-16, RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 8 PIECES.
1-17, RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 7 PIECES.
12.56. GROSS TEMPLATE: LARYNGECTOMY SPECIMEN.
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "TOTAL LARYNGECTOMY BILATERAL SELECTIVE NECK DISSECTION (P)", AND
CONSISTS OF A LARYGECTOMY SPECIMEN ATTACHED TO THE BILATERAL RADICAL NECK
DISSECTION, MEASURING ... CM FROM SUPERIOR TO INFERIOR, ... CM
FROM ANTERIOR TO POSTERIOR, AND ... CM FROM RIGHT TO LEFT, NOT
INCLUDING THE RADICAL NECK DISSECTION. THE RIGHT RADICAL NECK
DISSECTION MEASURES ... CM, AND THE LEFT RADICAL NECK MEASURES ... CM.
THE THYROID PORTION CONSISTS OF ONLY OF THE RIGHT LOBE,
AND MEASURES ... CM. THE SPECIMEN IS INKED BLACK.
THERE IS ALSO AN ULCERATIVE LESION, MEASURING ... CM, WITH A DEPTH
OF ... CM IS LOCATED AT THE RIGHT FALSE VOCAL CORD. THE ULCER INVOLVES
THE RIGHT TRUE VOCAL CORD, AND ABUTS MIDLINE ANTERIORLY, AND IS ... CM
FROM MIDLINE POSTERIORLY. THE REST OF THE MUCOSA SURFACE IS TAN AND
UNREMARKABLE. SECTIONING SHOWS THAT A FIRM TISSUE EXTENDS FROM THE
ULCER BASE TO APPROXIMATELY ... CM FROM THE ADJACENT THYROID
CARTILAGE. THE RIGHT AND LEFT VERTICAL NECK PORTIONS ARE EACH DIVIDED
INTO THREE PARTS OF I, II, AND III, FROM SUPERIOR TO INFERIOR.
FOUR POSSIBLE LYMPH NODES ARE IDENTIFIED, RANGING IN GREATEST DIMENSION
FROM ... TO ... CM IN THE RIGHT LEVEL I. SIX POSSIBLE LYMPH NODES
ARE IDENTIFIED RANGING IN GREATEST DIMENSION FROM ... TO ... CM
IN THE RIGHT LEVEL II. EIGHT POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN GREATEST DIMENSION FROM ... TO ... CM IN THE RIGHT LEVEL III.
FIVE POSSIBLE LYMPH NODES ARE IDENTIFIED, RANGING IN GREATEST DIMENSION
FROM ... TO ... CM IN THE LEFT LEVEL II. SIX POSSIBLE LYMPH NODES
ARE IDENTIFIED, RANGING IN GREATEST DIMENSION FROM ... TO ... CM
IN THE LEFT LEVEL II. FIVE POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN GREATEST DIMENSION FROM ... TO ... CM IN THE LEFT LEVEL II.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTION:
1-1, ULCERATIVE LESION, 1 PIECE.
1-2, ULCERATIVE LESION, 1 PIECE.
1-3, RIGHT ARYEPIGLOTTIC FOLD, 1 PIECE.
1-4, MIDLINE EPIGLOTTIS, 1 PIECE.
1-5, LEFT CORDS, 1 PIECE.
1-6, THYROID, 1 PIECE.
1-7, INFERIOR MARGIN, 2 PIECES