Frozen Section/Intraoperative Consultation Report

Report Title: Frozen Section / Intraoperative Consultation Report

Laboratory: [Laboratory name and location]

Accession/Case #: [Accession number]

Patient: [Patient full name] | MRN: [MRN] | DOB: [DOB] | Sex: [Sex]

Procedure Location: [Facility name], OR [Number/location]

Surgeon/Proceduralist: [Name and credentials]

Report Date/Time: [Date and time of this preliminary report]

⚠ PRELIMINARY INTRAOPERATIVE RESULT – Final diagnosis pending permanent sections

Clinical Context

Procedure: [Procedure name]

Indication/Question: [Clinical question or specimen intent, e.g., rule out malignancy, margin assessment, lymph node metastasis, tissue adequacy] (If not provided, state: "Not stated on requisition.")

Relevant History: [Pertinent clinical history, oncologic status, imaging, or prior pathology as provided by surgical team] (Include only information explicitly provided; do not infer.)

Specimens

(Include summary table only when two or more parts are submitted.)

Part	Specimen	Method	Received	Intraoperative Diagnosis	Communicated To / Time
[Part letter]	[Specimen designation/site/laterality]	[Frozen section / Touch imprint / Gross only]	[Time (24-hr)]	[Concise diagnosis]	[Recipient name, role / Time]

Part [Letter] – [Specimen designation/site/laterality]

Received: [Date/time (24-hr)] — [Specimen condition: fresh / in saline / fragmented / cautery artifact / oriented] (Receipt time is required.)

Method: [Frozen section (number of blocks) / Touch imprint/smear / Gross examination only – no frozen section performed]

Gross Description: [Size, sampling approach, orientation/inking, lymph node count] (Include only if gross features materially affect interpretation; otherwise omit this line.)

Intraoperative Diagnosis: [No malignancy identified / Carcinoma identified / No carcinoma at inked margin / Metastatic carcinoma identified / Atypical cells present – deferred to permanent sections / Non-diagnostic due to (reason) / Deferred to permanent sections] (Use clear, actionable phrasing. Do not provide definitive subtyping, staging, or grading.)

Comment: [Interpretation limited by freezing artifact / Sampling limited; permanent sections pending / Definitive classification deferred to permanent sections] (Include only when uncertainty, artifact, or sampling limitations are present; otherwise omit.)

Tissue Disposition: [Remainder submitted for permanent sections / Portion submitted for (ancillary study)] (Include only if non-routine; otherwise omit.)

Communication: Communicated to [Dr./Mr./Ms. Name] ([Role]) via [phone / in-person] at [Date/time (24-hr)]; read-back [confirmed / not obtained]. (Required for every specimen.)

(Repeat specimen block for each additional part. Every part must include Received time and Communication documentation.)

Authentication

Attending Pathologist: [Name, credentials]

Electronic Signature: [Signature block]

Signed: [Date/time (24-hr)]

Trainee: [Name, role] — [Attending oversight statement] (Include only if trainee participated.)

Addenda or corrections, if any, will appear below with date/time, reason, corrected diagnosis referencing the original, and documentation of re-communication to the surgical team.