1. Muscle, nerve and kidney biopsies (RK, RJ, MM, MB and IB cases) are always dictated by the techs and PA’s.
2. Speak slowly and forcefully and enunciate clearly into the microphone.
3. Avoid dictating when others are talking, laughing, or sawing, etc.
4. When dictating abbreviations specify letters, i.e. C (as in cat), D (as in day), etc.
5. When dictating body of gross start with container tissue source: "Left arm." If there is no tissue source, dictate “labeled with name and reg # only”. State the size of the container*. This will assist with container retrieval.
6. Cassette summary: A1 Tips (2NS)
A2-A4 Remainder of specimen (3ns each)*
ns = non saved (entirely submitted) ss = some saved
*It is good practice to dictate the number of pieces in each cassette. This practice is mandatory when grossing all derm specimens!!!
7. Words that are difficult to differentiate between: Ex. Intra/inter, hyper/hypo, etc. Need to be enunciated clearly and spelled out.
8. Dictate Frozen sections as follows:
A. Dictate all the Frozen Section Gross Description (handwritten information on pink page) for all frozen section specimens in their labeled order. Dictate the cassette summary for each part but do not read the frozen report yet. All frozen cassettes are called "frozen section control" or the acronym "fsc".
B. Dictate all the handwritten frozen section diagnosis for all specimen parts, which is titled "Frozen Section Report". Do them in the labeled order, dictating the part number, the diagnosis and then the initials of the Pathologist(s).
C. If a frozen section was sampled from a large specimen (i.e. to check a margin) and it needs fixation, do not dictate the frozen section until the specimen is ready to be grossed; state the specimen number and that it will be dictated at a later time.
D. When dictating a large specimen with a frozen section, dictate the entire specimen and include the handwritten information of the Frozen Section Gross Description. List the frozen section control cassettes in the cassette summary along with the cassettes for the entire specimen (i.e. "AFS1 - frozen section control block- ns; A2- anterior cervix -ss, etc.)
9. Arrows cannot be typed into computer-please dictate upper, lower, increasing or decreasing instead (i.e. don’t say “arrow up”).
*There are at least 6 container sizes:
- Extra small
- Short Small
- Tall Small
- Extra large
Gross Dictation Pointers
Account for what we received, including:
- Specimen container type and labeling
- Tissue and excision type (e.g. skin: punch biopsy vs shave biopsy, breast: core biopsy vs mastectomy)
- Overall dimensions
- Number of fragments (approximate if too many to count) with aggregate size (e.g. if sample is highly fragmented as in an endometrial curettage) Note: be very precise with mucosal and skin biopsies (i.e. “there are three bits”)
- Presence of orienting sutures/clips/ink
- Evidence of prior manipulation (i.e. post op incisions made by surgery)
Use appropriate style, including:
- Use complete sentences when possible
- Correct grammar
- Avoid abbreviations
- Use descriptive, not diagnostic terms (i.e. “there is a mass” – not “there is an infiltrating ductal carcinoma”)
With respect to pathology/abnormalities, describe:
Distribution and size of lesion(s)
- Texture, color and type (e.g. mass, ulcer, cavity, discoloration…)
- Relationship to margins of excision and relationship to any lesions (if appropriate)