Completing Request Forms

Reviewed June 2024
This page will be updated December 2024

Completing the Department of Cellular and Anatomical Pathology Request Forms for Histopathology, Neuropathology and Non-Cervical Cytology Tests

In order for the correct tests to be applied to the tissue, it is important that adequate clinical information is provided on the request form. This should include the following: nature, appearance and site of the lesion; duration and nature of symptoms; results of relevant investigations including imaging; relevant past medical history; clinical differential diagnosis.

Over 80% of specimens are reported within 10 days of specimen collection, however, if the result is required urgently, or if the patient has been referred under the 2 week-wait system, then the relevant boxes on the request form should be ticked.

It is the responsibility of the requesting clinician to ensure that both the specimen container and request form are correctly and adequately completed.

Failure to provide the required details will result in either return of the sample to the sender or the clinician being asked to come to the laboratory and provide the missing information which may delay the result.

The requirements for Cellular and Anatomical Pathology are as follows:

Request form

• Patient’s surname and forename

• Patient’s hospital number

• Patient’s NHS number

• Patient’s date of birth

• Patient’s address and postcode

• Patient’s gender

• Requesting clinician

• Requesting location

• Sample type

• Urgency

• Clinical details

• Date and time of collection

• Signature of requesting clinician

• Name of consultant (if different)

• Consent for research

Sample container

• Patient’s surname and forename

• Patient’s hospital number

• Patient’s date of birth

• Requesting clinician

• Requesting location

• Sample type

• Date of collection

Where possible, specimen containers must be sent to the laboratory in a sealed plastic bag. If the specimen is from a patient who is known or suspected to be an infection hazard a Danger of Infection label MUST be affixed to both the request form and sample. Danger of Infection specimens must be placed inside TWO plastic specimen bags.  For further information, please see the Sending High Risk Specimen section.

Urgent Specimens

Specimens accompanied by a request form marked URGENT (with an attached red spot sticker) are given priority over routine samples.  The clinical reasons for this should be clearly stated on the request form.

Sending Samples out of hours

The aim of the on-call service of this department is to provide an out of hours technical service for those types of request that cannot wait until the next working day. For the purposes of this protocol, the next working day is regarded as the core time 08.30 – 17.30 hours, Monday to Friday.  Outside of this time, the on-call Biomedical Scientist (BMS) can be contacted via the Derriford Hospital switchboard.

Please note that this is essentially a preparative service and there is no formal out-of-hours diagnostic service. If a diagnosis is required, a request should be made to a Consultant Histopathologist by the requesting Consultant Physician/Surgeon in advance, so that a pathologist can be available on an ad hoc basis.  In an emergency the Consultant Physician/Surgeon can try and contact a Consultant Histopathologist via switchboard.

The on-call laboratory service is otherwise restricted to the following urgent requests:

• Small biopsy specimen preparation:It may be possible for certain small biopsies to be prepared for histological processing outside of core time so that the relevant sections are available for diagnosis on the next working day if there is an urgent clinical need.

• Bronchial tract specimens: If cell differentiation count is required samples must reach the department promptly. The sample must be prepared for examination within four hours otherwise it will not be suitable for accurate diagnosis.The on-call BMS should be informed (contact via the switchboard) if the sample is taken out-of-hours.

• Cerebrospinal fluid specimen preparation: If the sample needs to be taken out-of-hours (after 5.30pm or on weekends) as part of other urgent investigations e.g. for meningitis, the sample should be refrigerated overnight and delivered to the laboratory between 9 and 10am on the next day (including Saturday and Sunday). The on-call BMS should be informed (contact via the switchboard) if the sample is taken out-of-hours.

• Intraoperative neurosurgical specimens: Out-of-hours brain smears can be prepared by the neurosurgeon in the operating theatre, using the solutions and instructions provided, so that they are available for immediate reporting by the neuropathologist on the next working day.