How to submit specimens for investigation

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This section contains details of how to submit specimens for investigation by ophthalmic pathology.

Request forms and sample labelling

For all specimens submitted to the laboratory, a fully completed request form MUST accompany each case.

You may use request forms provided by this department or by your own local histopathology department, as long as it is suitable for histopathology or cytology specimens.

Request forms are designed to provide:

  • unique identification of the patient.
  • a destination for the report and any charging information.
  • the laboratory with the clinician contact details if discussion of the case is required.
  • date and time of specimen collection/removal and investigations required (eg histology/cytology).
  • type of specimen and anatomical site of origin
  • clinical information so that the pathologist may handle the specimen appropriately and interpret microscopic findings in the proper context.
  • an awareness of any health and safety issues with a given specimen.
  • an indication if consent has been provided for research purposes.

With this in mind, please provide complete information on the request form. Failure to adequately complete any portion of a request form may lead to dangerous errors, the responsibility for which will lie with the referring ophthalmologist.

NB: The patient’s NHS number should be stated (when applicable), as this provides a unique identifier, together with patient’s first and last names, date of birth, gender, hospital number (if appropriate). Patient address is also required for cases originating outside of CMFT.

Each specimen container, no matter how small, must also be labelled with the appropriate patient identification data (minimum of 3 identifiers eg first and last name, date of birth/age, gender and preferably patient’s NHS/Hospital No). The information must be consistent with the request form, to prevent errors in specimen and patient identification. Multiple specimens from the same patient should also identify the specimen type/site.

If there are discrepancies between the request form and specimen labelling, specimens in inadequately labelled containers or accompanied by inadequately completed request forms; the requesting clinician will be required to complete the documentation by visiting the laboratory or the specimen may be returned to the referring clinician for proper completion, resulting in a delay in processing.

High risk/danger of infection specimens

It is the responsibility of the requesting clinician to indicate on the REQUEST FORM AND SPECIMEN if the patient is known or suspected to be within a “High Risk/Danger of Infection” category (eg HIV, TB, Hepatitis B, Hepatitis C), to facilitate appropriate handling.

Frozen sections (including specimens for immunofluoresence) will NOT be carried out on high risk specimens.

Specimen containment

It is the responsibility of the referring clinical/surgical team to ensure that all specimens are submitted to the laboratory in suitable and approved containers.

Approved specimen containers have leak-proof lids and the appropriate hazard warning sign for the fixative eg formalin.

Ensure specimen containers are closed securely and placed inside a sealed specimen bag.

Specimens received leaking or damaged are a danger to all those who come into contact with them, including theatre staff, porters and laboratory staff.

Leakage from a specimen container may seriously compromise the diagnostic process. If a specimen is deemed unsuitable for safe processing by the laboratory staff, it will be disposed of and the requesting clinician informed of the problem as soon as is practicable.


(Last updated May 10th 2016)