Patient and Specimen Identification

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Chapter 7 - Clinical laboratory

Hospital Corpsman Revised Edition

Blood collection

Patient and Specimen Identification
Before accepting laboratory request forms and specimens in the laboratory, check patient identification information on both the request form and the specimen container label for completeness and legibility. Proper documentation of patient identification information on these items can prevent a great number of errors. Also, make sure the specimen(s) submitted is in fact the specimen of the patient submitting it. You need not stand over the patient while the specimen is being collected; however, keep in mind that for certain tests (such as drug or alcohol screening tests) individuals may attempt to substitute specimens.

Figure 7-1.-SF-550, Urinalysis Request Form.

Filing Laboratory Forms
After healthcare providers have reviewed laboratory test reports, they will initial the form. Initialing the form indicates the healthcare provider has reviewed the test results. After the healthcare provider releases the laboratory report, it should be filed in the patient's inpatient or outpatient health record, as appropriate. If a standard form is used to record test results, it should be attached chronologically to the SF-545, Laboratory Report Display, inside the patient's health record. The SF-545 functions as a display form for multiple laboratory reports. See figure 7-2. Use the preglued areas provided on the lab forms. However, since the glue is notorious for losing its grip after a while, you may use tape or staples to attach the form to the SF-545. Each SF-545 can accommodate a limited number of laboratory reports, so do not overcrowd the display form. When the SF-545 is full, add a new SF-545 to the health record and place it in front of the old SF-545. In this way, the most current lab reports will remain in chronological order.

Automated or computer-generated laboratory test reports, depending on the form's size, may be either mounted on the SF-545 or placed adjacent to the SF-545 in the health record. Keep in mind that these automated or computer-generated forms should also be filed chronologically.

ETHICS AND GOOD PRACTICES IN THE LABORATORY

The nature of laboratory tests and their results must be treated as a confidential matter between the patient, the healthcare provider, and the performing technician. Chapter 16 of the MANMED outlines the Navy's ethics policy with regard to disclosure of the contents of a patient's medical record, including lab reports. It is good practice to prevent unauthorized access to these reports, to leave interpretation of the test results to the attending provider, and to refrain from discussing the results with the patient.