Laboratory Anatomic Pathology (AP) Version 5.2 User Guide February 2019 Department of Veterans Affairs (VA) Office of Information and Technology (OIT) Product Development (PD) Revision History Date Description (Patch # if applicable) Author 02/2019 LR*5.2*504 HPS Clinical Added Missing AP Alert Search to the Menu Options and Sustainment Team added LRAPALERT section REDACTED 09/2015 LR*5.2*442, Updates for ICD-10 Patient Treatment File REDACTED (PTF) Modifications: • Updated title page, headers, footers, and Revision History. • Corrected styles and spacing issues throughout document. • Reformatted table in Appendix B. • Added text to Tissue Committee Review Cases Option (p.286, 377). 08/2014 LR*5.2*422 – Updates for ICD-10 REDACTED Overall: Ensured all screen captures followed the SSN guidelines specified in Displaying Sensitive Date Guide. Updated Title page Added Revision History (pp i-ii) Changed ICD9 to ICD (pp.3, 18, 192, 196) "FS/Gross/Micro/Dx/ICD Coding [LRAPDGI]" (pp. 84, 360) "Autopsy protocol & ICD coding [LRAPAUDAA]" and "FS/Gross/Micro/Dx/ICD Coding [LRAPDGI]" (p.20) "Autopsy protocol & ICD coding [LRAPAUDAA]" (pp. 40 49, 343,362) ICD Coding, Anat Path [LRAPICD] "Select ICD DIAGNOSIS:" and "FS/Gross/Micro/Dx/ICD Coding [LRAPDGI]" (p. 41) ICD Coding, Anat Path [LRAPICD] "Select ICD DIAGNOSIS:" (pp. 67, 363) 01/2001 Revised. VA OIT 10/1994 Initial document published. VA OIT Laboratory AP User Guide ii February 2019 Preface NOTE: The Veterans Health Information Systems and Architecture (VISTA) Laboratory Anatomic Pathology User’s Manual released in October 1994 has been edited to include an Appendix B section. The appendix contains file, fields, options changes, and examples created by the release of patch LR*5.2*248. The Anatomic Pathology User’s Manual was designed as a training guide and reference manual for Veterans Affairs Medical Center (VAMC) Site Managers, Lab Applications Coordinators, and all users of the Anatomic Pathology module of the Laboratory software application. It should be used in conjunction with other documentation of the Laboratory software application. The manual shows users how to enter, edit, and display information for Cytopathology, Autopsy Pathology, Surgical Pathology, Electron Microscopy, preselected lab test lists, and lists of unverified pathology reports. It also shows how to print reports, path micro/dx modification, cum path data summaries, and preselected lab test lists. Laboratory AP User Guide iii February 2019 Table Of Contents INTRODUCTION ------------------------------------------------------------------------------------------- 2 OVERVIEW OF ANATOMIC PATHOLOGY MODULE ------------------------------------------------------ 2 FUNCTIONALITY --------------------------------------------------------------------------------------------- 3 ORIENTATION --------------------------------------------------------------------------------------------- 5 BEFORE YOU BEGIN ---------------------------------------------------------------------------------------- 5 SPECIAL KEYS, COMMANDS, AND CONVENTIONS ------------------------------------------------------ 5 MANUAL CONVENTIONS ----------------------------------------------------------------------------------- 8 PACKAGE MANAGEMENT---------------------------------------------------------------------------- 10 PACKAGE OPERATIONS ------------------------------------------------------------------------------ 12 ANATOMIC PATHOLOGY MENU -------------------------------------------------------------------------- 12 Menu Descriptions ------------------------------------------------------------------------------------- 13 Anatomic Pathology Menus --------------------------------------------------------------------------- 15 WORKFLOW ------------------------------------------------------------------------------------------------- 21 A. Log-in --------------------------------------------------------------------------------------------- 21 B. Data Entry ---------------------------------------------------------------------------------------- 21 C. Final Reports ------------------------------------------------------------------------------------- 22 Summary of Selected AP Options -------------------------------------------------------------------- 24 SNOMED CODING/SEARCHES --------------------------------------------------------------------------- 25 Reports --------------------------------------------------------------------------------------------------- 28 Frozen Sections -------------------------------------------------------------------------------------- 28 Bone Marrows --------------------------------------------------------------------------------------- 28 Autopsy ----------------------------------------------------------------------------------------------- 29 ANATOMIC PATHOLOGY MENU OPTIONS ---------------------------------------------------- 33 DATA ENTRY, ANAT PATH [LRAPD] ------------------------------------------------------------------- 34 Descriptions --------------------------------------------------------------------------------------------- 34 Data entry for Autopsies [LRAPAUDA] -------------------------------------------------------- 34 Coding ------------------------------------------------------------------------------------------------ 35 Data Entry for Autopsies [LRAPAUDA] ----------------------------------------------------------- 37 Provisional Anatomic Diagnoses [LRAPAUPAD] -------------------------------------------- 37 Autopsy Protocol [LRAPAUDAP] --------------------------------------------------------------- 39 Autopsy Protocol and SNOMED Coding [LRAPAUDAB] ---------------------------------- 40 Laboratory AP User Guide iv February 2019 Autopsy Protocol and ICD Coding [LRAPAUDAA] ------------------------------------------ 48 Final Autopsy Diagnoses Date [LRAPAUFAD] ----------------------------------------------- 50 Autopsy Supplementary Report [LRAPAUSR] ----------------------------------------------------- 51 Autopsy [LRAPAUDAS] -------------------------------------------------------------------------- 53 Blocks, Stains, Procedures, Anat Path [LRAPSPDAT] ------------------------------------------- 56 Surgical Pathology ---------------------------------------------------------------------------------- 56 Cytology ---------------------------------------------------------------------------------------------- 56 Electron Microscopy -------------------------------------------------------------------------------- 56 Autopsy ----------------------------------------------------------------------------------------------- 56 General ------------------------------------------------------------------------------------------------ 57 Example 1: Routine Data Entry for Surg Path (workload off) ------------------------------ 57 Example 2: Routine Data Entry for Surgical Pathology Frozen Section ------------------ 59 Example 3: Editing Data for Cytology --------------------------------------------------------- 62 (data already entered based on workload profiles) --------------------------------------------- 62 Example 4: Data Entry for EM ------------------------------------------------------------------ 65 Example 5: Date/Times are not in Sequence -------------------------------------------------- 67 Example 6: More than one Specimen ---------------------------------------------------------- 69 Coding, Anat Path [LRAPCODE] ------------------------------------------------------------------- 71 SNOMED Coding, Anat Path [LRAPX]--------------------------------------------------------- 71 ICD Coding, Anat Path [LRAPICD] ------------------------------------------------------------- 72 Clinical HX/Gross Description [LRAPDGD] ------------------------------------------------------ 74 Example 1: Entry of Information for a Surgical Pathology/ -------------------------------- 75 ASK FROZEN SECTION set to NO ------------------------------------------------------------- 75 Example 2: Entry of Information for a Surgical Pathology Specimen with a ------------ 76 Frozen Section ASK FROZEN SECTION set to YES ---------------------------------------- 76 FS/Gross/Micro/Dx [LRAPDGM] ------------------------------------------------------------------- 78 FS/Gross/Micro/DX/SNOMED Coding [LRAPDGS] --------------------------------------------- 81 Example 2: Entry of Information for a Surgical Pathology Specimen -------------------- 85 with a Frozen Section ------------------------------------------------------------------------------- 85 Example 3: Using a Template to enter a Bone Marrow Report ---------------------------- 87 Example 4: Using a Template to Enter a Bethesda system Report for a Cytology ------ 95 FS/Gross/Micro/Dx ICD [LRAPDGI] -------------------------------------------------------------- 97 Enter Old Anat Path Records [LRAPOLD] -------------------------------------------------------- 99 Laboratory AP User Guide v February 2019 Supplementary Report, Anat Path [LRAPDSR] ------------------------------------------------- 101 Special Studies-EM;Immuno;Consult;pic, Anat Path [LRAPDSS] --------------------------- 104 Edit/Modify Data, Anat Path [LRAPE] ----------------------------------------------------------- 106 Description ----------------------------------------------------------------------------------------- 106 Edit Log-In & Clinical Hx Anat Path [LRAPED] ----------------------------------------------- 107 Modify Anat Path Gross/Micro/Dx/Frozen Sections [LRAPM] ------------------------------- 110 Example 1: Modify Anat Path Gross/Micro/Dx/Frozen