CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Q. Can I replace the name of the intraoperative consultant pathologist with the name of the pathologist who verified the main report?
A. There are three potential anatomic pathology checklist requirements that could be in play here. The first two are from the rapid diagnosis section and the third is from the surgical pathology section:
- ANP.11850, Intraoperative Results, phase II: The results of intraoperative surgical consultations are documented and signed by the pathologist who made the diagnosis. Note: The intent of this requirement is for the laboratory to maintain a contemporaneous report of the consultation. This may be a handwritten, signed report or a computer-generated report with electronic signature.
- ANP.12000, Final Report, phase II: All intraoperative consultation reports are made a part of the final surgical pathology report.
- ANP.12170, Report Review, phase II: All reports are reviewed and signed by the pathologist. Note: The inspector must review a broad sampling of surgical pathology reports issued since the previous on-site inspection, representing at least the most common types of specimens seen in the laboratory. When diagnostic reports are generated by computer or telecommunications equipment, the actual signature or initials of the pathologist may not appear on the report. It is nevertheless essential that the laboratory have a procedure that ensures and documents that the responsible pathologist has reviewed and approved the completed report before its release. In the occasional situation when the diagnosing pathologist is not available for timely review and approval of the completed report, the laboratory may have a policy and procedure for review and approval of that report by another pathologist. In that circumstance, the names and responsibilities of both the pathologist who made the diagnosis and the pathologist who performs final verification must appear on the report (emphasis added).
The short answer is no, the name cannot be replaced. The names of both individuals must be on the final report. In this particular situation, we would expect the laboratory to maintain a copy of the intraoperative consultation and incorporate the essential elements of that report into the final report. The final report would require both pathologists’ names on it as well.
Dawna Mateski, MT(ASCP)
Senior Technical Specialist, CAP Laboratory Accreditation Program
College of American Pathologists Northfield, Ill.