Specimen Receipt Log
| Form ID |
FRM-PATH-001 |
Revision |
1.0 |
Log Information
| Field |
Entry |
| Date |
|
| Shift |
☐ Day ☐ Evening ☐ Night |
| Accessioning Technician |
|
| Technician ID |
|
Specimen Receipt Record
Specimen 1
| Field |
Entry |
| Time Received |
|
| Received From |
☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number |
|
| Patient Name |
|
| MRN |
|
| DOB |
|
| Specimen Type |
|
| Specimen Site |
|
| Number of Containers |
|
| Fixative |
☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time |
|
| Container Labeled Correctly? |
☐ Yes ☐ No |
| Requisition Complete? |
☐ Yes ☐ No |
| Specimen Condition |
☐ Acceptable ☐ Compromised (see notes) |
| Priority |
☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? |
☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) |
|
Specimen 2
| Field |
Entry |
| Time Received |
|
| Received From |
☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number |
|
| Patient Name |
|
| MRN |
|
| DOB |
|
| Specimen Type |
|
| Specimen Site |
|
| Number of Containers |
|
| Fixative |
☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time |
|
| Container Labeled Correctly? |
☐ Yes ☐ No |
| Requisition Complete? |
☐ Yes ☐ No |
| Specimen Condition |
☐ Acceptable ☐ Compromised (see notes) |
| Priority |
☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? |
☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) |
|
Specimen 3
| Field |
Entry |
| Time Received |
|
| Received From |
☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number |
|
| Patient Name |
|
| MRN |
|
| DOB |
|
| Specimen Type |
|
| Specimen Site |
|
| Number of Containers |
|
| Fixative |
☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time |
|
| Container Labeled Correctly? |
☐ Yes ☐ No |
| Requisition Complete? |
☐ Yes ☐ No |
| Specimen Condition |
☐ Acceptable ☐ Compromised (see notes) |
| Priority |
☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? |
☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) |
|
Specimen 4
| Field |
Entry |
| Time Received |
|
| Received From |
☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number |
|
| Patient Name |
|
| MRN |
|
| DOB |
|
| Specimen Type |
|
| Specimen Site |
|
| Number of Containers |
|
| Fixative |
☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time |
|
| Container Labeled Correctly? |
☐ Yes ☐ No |
| Requisition Complete? |
☐ Yes ☐ No |
| Specimen Condition |
☐ Acceptable ☐ Compromised (see notes) |
| Priority |
☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? |
☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) |
|
Specimen 5
| Field |
Entry |
| Time Received |
|
| Received From |
☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number |
|
| Patient Name |
|
| MRN |
|
| DOB |
|
| Specimen Type |
|
| Specimen Site |
|
| Number of Containers |
|
| Fixative |
☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time |
|
| Container Labeled Correctly? |
☐ Yes ☐ No |
| Requisition Complete? |
☐ Yes ☐ No |
| Specimen Condition |
☐ Acceptable ☐ Compromised (see notes) |
| Priority |
☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? |
☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) |
|
Special Handling/Fresh Specimens
Document any specimens requiring immediate processing (frozen sections, special studies, etc.)
| Accession # |
Specimen Type |
Special Handling Required |
Time to Grossing |
Pathologist Notified |
|
|
|
|
☐ Yes |
|
|
|
|
☐ Yes |
Discrepancy Log
| Time |
Accession # |
Discrepancy Type |
Description |
Resolution |
Resolved By |
|
|
☐ Labeling ☐ Requisition ☐ Condition ☐ Other |
|
|
|
|
|
☐ Labeling ☐ Requisition ☐ Condition ☐ Other |
|
|
|
Shift Summary
| Field |
Count |
| Total Specimens Received |
|
| Surgical Pathology |
|
| Cytology |
|
| Frozen Sections |
|
| STAT/Rush Cases |
|
| Specimens with Discrepancies |
|
| Specimens Held/Not Accessioned |
|
Quality Notes
Document any quality issues, equipment problems, or unusual occurrences:
Shift Handoff
| Field |
Entry |
| Pending Issues for Next Shift |
|
| Outstanding Discrepancies |
|
| Equipment Issues |
|
| Shift Sign-Off |
|
| Date/Time |
|
Supervisor Review
| Field |
Entry |
| Reviewed By |
|
| Date |
|
| Comments |
|
| Signature |
|
Form FRM-PATH-001 Rev 1.0 - Specimen Receipt Log
