Documentation Standards Flashcards

A phlebotomist writes the wrong collection time on a paper log. What is the correct way to fix it?

Answer: Draw a single line through the error, write the correct time, and initial and date it

A single line keeps the original entry readable, and the initials and date show who made the correction and when.

When should specimen tubes be labeled during a routine venipuncture?

Answer: Immediately after collection, in the presence of the patient

Labeling at the bedside right after collection, with the patient present, prevents mislabeled specimens.

Which pair of identifiers is the minimum required by The Joint Commission before specimen collection?

Answer: Patient full name and date of birth

The Joint Commission requires at least two patient-specific identifiers, and room number is never one of them.

A specimen arrives at the lab with a label that has no collector's initials. What is the most likely outcome?

Answer: The specimen may be rejected per lab policy

Missing required label information such as the collector's ID is a common reason labs reject specimens.

Where should a phlebotomist document that a patient refused a blood draw?

Answer: On the requisition or per facility policy, notifying the nurse or physician

A refusal must be documented and reported to the responsible nurse or physician so care can continue.

For a fasting glucose test, which extra detail is most important to record?

Answer: Whether the patient actually fasted, and for how long

Fasting status directly affects glucose results, so it has to be confirmed and recorded.

An outpatient's name on the requisition differs from their ID band spelling by one letter. What should the phlebotomist do?

Answer: Stop and resolve the discrepancy before collecting

Any identification mismatch must be resolved before collection to prevent patient misidentification.