Intraoperative Consultation (Frozen Section)

How to handle dictation of an Intraoperative (Frozen Section) Diagnosis:

  • In the Gross Description: You should 1) dictate the the specimen was received "Fresh for intraoperative diagnosis" and 2) your text should reflect what was done to the tissue during the frozen and what component of the specimen was frozen.
  • In the Cassette Summary: You should note which cassettes contain frozen section remnants and what those remnants represent.
  • In the Intraoperative Diagnosis field: Dictate the diagnosis here according to the Dragon template "frozen diagnosis" :
    • [block] FS ([specimen]): "[diagnosis]" per Dr. [attending], reported by Dr. [] to Dr. [surgeon] at [time] on [date].
  • In the Intraop Consult Pathologist(s) field: Make sure that the Attending and Resident/PA listed on the frozen worksheet are the same as those listed in this field: (found in Histology Data Entry/EditGross Description Entry/Edit or Final Diagnosis Entry/Edit)

EXAMPLES

Gross Description

A.  The first container is additionally identified as, "skin lesion R lip ". Received fresh for intraoperative diagnosis is a 0.1 x 0.1 x 0.1 cm pink-tan tissue fragment. The specimen is entirely frozen, and the frozen section remnant is entirely submitted in cassette A1 FS.

Intraoperative Consultation Diagnosis

A1 FS (skin lesion R lip): "no evidence of neoplasm" per Dr. X, reported to Dr. Y by Dr. Z at 9:48 AM on 1/30/14.

 

Gross Description

C.  The third container is additionally identified as, "right cheek radical excision". Received fresh for intraoperative diagnosis is a skin ellipse oriented by Dr. X measuring 6.8 x 4.4 cm and excised to a depth of 2.6 cm. The margin at the lip is redesignated 12:00, and superior is designated 3:00, and inferior is designated 9:00. The superior margin is inked blue, the inferior margin is inked green, and the deep margin is inked black. On the deep margin surface there is a portion of mucosa at 12:00 measuring 2.5 x 2.1 cm. The specimen is bisected to reveal an ill-defined, firm area within the subcutaneous fat measuring approximately 2 x 1.5 x 1.5 cm. A representative section of this area is frozen (C1 FS). The specimen is serially sectioned from 12:00 to 6:00 to reveal another 1.5 x 0.8 x 0.5 cm ill-defined, firm, gray area in the subcutaneous fat that is 0.4 cm from the deep margin and 0.4 cm from the superior margin and 1.5 cm from the inferior margin. A representative section of this firm gray area is frozen (C2 FS). Gross photos are taken. The specimen is entirely submitted as follows:

C1 FS:             Frozen section remnant (first firm area)
C2 FS:             Frozen section remnant (second firm area)
C3-C25:          Remainder of the specimen submitted from 12:00 to 6:00

Intraoperative Consult Diagnosis

C1-2 FS (right cheek radical excision): "no evidence of neoplasm" per Dr. Y, reported by Dr. Y to Dr. X at 9:48 AM on 1/30/14.