LTD Specimen Labeling/Request Form Completion Version 6
Specimen Labeling and Request Form Completion
Purpose:
The purpose of this policy is to describe the process of labeling laboratory
specimens and proper completion of laboratory requisition/script.
Scope/Responsibility:
At Collection:
- It is the responsibility of the collector to ensure all specimens are labeled
correctly in the presence of the patient or appropriate adult.
- Specimens must be submitted to the laboratory with proper requisitions or
orders.
Upon Receipt in Laboratory:
- The laboratory is responsible for ensuring that information obtained from
the specimen and requisition match.
- Any discrepancies found between specimens and associated
requisitions MUST be questioned with collectors
- Incorrectly identified specimens or specimens without necessary Blood
Bank documentation MUST be recollected.
Applies to: All specimens received in an Akron Children’s Hospital Laboratory
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 of the request form. (Labels from
the lab system may substitute for a requisition as they contain all pertinent
information.)
Blood Bank Specific Information:
Ordering through EPIC- the required patient and transfusion history must be
completed by the APP.
Ordering outside of EPIC- a manual Blood Bank Requisition must be
completed which includes the history sections mentioned above.
In either case a completed Blood Bank requisition is required to include the
signature of the APP ordering the test.
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In addition at the time of specimen collection the two signatures (collector and
witness) verifying the identification of the patient should be placed on the
Blood Bank requisition.
Labeling:
1. Two patient identifiers from the identification band or provided verbally if no
band is present and from the order (script, request form, audit, order labels)
must be compared at the time of collection.
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 contain:
Two patient identifiers (patient’s full name and medical record number
and/or date of birth)
Date of collection
Collectors employee number - 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.
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 acceptable identifiers!
3. Special circumstances require the following additional information on the
specimen:
Specimens sent with an audit slip or laboratory requisition.
Time of collection when specimen is for Blood Bank or one drawn in a
series; e.g. Glucose Tolerance or Stimulation Tests.
The employee number of the individual collecting the specimen must be
on all Blood Bank specimens.
Specimens sent with no paperwork (Not applicable to Blood Bank); e.g. script
or lab labels only
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.)
Time of collection
Source
- Blood – capillary or venous
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- Urine – cath, clean catch, etc.
- Swab – throat, NPH (nasopharyngeal), wound (MUST add location, ex.
Right (R) Leg)
Transport of a newborn (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 completed ‘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 (Epic or manual).
The requisition must be completed and signed by the ordering APP.
The patient history and transfusion history sections are critical to patient
safety.
Any departments ‘live’ on Epic must place Blood Bank orders in Epic.
The manual requisition is a requirement for all non-Epic sites collecting
Blood Bank samples to be sent to Akron Children’s Hospital Blood Bank.
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 which accompanies an
already drawn specimen, the following information should be on the request
form:
Patient Information
- Two patient identifiers which were used to identify the patient
- Sex – male or female
- Clinical information when appropriate – e.g. Patient History for Genetic
testing, Time of dose of medication for drug level (peak or trough), etc.
Specimen Information
- Collection date and time
- Source - e.g. urine, wound, NPH
- Descriptive information, e.g. left or right, clean catch or catheter, peak
or trough, capillary, venous, or arterial, pertinent to the report.
- Tests requested
Physician Information
- Full name and for outpatients the National Provider Identification
number (NPI)
Report Routing Information
- Inpatients – Patient location where report should be sent.
- Outpatients – Physician’s address/location
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4. Transportation of a newborn (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.
Patient Information
- Name and date of birth
- Clinical information when appropriate – e.g. Patient History for genetic
testing, time of dose of medication, etc.
- ICD-10 code and/or diagnosis.
Specimen Information
- Order date and time
- Tests requested
- Specific information, i.e. clean catch or catheter for a urine culture.
Physician Information
- Full name and for outpatients the National Provider identification
number (NPI) for non-Akron Children’s physicians.
Routing Information
- Inpatients – Patient Unit
- 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.
