UNIVERSITY OF PITTSBURGH MEDICAL CENTER
PRESBYTERIAN-SHADYSIDE HOSPITAL
Pittsburgh, Pennsylvania
DEPARTMENT OF PATHOLOGY
POLICIES AND PROCEDURES
Subject: Release of Slides and Blocks
Effective Date: June 1, 2008
(This policy replaces policies: Coordination of Original and Duplicate Diagnostic Material
(March 2006)
Requests for Slides for Medical/Legal Cases (April 1996)
Slide and Block Requests (June 2003), that are found in the Departmental
Administrative Manual
1.0 POLICY
This policy outlines the necessary steps for obtaining the release of original and duplicate
diagnostic material from the UPMC Department of Pathology. In general, all material
released from storage or archives must be requested IN WRITING. In general, all material
released (such as blocks and slides) will be accompanied by a copy of the original pathology
report. A separate request for the report is not necessary for slides and/or blocks released.
Requests by patients, physicians, or attorneys for slides, blocks and reports will generally be
accommodated provided that an Authorization for Release of Protected Health Information
Authorization (see Attachment 6.1) has been signed by the patient authorizing such a
release. It is the policy of UPMC Presbyterian-Shadyside Hospital to only provide recut or
original slides to another CLIA-certified laboratory, under the care of a specific, responsible
board-certified pathologist who is credentialed to perform diagnostic interpretations on
comparable specimens in that CLIA-certified laboratory. For requests by court order original
materials will be delivered directly to the designated site.
Presbyterian-Shadyside Hospital does not release irreplaceable pathology materials, e.g.
cytology preparations, except in rare cases which are ordered by the onsite Chief of
Anatomic Pathology or UPMC Legal Department. If any original, irreplaceable materials
are to be released a digital slide scan must be made of the materials prior to them being
sent, (especially relevant for cytology materials). The Chief of Pathology should be
contacted to make arrangements for board certified pathologists, who are credentialed
and directly affiliated with a CLIA-certified laboratory to view the original slides in the
UPMC Presbyterian-Shadyside Pathology laboratory, under the supervision of the
Presbyterian-Shadyside Pathology Department.
For each separate area where pathology material is stored, there is a designated Pathology
“Material Steward” who is responsible for the release and re-filing of materials.
2.0
SCOPE
This policy applies to all slides and blocks, whether original or recuts. It also applies to
organs and tissues remnant following examination by UPMC Presbyterian-Shadyside
Pathology. Such organs and tissues are part of the original results and therefore should
not be released.
The areas where materials are stored are:
 On-site general surgical slides (including PUH and SHY)
 On-site dermatopathology slides and blocks
 On-site general surgical blocks (all departments are kept together)
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On-site cytology slides
On-site transplant slides
On-site Hematopathology slides
On-site Neuropathology slides
On-site archived documentation (such as requisitions)
Off-site (archived) blocks and slides
Off-site (archived) documentation (such as requisitions)
3.0
RESPONSIBILITY
All Pathology faculty and staff are required to comply with this policy.
4.0
PROCESS: INSTRUCTIONS FOR MAILING SLIDES OR BLOCKS OF
PARAFFIN EMBEDDED TISSUE TO OUTSIDE RECIPIENTS.
4.1
REQUESTS FROM PHYSICIANS AND PATIENTS:
4.1.1
A request by the physician, patient or attorney must be in writing and an
Authorization signed by the patient. Requests should also include a
copy of the CLIA certification or the CLIA number for the laboratory to
which the slides must be sent. (See Attachment 6.1).
4.1.2 Appropriate and complete requests for slides should be completed and
mailed within a reasonable time following the initial request date, not to exceed
two weeks under normal circumstances. All slides must be mailed via UPS and/or
registered two day mail service to assure that the package can be tracked from
pick up to delivery. All slides sent out, originals or recuts, are to be labeled with
the patient’s name, (last name, first name) on each slide. Slides that are sent to
Oakland campus sites should be sent via courier. A fee of $25.00* for each case
requested will be assessed to cover processing and material shipping charges
and will be billed directly to the institutional account of the facility requesting
pathology materials. *This is exclusive of all hospitals within the UPMC system.
4.1.3
Upon receipt of the request, the letter of agreement for the return of slides
(see Attachment 6.2) should be faxed to the recipient laboratory.
Materials are not to be released to the recipient laboratory until the signed
letter of agreement is received.
4.1.4
Upon return of the signed agreement letter, (Attachment 6.2), recut
slides may be released and the letter should be filed with the completed
Authorization form in the slide release authorization binder.
4.1.5
The request for slides is forwarded to the secretary of the sign out
pathologist. The sign out pathologist will order necessary recuts on
cases that are requested.
4.1.6
In some cases, the pathologist may choose to send original slides on a
case by case basis but, the original slides will have to be scanned prior
to being sent out, if possible. This can be done only with the approval of
the Medical Director. Every effort should be made to send recuts
slides/unstained slides.
4.1.7
When the recut slides are received from Histology the secretary will write
on each slide that is being sent out the name of the patient (last name,
first name). The slides are to be given to the pathologist who signed out
the original material to review and then sign the release form (Attachment
6.3) so that the materials can be sent to the requesting institution. The
secretary is to give to the Pathology Business Department a copy of
Attachment 6.2 so that the requesting institution account can be billed.
4.1.8
Slides to be released are then packed in plastic containers and a padded
envelope and sent with copies of our pathology report, a copy of the
signed letter of agreement and the form letter requesting return of the
slides (see Attachment 6.4). The return date should be determined as
the 30 days from the date that it is mailed.
4.1.9
The original Authorization with patient’s signature, the original written
request papers (if submitted), a copy of our report, the signed Letter of
Agreement (see Attachment 6.2), Pathologist Review for Slide Release
Form (see Attachment 6.3) and form letter (see Attachment 6.4) are kept
in the slide release authorization binder and filed alphabetically.
4.1.10 Recut and original slides must be recorded in the slide send out activity in
the CoPath system before they are sent out. Recut slides should not be
recorded in the slide send out activity with a return date.
4.1.11 When an outside pathology report is returned with the physician
consultant’s diagnosis, the original is to be forwarded to the QA
Department, a copy is given to the pathologist who signed out the case, a
copy is made for the Medical Director and one is attached to our original
filed report. Upon review, the Medical Director should initial and date the
physician consultant’s report. The receptionist will also scan a copy of the
physician consultant’s diagnosis report into the appropriate case in the
CoPath system.
4.1.12 Returned slides and/or blocks shall be returned to the specimen
processing staff/Material Steward for filing and slide tag removal.
4.1.13 The Pathology administrative office staff will contact the institution for a
consult report if not present when the materials are returned.
4.1.14 The receptionist or secretary should record the returned materials in the
slide send out activity in the CoPath system.
4.1.15 If original slides are not returned after 30 days, APLIS will generate a
letter requesting return of the material. Before any letter is mailed, contact
the specimen processor staff to verify the absence of slides from our slide
repository. If necessary, forward a written request for return of the slides
(see Attachment 6.5).
4.2
REQUESTS FROM ATTORNEYS FOR PATHOLOGY MATERIALS
4.2.1
The UPMC Corporate Legal Department and Risk Management will be
advised of the written request made by an attorney by order of court for
pathology materials. A faxed copy of the court order or subpoena
received from the attorney/s is to be sent to Risk Management and the
Corporate Legal Department. After UPMC Corporate Legal Department
and Risk Management advises that materials can be released, staff
should release only the specific material listed in the requesting letter
or subpoena to the requester. UPMC Corporate Legal Department and
Risk Management should advise whether or not original slides should be
sent instead of recuts. A fee of $100 for each case will be charged for the
processing of legal requests. No materials will be released until full
payment is received. Checks are to be made payable to “UPMC
Department of Pathology”.
4.2.3
4.4
Follow steps 4.1.4 through 4.1.14 for preparation, review of original or
recut slides and receipt of returned materials. Use letter of agreement for
return of Pathology materials in Attachment 6.6 and Attachment 6.7.
PRESBYTERIAN-SHADYSIDE PATHOLOGY REQUEST FOR PHYSICIAN
CONSULTANT REVIEW
Presbyterian-Shadyside Pathology Department may determine, as part of its
QA/QC process, that diagnostic material in any form may be sent to an outside
consultant pathologist in order to seek independent diagnostic evaluation. Such
consultants should be respected experts in their field/subspecialty and approved
by the division director of Presbyterian-Shadyside Pathology. They should also be
appropriately credentialed and privileged to practice in a CLIA-certified laboratory.
INSTRUCTIONS FOR SUBMITTING SLIDES FOR CONSULTATION:
4.4.1
The Pathology Faculty may request that original or recut slides be
forwarded to a physician consultant for review.
4.4.2
If the physician consultant is another UPP Pathologist who does not
reside at Presbyterian-Shaydside or a pathologist outside of UPP, then
fax the letter of agreement for the return of slides (see Example B) to the
recipient. Upon return of the signed letter, it should be filed with the
Intradepartmental Consult form.
4.4.3
All slides and blocks removed from the files will be ‘tagged’ in the file with
a tag noting the date, recipient’s name (not the requester’s name) and
where slides/blocks were sent. Prior to being sent out, all slides, original
and recuts are to be labeled with the patient’s name, (last name, first
name). Materials should be reviewed first by the sign out pathologist and
Attachment 6.3 MUST be completed and retained by our office.
4.4.4
Any request for slides to UPP pathologists at the Oakland campus sites
may be delivered by the UPMC contracted courier. All other locations will
require shipment via UPS two-day delivery.
4.4.5
Slides and blocks must be recorded in the slide send out log.
4.4.6
When a pathology report is returned with the consultant’s diagnosis, the
original copy is given to the pathologist who signed out the case. A copy
is made for the Medical Director, the QA unit and one is attached to our
original report. Upon review, the Medical Director shall initial and date the
physician consultant’s report.
4.4.7
The returned slides and/or blocks shall be returned to the specimen
processing/Material Steward for refilling.
4.4.8
The secretary for the sign out pathologist is to contact the institution for a
copy of the consult report if it is not received when the materials are
returned.
4.4.9
The receptionist or secretaries shall record the returned materials in the
slide send out log.
4.4.10 If, slides are not returned after 30 days, APLIS will generate a letter
requesting return of the material. Before any letter is mailed, contact
specimen processor/material steward to verify the files. If necessary,
forward a written request for return of the slides (Attachment 6.5).
4.4.11
4.5
Requests for materials such as whole or partial organs, tissues or other
remnant materials including orthopedic hardware
4.5.1
4.6
There will be no retrieval, handling or shipping charges.
The Pastoral Care Department many be consulted for clarification of
specific religious rites and cultural practices pertaining to handling of
excised organs or other anatomic materials. If advised by Pastoral Care
that religious practices require release, then these materials will be
released only to a licensed Funeral Director as described in UPMC PUH
SHY Policy MS-02. Other than for compliance with religious practices,
no materials will be released except as required under 4.2 above
.
UPP Pathology requests for conferences, correlations or research
4.6.1
UPP pathologists, fellows or residents will request original slides for
presentation and review at patient educations conferences or for review
and correlation with active clinical cases. These requests do not require
a signed Authorization (Attachment 6.1) or a Letter of Agreement
(Attachment 6.2).
4.6.2
UPP pathologists, fellows or residents will request original slides and/or
blocks for research studies. These requests do not require a Letter of
Agreement (Attachment 6.2). For any UPMC site conducting research,
the project should be reviewed and approved by the Chief of Pathology
and the Office Manager will maintain a list of approved research
projects.
4.6.3
The secretary of the sign out pathologist will locate the original slides.
4.6.4
All slides and blocks removed from the files will be tagged in the file with
a tag noting the date, recipient’s name (not the requester’s name) and to
which CLIA certified lab the slides and blocks were sent.
4.6.5
Slides must be recorded in the slide send out activity in the CoPath
system before they are sent out.
5.0
4.6.6
The returned slides/blocks shall be recorded in the slide send out log
and returned to the Material Steward for filing and slide tags removed.
4.6.7
If slides are not returned after 12 weeks, APLIS will generate a letter
requesting return of the material. Before any letter is mailed, the
Material Steward will be contacted to verify that the materials have not
been returned.
ATTACHMENTS
6.1
6.2
6.3
6.4
6.5
6.6
6.7
Authorization for Release of Protected Health Information
Letter of Agreement to Return Patient Slide and/or Blocks
Pathologist Review of Slide Release Form
Letter to accompany all Slides and/or Blocks
Requests for Return of Slides and Blocks from Consultant or Attorney
Court Order Letter of Agreement to Return Patient Slides and/or Blocks
Court Order Letter to Accompany All Slides and/or Blocks