Labeling Specimens

1. All specimens for laboratory testing should be labeled with the following information:

• Patient's first and last name
• Unique patient identifier (Eg. Inpatients, Patient Account #; Outreach Patients, Last four digits of social security number, date of birth, etc.)
• Date and time of collection
• Identification of collector (Initials)

2. All specimens for laboratory testing must be accompanied by a lab requisition slip or electronic order (inpatients). The request slip should contain the following information:

• Patient's first and last name as it is presented on insurance or social security card
• Patient's birth date
• Patient's sex
• Patient's social security number
• Name and address of clinic or hospital sending specimen
• Date and time of collection and collector's initials
• Laboratory test(s) to be performed, with ICD-9 codes for each test ordered
• First and last name of physician requesting test
• Specimen source
• Call back/fax information if applicable
• Insurance information
• Clinical information when appropriate

• Medicare/Medicaid patients-number and alpha code plus patient's home address
• Insurance company
• Responsible party
• Group number
• Policy number
• Complete address and name of insurance company
• Name and employer of policy holder

• Signature of Medicare patient, advanced beneficiary notice, for all tests lacking medical necessity documentation.

3. Unlabeled or improperly identified specimens should be recollected. Outreach personnel will contact the clinic to request recollection of any unlabeled or improperly identified specimen. If recollection is not feasible and specimen is deemed "precious," the appropriate clinic personnel will be responsible for identifying the specimen.    

The Outreach Department will acknowledge verification of the specimen only after being authorized by clinic personnel to do so. A note will be made upon admission that the specimen was received unlabeled, along with the name of the person at the clinic verifying the specimen. This information will be recorded on the appropriate quality assurance form.

Exceptions:

• All unlabeled or improperly identified specimens for cytology and histology are unacceptable and will be returned to the physician's office.

It is recommended that a copy of the requisition be maintained in the patient's file by the ordering facility.