LESSON 14 AND 15: d. Source of specimen (e.g.
, skin)
LABELLING AND STORAGE; RECORD KEEPING
LABELLING
 Last step in histopathology processing
 Process of indicating the year and specimen
number on one end of the prepared slide for
proper identification.
 A part where there are a lot of errors and
mistakes.
 A number of surgical pathology laboratories
have published process flow modifications that
lead to reduction in labelling errors, including:
- Handling of only one specimen and tissue
cassette at a time during specimen
accessioning and examination.
- Elimination of pre-labeling or batch labeling
of tissue cassettes and glass slides.
- Implementation of instrumentation for
automated block and slide labeling,
particularly interfacing hospital and
laboratory information system or LIS.
- Handling of single tissue cassette and single
glass slide only at the time of cutting.
 The most significant reduction in specimen
misidentification and labeling errors of blocks
and slides have been achieved through the
implementation of bar coding or coding on all
specimen containers, blocks, and slides.
 Slide error reads the approach to zero (for
modifications plus bar coding of specimen).
PERMANENT LABELLING
 Done by using a sticker with bar code or marker.
SPECIMEN HANDLING: PROPER LABELLING (CAP, 2022)
 Specimen is labeled in the presence of the
patient.
 Specimen label must contain at least two
patient-specific identifiers:
a. Full patient name
b. Assigned identification number (e.g.,
health record/master index number)
c. Date of Birth
 Customizable label elements – additional
identifiers that are acceptable:
a. Patient gender
b. Accession or requisition number
c. Ordering physician
e. Site of specimen (e.g., left
 Standardized format for label information
should be implemented:
- Last name, first name
- Date of Birth: DD-MMM-YYYY (i.e., 12 MAR
1968)
- Gender: M, F, U (unknown), T (transgender),
I (intersex)
 Written documentation developed for the
correct positioning of the label on the collection
container.
- Do not attach label to the container lid (in
whole or part).
- Do not overlap label resulting in patient
data being covered (especially when there is
a bar code).
 Written documentation for the correction of
labelling errors – to be followed when
specimens cannot be replaced.
 All subsequent labelling of patient samples
(blocks and slides) must follow same patient-
specific identifying process.
 Submitted slides may be labeled with a single
patient-specific identifier, but two are
preferred.
Figure 3: Laboratories in which patient identifiers are
handwritten can use the sides of the tissue cassettes to
record additional identifiers.
Figure 4: Has two or more identifiers and the stain used.
Used from automated instrumentation.
Figure 5: Has two or more identifiers and the stain used
(handwritten).
 In microscopic slides, the accession designation
(SP14-50009) should be the most prominent (in
larger font or bolded).
STORAGE
 Wet tissue (stock bottle): 2 weeks after final RECORD KEEPING
report.  Purpose: for easy retrieval of records with
 Serum/Body Fluids: 2 days (refrigerator appropriate and standardized filing.
temperature)
 Tissue Blocks: 3 years to 10 years HISTOPATHOLOGY REPORTS
 Slides: indefinite 1. Surgical Pathology
2. Cytopathology
STORAGE OF AUTOPSY MATERIAL 3. Autopsy Report
1. Non-Forensic
- Wet tissue (stock bottle): 3 months after  The number of copies of histopathology reports
final report is THREE: one for the patient, one for the
- Paraffin Blocks: 10 years (Subject to Note A) doctor, and one for the laboratory.
- Slides: 10 years
SIGNATORIES OF FORMS
 For autopsy of paraffin blocks, it is 1. Attending Physician
recommended to extend the required retention - Signs the request forms.
period to indefinitely, or for at least a 2. Pathologist
generation (approximately 20 years). However, - Signs the pathology result forms.
this is not a requirement for accreditation.
 These blocks represent the last opportunity for ROUTINE TURN-OVER OF RESULTS
tissue-based biomarker genetic and other  Surgical Pathology and Cytology: 2 days
testing in the interest of family members and  Frozen Sections: 5 to 15 minutes
public health, that’s why they could extend  Autopsy Reports: 7 days
depending on the type of laboratory.
 Strategies such as retaining even a select RETENTION OF PATHOLOGY REPORTS (HENRY’S)
number of blocks from each case permanently  Clinical Pathology Laboratory Reports: 2 years
or partnering with a regional biorepository or  Autopsy Forensic Reports: Indefinite
permanent storage may be considered with  Surgical Pathology (and Bone Marrow)
that. Reports: 10 years
 Cytogenetics Reports: 20 years
2. Forensic
- Wet tissue: 3 years COLLEGE OF AMERICAN PATHOLOGISTS (CAP)
- Paraffin Blocks: 10 years GUIDELINES ON RECORD AND MATERIAL RETENTION
- Slides: 50 years (or 30 years if a DNA sample 2021
is available Type of Record/Material Retention Period
- Body Fluids and Tissues for Toxicology: 1 Accession log records 2 years
year Paraffin blocks (including 10 years (subject to
- Dried Blood Stain or Frozen Tissue for DNA: cell blocks) Notes 2 and 3 below)
Indefinite Immunohistochemistry 2 years
- Body Transfer and Disposition Records: batch control slides
Indefinite Glass slides 10 years – slides must
remain readable for this
STORAGE OF ELECTRON MICROSCOPY SAMPLES period
Surgical pathology 10 years
 Wet Tissue: 2 weeks after the final report
reports
 Resin blocks: 10 years
Reports of outside 10 years after the date
consultations on that the original report
laboratory cases was issued
(whether or not
requested by the
laboratory)
Fluorochrome-stained At the discretion of the
slides laboratory director
Images or permanent 10 years: neoplastic
slides of in-situ disorders
hybridization (ISH) 20 years: constitutional
studies disorders
(Subject to protocols)
Digital Images used for 10 years if original glass
primary diagnosis slides are not available;
may not replace glass
slides
Datasets from In-Vivo 10 years – data must be
Microscopy (IVM) or Ex- retrievable for this period
Vivo Microscopy (EVM) (subject to protocols)
systems used to aid in
interpretation or
diagnosis
Electron Microscopy 2 years
(EM) accession log
records
EM Pictures and Reports 10 years
Non-Forensic
- Autopsy 10 years
Reports
- Autopsy Per institutional medical
Consent record retention policy
(minimum: 10 years)
Forensic
- Autopsy Indefinite
Reports
- Gross Indefinite
Photographs
/Negatives