Documentation Standards Flashcards

An unlabeled tube arrives in the lab and the phlebotomist says they know whose it is. What is standard practice?

Answer: The specimen is rejected and recollected

Unlabeled specimens are generally rejected because their identity can't be verified.

What should be documented if two venipuncture attempts fail?

Answer: The failed attempts and notification of a supervisor or another phlebotomist

Unsuccessful attempts are documented, and after two failures the patient is usually referred to another collector.

Which abbreviation practice best follows documentation standards?

Answer: Using only facility-approved abbreviations and avoiding 'Do Not Use' list items

The Joint Commission's 'Do Not Use' list and facility-approved abbreviations prevent misreading.

A patient asks the phlebotomist for their test results. What is the appropriate response?

Answer: Refer the patient to their healthcare provider

Phlebotomists are not authorized to interpret or release results; that is the provider's job.

What is the main purpose of a test requisition?

Answer: To communicate the ordered tests and patient information to the lab

The requisition is the authorized order telling the lab which tests to perform and for whom.

If a specimen is collected from an arm with an IV running above the site, what should be documented?

Answer: That the specimen was drawn below the IV and the IV was stopped per policy

Documenting IV-arm collection helps the lab and provider spot possible contamination or dilution.

Which practice violates documentation standards?

Answer: Pre-labeling tubes before seeing the patient

Pre-labeling tubes raises the risk of mislabeling and is prohibited.