Specimen Acceptability Criteria

• Specimens must be collected in proper containers.
• Outdated containers may not be used.
• Samples that are improperly labeled or stored may not be processed.
• Specimens may need to be rejected for quality purposes if the quantity is not sufficient, or if the sample is clotted or hemolyzed.

Specimen Labeling Requirements

For patient safety, each specimen container must have a label firmly affixed to the container, not the container lid or biohazard specimen transport bag, that contains the following minimum information:

• Patient’s full name (last name, first name);
• Patient’s medical record number;
• Date of specimen collection;
• Time of specimen collection (time sensitive specimens); and
• Specimen description or anatomic site of the specimen (non-blood body fluids, microbiology, cytology and surgical tissue specimens).

Properly labeled specimen(s) must be accompanied by a requisition (electronic order) containing the following information:

• Patient’s full name (last name, first name);
• Patient’s medical record number;
• Date and time of specimen collection;
• Source or site of specimen (non-blood body fluids, microbiology, cytology, and surgical tissue specimens);
• Preoperative and postoperative diagnosis and clinical history (cytology and surgical tissue specimens);
• Test(s) requested;
• Collector identification;
• Patient location;
• Ordering physician name and doctor code (senior staff only); and
• ICD diagnostic code (OPD charges and IPD professional charges).

The person that collects a specimen from a patient for laboratory analysis is responsible for establishing the identity of both the patient and the specimen(s) at the time of collection. Patient identification must be verified immediately before any specimen collection procedure. Specimens MUST be labeled in the presence of the patient.

• Patients with ID bands will be identified by comparing their ID band to the specimen label or requisition.
• Patients who are not required to wear an ID band will be identified by asking the patient to state their first name, last name and date of birth.

Specimens submitted to the laboratory without the required information will not be accepted for processing. Unlabeled blood and urine specimens will not be accepted for testing and may require recollection. Although extenuating circumstances may exist and some information may be retrievable after specimen receipt by the laboratory, this will require the licensed caregiver, physician or nurse, to come to the laboratory to provide the missing information and sign a Specimen Labeling Resolution form, accepting responsibility for the accuracy of post-collection labeling. Post-collection labeling (rehabilitation) will be permitted under the following circumstances only:

• The test is a Vital Value and delay resulting from recollection could compromise care;
• Clinical reasons exist for avoiding recollection (requires approval of pathologist/division head, laboratory supervisor, or designee); or
• The patient is unavailable for recollection (requires approval of pathologist/division head, laboratory supervisor, or designee).

Test Requisition

Electronic order entry or paper requisition forms may be used to initiate laboratory tests.  It is the responsibility of individuals performing electronic order entry of laboratory tests to accurately and completely transcribe the tests ordered by the physician.  A laboratory order must include:

• The patient's last name, first name, medical record number (MRN)
• Patient location
• Ordering physician including secondary provider
• Diagnostic code(s) for requested tests
• Specimen collection date and time
• Individual tests meeting medical necessity or HCFA approved panels, or tests where the physician has acknowledged medical necessity requirements and reimbursement limits
• A paper requisition must accompany every surgical pathology and cytopathology specimen