How soon must the report of intraoperative pathology consultation (frozen section) be placed in the clinical record of the patient?

Any examples are for illustrative purposes only

Standards require the placement of the intraoperative pathology report in the clinical record of the patient but there is no defined time period for the inclusion of the report in the clinical record.  Standards require that the laboratory director ensures the reporting of test results within a defined time frame.  They also require the laboratory director to develop a process for clinical staff to receive results on an emergency or STAT basis.  National Patient Safety Goals require a definition of the acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures.

All of these requirements must be considered in the development of policies relating to the inclusion of intraoperative pathology consultation results in clinical records.  Requirements must be consistent in all policies.  Laboratories will be surveyed for compliance with the policies.

The results of the interpretation of frozen section examinations are interim results which are used for patient care decisions during surgical procedures.  Although these results may be communicated verbally to surgeons, it is preferable to include the original frozen interpretive report (manual or electronic) in the clinical record to officially document the laboratory result in a time frame concurrent with application of the information in patient care decisions.