Gross Examination Only Specimens

Specimens for gross examination only are some of the most trying specimens to dictate. Choosing words to describe these objects is often difficult. Documentation of these specimens is important even though no tissue is being examined microscopically. If a patient has a chemotherapy port removed, dictation of the appropriate brand and serial number is necessary. If that chemotherapy port happens to be associated with a class action lawsuit, the correct serial number is important and must be correct in the dictation. Remember, gross only specimens have no other documentation in pathology, other than the gross description. These descriptions must be detailed and accurate.