report given by the physician who studies tissue removed from a patient

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The Medical Record Flashcards | Quizlet

34 hours ago A medical record report given by a pathologist who studies tissue removed from the patient (for example: bone marrow, blood, or tissue biopsy). physician's offices Individual or groups of physicians providing diagnostic and treatment services in a … >> Go To The Portal


How long after tissue sample is taken will pathology report be ready?

How long after the tissue sample is taken will the pathology report be ready? The pathologist sends a pathology report to the doctor within 10 days after the biopsy or surgery is performed. Pathology reports are written in technical medical language.

What happens in a pathology report?

After identifying the tissue as cancerous, the pathologist may perform additional tests to get more information about the tumor that cannot be determined by looking at the tissue with routine stains, such as hematoxylin and eosin (also known as H&E), under a microscope ( 2 ). The pathology report will include the results of these tests.

How are tissue samples cut into thin sections for biopsy?

Two methods are used to make the tissue firm enough to cut into thin sections: frozen sections and paraffin-embedded (permanent) sections. All tissue samples are prepared as permanent sections, but sometimes frozen sections are also prepared.

What happens to tissue removed during a biopsy?

Tissue removed during a biopsy is sent to a pathology laboratory, where it is sliced into thin sections for viewing under a microscope. This is known as histologic (tissue) examination and is usually the best way to tell if cancer is present. The pathologist may also examine cytologic (cell) material.

What is an ancillary report?

Ancillary Reports. Reports from various treatments and therapies patient has received such as rehabilitation, social services or respiratory therapy. Diagnostic Reports. Results of diagnostic tests performed on patient, principally from clinical lab and medical imaging. Informed Consent.

What are the records of the patient's care throughout the day?

Record of the patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition.

Which suffix indicates a surgical removal?

The surgical terminology suffix "-ectomy" was taken from Greek εκ-τομια = "act of cutting out". It means surgical removal of something, usually from inside the body.

What are progress notes in a medical record?

Progress Note. Description. Represents a patient's interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

What is a medical report?

A medical report is a comprehensive report that covers a person's clinical history. A medical report is a vital piece of evidence that can validate and support your claim for Social Security Disability benefits.

What is a operative report in medical?

The operative report is perhaps the single most important document in a surgical chart. It is the official document that captures what transpired in the operating room. It must support the medical necessity for treating the patient, describe each part of the surgical procedure(s), and reveal the results of the surgery.

What is the medical term for remove?

Definition of excision : the act or procedure of removing by or as if by cutting out especially : surgical removal or resection.

What is surgical removal?

The removal of tissue by scalpel or other cutting instrument.

What term refers to the surgical removal of an organ or tissue?

Resection is the medical term for surgically removing part or all of a tissue, structure, or organ. 1 Resection may be performed for a wide variety of reasons. A resection may remove a tissue that is known to be cancerous or diseased, and the surgery may treat or cure a disease process.

Which type of report is usually dictated while the physician is performing an examination on tissue and is often needed immediately by a second physician?

The pathology report is dictated by the pathologist. The PATH report is a separate report describing specific disease findings and is usually limited to tissue.

What are doctors notes called?

The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction.

What is clinical documentation system?

Background. Computerized clinical documentation systems (CDS) provide for the documentation of patient care using computers. For example, the CDS records the vital signs directly from the cardio-respiratory monitors, while other documentation, such as nursing assessments are entered by the clinician.

What is a pathology report?

A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also cont...

How is tissue obtained for examination by the pathologist?

In most cases, a doctor needs to do a biopsy or surgery to remove cells or tissues for examination under a microscope. Some common ways a biopsy ca...

How is tissue processed after a biopsy or surgery? What is a frozen section?

The tissue removed during a biopsy or surgery must be cut into thin sections, placed on slides, and stained with dyes before it can be examined und...

How long after the tissue sample is taken will the pathology report be ready?

The pathologist sends a pathology report to the doctor within 10 days after the biopsy or surgery is performed. Pathology reports are written in te...

What information does a pathology report usually include?

The pathology report may include the following information ( 1 ): Patient information: Name, birth date, biopsy date Gross description: Color, weig...

What might the pathology report say about the physical and chemical characteristics of the tissue?

After identifying the tissue as cancerous, the pathologist may perform additional tests to get more information about the tumor that cannot be dete...

What information about the genetics of the cells might be included in the pathology report?

Cytogenetics uses tissue culture and specialized techniques to provide genetic information about cells, particularly genetic alterations. Some gene...

Can individuals get a second opinion about their pathology results?

Although most cancers can be easily diagnosed, sometimes patients or their doctors may want to get a second opinion about the pathology results ( 1...

What research is being done to improve the diagnosis of cancer?

NCI, a component of the National Institutes of Health, is sponsoring clinical trials that are designed to improve the accuracy and specificity of c...

What is the procedure to remove tissue under a microscope?

In most cases, a doctor needs to do a biopsy or surgery to remove cells or tissues for examination under a microscope. Some common ways a biopsy can be done are as follows: A needle is used to withdraw tissue or fluid.

What is the procedure to cut tissue into thin sections?

The tissue removed during a biopsy or surgery must be cut into thin sections, placed on slides, and stained with dyes before it can be examined under a microscope. Two methods are used to make the tissue firm enough to cut into thin sections: frozen sections and paraffin-embedded (permanent) sections.

How to tell if a biopsy is cancerous?

This is known as histologic (tissue) examination and is usually the best way to tell if cancer is present. The pathologist may also examine cytologic (cell) material.

How are tissue samples prepared?

All tissue samples are prepared as permanent sections, but sometimes frozen sections are also prepared. Permanent sections are prepared by placing the tissue in fixative (usually formalin) to preserve the tissue, processing it through additional solutions, and then placing it in paraffin wax.

How long does it take for a pathologist to send a report?

The pathologist sends a pathology report to the doctor within 10 days after the biopsy or surgery is performed. Pathology reports are written in technical medical language. Patients may want to ask their doctors to give them a copy of the pathology report and to explain the report to them. Patients also may wish to keep a copy ...

What is the purpose of endoscope?

An endoscope (a thin, lighted tube) is used to look at areas inside the body and remove cells or tissues. Surgery is used to remove part of the tumor or the entire tumor. If the entire tumor is removed, typically some normal tissue around the tumor is also removed. Tissue removed during a biopsy is sent to a pathology laboratory, ...

What is the role of a pathologist in cancer diagnosis?

A pathologist is a doctor who does this examination and writes the pathology report. Pathology reports play an important role in cancer diagnosis and staging (describing the extent of cancer within the body, especially whether it has spread), which helps determine treatment options.

What is tissue removed from a patient?

Tissue is removed from the patient and transported to the pathology laboratory to await examination. The patient undergoes a procedure where a sample of tissue is removed from the body. The amount of tissue removed will depend on the reason for the procedure and the type of procedure performed. All tissue samples sent to pathology ...

What is a specimen in pathology?

All tissue samples sent to pathology for examination are called specimens. Specimens are referred to as biopsies, excisions, or resections depending on the amount of tissue removed. Multiple unique patient identifiers are placed on all specimens before they are sent to pathology.

How long should a specimen be in formalin?

The amount of time a specimen spends in formalin depends on the size of the specimen and the type of tissue that was removed. Small specimens like biopsies may only need to be in formalin for several hours whereas large resections may be left in formalin for 2-3 days.

What is a hematoxylin and eosin stained slide?

One hematoxylin and eosin stained slide is usually made automatically for each block of tissue. Additional slides made me prepared for other types of tests including immunohistochemistry.

What color is tissue in a microscope?

These dyes give the tissue its characteristic pink and purple colour that many people recognize as the typical microscopic slide.

How does a microtome work?

A microtome uses a very sharp blade to cut the tissue into sections about the width of a human hair. After the section is cut, it is gently placed on a glass slide which is then left to dry. At this stage, the tissue on the slide is almost invisible. Step 7.

What is the preservative used to remove tissue from the body?

Step 4. The tissue is placed in a preservative called formalin. Tissue removed form the body rapidly breaks down. Formalin is called a preservative because it prevents tissue from breaking down. Most types of specimens need to be placed in formalin before they can be viewed under a microscope.