Specimen Identification
Make sure that the specimen is in fact that of the patient submitting it. You need not stand over the patient while it is being collected; however, keep in mind that there are instances when it would be advantageous for persons to substitute specimens.
Use of Proper Forms
The Armed Forces have gone to great lengths to produce workable and effective laboratory forms to serve their purpose with a minimum of confusion and chance for error. These forms are standard forms of the 500 series. Their primary purpose is to request, report on, and record clinical laboratory tests. With the exception of the SF-545, Laboratory Report Sheet, they are multicopy, precarbonized for convenience. The original eventually is filed in the patient’s clinical record, and the carbon becomes part of the laboratory’s master file. For a complete listing of these forms and their purposes, refer to chapter 23 of the Manual of the Medical Department.
Use of Laboratory Forms
It goes without saying that a separate form is used for each patient and test. The patient’s name, rank, Social Security number, and unit identification will be entered on each request in sufficient detail to assure proper identification.
Since the results of the requested laboratory test are usually closely associated with the patient’s health and treatment, the requesting physician’s name and location shall be clearly stated. This assures that the report will get back to the physician as expeditiously as possible. There is nothing more aggravating to both patient and physician than a lost or misplaced laboratory report.
Since the data requested, the date reported, and the time of specimen collection are usually important in support of the clinical picture, these facts should be clearly written on the request in the areas provided for them.
The type of tests requested should be clearly marked to eliminate all misunderstanding.
Filing the Laboratory Requests
After the physician has seen the results of the laboratory tests, the forms must be filed in the clinical record of inpatients. SF-545, Laboratory Report Sheet, is provided for this. The originals of the test forms are to be stapled on this sheet IN CHRONOLOGICAL ORDER and neatly spaced, as directed on the form. Each sheet will accommodate a certain number of laboratory reports. DO NOT OVERCROWD with more reports—use additional sheets if necessary.
The results of the laboratory tests performed on active duty outpatients will be placed on the SF-545 in the health (medical) treatment record.
ETHICS IN THE LABORATORY
The nature of laboratory tests and their results must be treated as a confidential matter between the patient, physician, and the performing technician. It is good practice to prevent unauthorized access to these reports, to leave interpretation of the test results to the attending physician, and to refrain from discussing them with the patient.
REFERENCES
1. Clinical Diagnosis and Management by Laboratory Methods, ed 16. W. B. Saunders Co, 1979
2. Laboratory Medicine: Hematology, ed 6. C.V. Mosby Co, 1982
3. Hematology for Medical Technologists, ed 5. Lea & Febiger Co, 1983
4. Hematology: Principles and Procedures, ed 2. Lea & Febiger Co, 1976
5. Modern Urine Chemistry, Ames Division, Miles Laboratories, Inc
6. A Handbook of Routine Urinalysis, J. P. Lippincott Co, 1983