RECORDS, REQUESTS FOR INFORMATION.
AUTOPSY PATHOLOGY SLIDE,
BLOCK, AND RECORD POLICIES.
DRAFT COPY ONLY.
(Procedure 210).
http://www.netautopsy.org/axsop/axsop210.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: Veterans Health Administration Privacy Practices: http://vaww.vhaco.va.gov/privacy/Notice.htm, 153, 231, 234.

PRINCIPLE OF THE TEST.

      Proper maintenance of records and materials is necessary for a quality autopsy service.

SPECIMEN REQUIRED.

At the Veterans Affairs Medical Health Care System (VAMHCS), autopsies are performed on deceased patients with a valid Authorization for Autopsy (U. S. Standard Form 523), a complete hospital chart, and a death note signed by a physician included in the chart.

REAGENTS, INSTRUMENTATION.

Valid medicolegal documents.

STEP-BY-STEP DESCRIPTION.

1. All slides, paraffin blocks, and paper records on veterans autopsied at the VAMHCS are maintained by the institution in perpetuity.

2. Buckets of wet tissue obtained after the initial dissection are retained until the case is signed out. After that time, the wet tissue is ordinarily reduced to a small volume of tissue, and retained as a 'posterity container'.

REQUEST FOR INFORMATION POLICY. 1. The written pathology report from the cytology, surgical pathology or autopsy from veterans receiving care at the Veterans Affairs Maryland Health Care System (VAMHCS), which is contained in the veteran's medical record, is subject to disclosure at the request of the veteran, or if he/she is deceased, the veteran's next-of-kin. Requests must be submitted in writing, either hand-delivered, by mail, or by fax. The fax number for the Pathology and Laboratory Medicine Service is: 410-605-7911. The release-of-information request must include the following information: veteran's full name, printed and legible; veteran's full social security number; veteran's signature; requesting physician; reason for request; today's date; nature of procedure performed at VAMHCS; date that procedure was performed at VAMHCS.



2. Wet tissue, tissue blocks, and slides from the cytology, surgical pathology, or autopsy specimens taken from patients at the VAHMCS are the sole and exclusive property of the United States of America. They are not necessarily subject to release of either the living veteran or his/her surviving family.

      3. Access to federally owned property may legally occur by several means. Ordinarily, it is our practice to compel the requestor to obtain a federal court subpoena. (State courts lack civil jurisdiction over federally-owned property.)

      4. Upon receipt of such subpoena, it is our practice to compel the requestor to send his physician to our medical center, where the pathology is made available for examination. Unfortunately in the past, our release of original materials to the examining private physician, in order to permit examination away from our medical center, has resulted in our failure to receive return of the materials. This has occurred despite repeated promises of return by the law firms involved.

      5. If wet tissue, tissue blocks, or slides are requested to leave the VAMHCS for legal actions, this must be approved by the Office of District Counsel, Department of Veterans Affairs, 31 Hopkins Plaza, Baltimore, MD 21201.

      6. If wet tissue, tissue blocks, or slides are requested to leave the VAMHCS for patient-care purposes, then this request must include a release-of-information form, signed by the veteran (or certified by the veteran's physician that the veteran is unable to sign, including the reason for this inability). The release-of-information form must include the following information: veteran's full name, printed and legible; veteran's full social security number; veteran's signature; requesting physician; reason for request; today's date; nature of procedure performed at VAMHCS; date that procedure was performed at VAMHCS.

      7. Any of the above provisions are subject to modification or revision at any time by the VETERANS AFFAIRS OFFICE OF DISTRICT COUNSEL.

REFERENCE.

      1. Hutchins GM, ed.
Autopsy Performance and Reporting.
Northfield, IL: College of American Pathologists. 1990.