Lab Test Procedure : Specimen Labeling/Request Form Completion

Purpose: The purpose of this policy is to describe the process of labeling laboratory specimens and proper completion of a laboratory requisition/script.

Scope/Responsibility: It is the responsibility of staff to properly label all laboratory specimens. It is the requirement of the Akron Children's Enterprise as specified when sending specimens to any laboratories operated by Akron Children's Hospital to follow the guidelines for labeling all specimens:

Applies to: Akron Children's Hospital Enterprise

Policy: All specimens must be labeled at the side of the patient prior to leaving the room.
All specimens coming into the laboratory are required to be labeled as stated in the guidelines.
All specimens sent to the laboratory must be accompanied by a requisition/audit slip which contains the same two patient identifiers used to identify the patient and the information as detailed in the section on the request form. (Labels from the lab system may substitute for a requisition as they contain all pertinent information.)
Blood Bank Specific Information When ordering through EPIC, the required patient and transfusion history must be completed by the LIP. If ordering outside of EPIC, as always a manual Blood Bank Requisition must be completed which includes the history sections mentioned above. In either case a completed Blood Bank reuisition is required to include the signature of the LIP ordering the test. In addition at the time of specimen collection the two signatures verifying the identification of the patient should be placed on the Blood Bank requisition.

Guidelines:
Labeling

1. Two patient identifiers from the identification band or provided verbally if no band is present and the order (script, request form, audit, order labels) must be compared at the time of collection for presence of the two matching patient identifiers.

2. After collecting the specimen and before leaving the patient room/bedside, label each collection tube/container, using a patient label generated by the hospital or laboratory system or handwritten. The label must minimally contain two patient identifiers (patient's full name and medical record number and/or date of birth).and date of collection In case of unidentified patients, label should contain assigned patient name at time of collection and both the medical record and account numbers. Room number and bed are not accepatable identifiers. Room number and bed are not acceptable identifiers.

3. The phlebotomist is identified by placing the employee number on the specimen container. This will then be entered into the LIS at accessioning to become part of the permanent record.

4. Special circumstances require the following additional information on the specimen:
a. Specimens sent with an audit slip or laboratory requisition.
1. Time of collection when specimen is one drawn in a series; e.g. Glucose Tolerance or Stimulation Tests.
2. The employee number of individual collecting specimen must be on all Blood Bank specimens.
b. Specimens sent with no paperwork (Not applicable to Blood Bank) e.g. script or lab labels only
1. Specimen Collector ID - hospital employee number (initials if not an employee). (In a trauma situation an alternate staff member who has verified the two patient identifiers may write the employee number of the individual who drew the blood and add their own initials.)
2. Time of collection
3. Source
Blood - capillary or venous
Urine - cath or clean catch
Swab - throat, NPH, leg (location of where swab was taken)

4. Transport - When picking up a newborn and the referring hospital is sending mother's blood, the mother's blood must be labeled with her full name, date of birth, the date of the draw, and the initials or signature of the person drawing the blood. A "Transport Form to Accompany Mother's Blood" must be sent to the lab with the specimen.

Request Form
1. All requests for Blood Bank Testing, must be submitted on a double signed Blood Bank Requisition. The requisition must be completed and signed by the ordering LIP. The patient history and transfusion history sections are critical to patient safety. (Any departments "live" on EPIC must place Blood Bank orders in EPIC but the manual requisition is still required) Emergency Department- If the staff drawing the blood is unable to sign the blood Bank requisition due to their involvement in the care of the patient, i.e. trauma care, an alternate staff person who has verified the two patient identifiers may obtain the name of the person obtaining the specimen and write it on the specimen tube and the transfusion request form. The labeling staff person should add their own employee number to the requisition and specimen label.
2. For Inpatient areas using audit trails, complete the blanks requesting collection time, employee ID, and source - capillary, venous, arterial.

3. For Inpatient/Outpatient areas sending a request form/requisition (other than an audit trail) which accompanies an already drawn specimen, the following information should be on the request form:
a. Patient Information
1. Two patient identifiers which were used to identify the patient - name and date of birth / medical record number. If patient name is 'unknown' use Medical Record and Account Number.
2. Sex - male or female
3. Clinical information when appropriate - e.g. Patient History for Genetic testing, Time of dose of medication for drug level (Peak or trough), etc.
b. Specimen Information
1. Collection date and time
2. Source e.g. urine, wound, NPH
3. Descriptive information, e.g. left or right, clean catch or catheter, peak or trough, capillary, venous, or arterial, pertinent to the report.
4. Tests requested
c. Physician Information
1. Full name and for outpatients the National Provider Identification number (NPI).
d. Report Routing Information
1. Inpatients - Patient location where report should be sent.
2. Outpatients - Physician's address/location

4. Transport - When transporting a newborn and delivering mother's blood to ACH lab the form titled " Transport Form to Accompany Mother's Blood" must accompany the mother's blood to the lab. In addition the baby's label will be placed on the mother's blood in such a manner that both may be read.
5. For outpatient physicians sending a script requesting laboratory testing, the following information must be provided.
a. Patient Information
1. Name and date of birth
2. Clinical information when appropriate - e.g. Patient History for Genetic testing, Time of dose of medication, etc.
3. ICD-9 code and/or diagnosis.
b. Specimen Information
1. Order Date and time
2. Tests requested
3. Specific information, i.e. clean catch or catheter for a urine culture.
c. Physician Information
1. Full name and for outpatients the National Provider Identification number (NPI) for non-Akron Children's physicians.
d. Routing Information
1. Inpatients - Patient Unit
2. Outpatients - Physician's address/location

Blood Bank Disclaimer: Mislabeled Blood Bank specimens will not be processed, regardless of the situation. This includes any mismatched or missing information involving the specimen and/or the Blood Bank requisition. All mislabeled Blood Bank specimens will be redrawn.

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