Pathology Requisition Form and Specimen Labeling

Whether a small biopsy or large resection, all specimens should be submitted appropriately labeled and with a completed requisition form. This is necessary not only for legal compliance, but will help prevent unnecessary processing delays and provide valuable information to the pathologist for interpretation.

How do I know if the label and requisition form have been completed correctly?

If you can answer the five W’s, you are in good shape!

The specimen label and requisition should contain:

• Who is the patient? The patient’s name and date of birth (an Epic label will suffice).

• What and Where is the specimen from? What is the type of tissue (for example, biopsy, excision, fluid, cyst aspiration, etc.). Where in the body is the specimen from (for example, esophagus, right breast, right colon, etc.).

• When was the procedure performed.

• Why: The clinical History (This information can be placed on the requisition only). Believe it or not, this can have a significant impact on the diagnosis! This is often the most overlooked, but is extremely valuable. Knowing the clinical history in the appropriate clinical context in which the specimen was taken is vital to providing the best interpretation. Is there anything specific you are looking for? This does not have to be a lengthy dissertation; short and sweet will do the job! (example: left colon biopsy – normal endoscopy, history of watery diarrhea, R/O microscopic colitis; left arm skin biopsy – multiple raised, scaly plaques, present for 6 months, waxing and waning).

– Suneal Jannapureddy, M.D., Pathologist at Piedmont Henry Hospital