Filing Laboratory Forms
After healthcare providers have reviewed
laboratory test reports, they will initial the form.
Initialing the form indicates the healthcare provider has
reviewed the test results. After the healthcare provider
releases the laboratory report, it should be filed in the
patients inpatient or outpatient health record, as
appropriate. If a standard form is used to record test
results, it should be attached chronologically to the
SF-545, Laboratory Report Display, inside the patients
health record. The SF-545 functions as a display form
for multiple laboratory reports. See figure 7-2. Use the
preglued areas provided on the lab forms. However,
since the glue is notorious for losing its grip after a
while, you may use tape or staples to attach the form to
the SF-545. Each SF-545 can accommodate a limited
number of laboratory reports, so do not overcrowd the
display form. When the SF-545 is full, add a new
SF-545 to the health record and place it in front of the
old SF-545. In this way, the most current lab reports will
remain in chronological order.
Automated or computer-generated laboratory test
reports, depending on the forms size, may be either
mounted on the SF-545 or placed adjacent to the
SF-545 in the health record. Keep in mind that these
automated or computer-generated forms should also
be filed chronologically.
ETHICS AND GOOD PRACTICES IN THE
LABORATORY
The nature of laboratory tests and their results
must be treated as a confidential matter between the
patient, the healthcare provider, and the performing
technician. Chapter 16 of the MANMED outlines the
Navys ethics policy with regard to disclosure of the
contents of a patients medical record, including lab
reports. It is good practice to prevent unauthorized
access to these reports, to leave interpretation of the
test results to the attending provider, and to refrain
from discussing the results with the patient.
BLOOD COLLECTION
LEARNING OBJECTIVE:
Identify the
correct steps to perform blood collection by
t h e
f i n g e r
p u n c t u re
m e t h o d
a n d
venipuncture method, and recall Standard
Precautions and other safety precautions
that apply to blood collection.
There are two principal methods of obtaining
blood specimens: the finger puncture method and the
venipuncture method. For most clinical laboratory
tests requiring a blood specimen, venous blood
obtained by venipuncture is preferred. Blood collected
by venipuncture is less likely to become contaminated,
and the volume of blood collected is greater. Infection
control practices, equipment requirements, and
step-by-step instructions on performing both of these
blood collection methods will be discussed in the
following sections.
STANDARD PRECAUTIONS
Under the concept of Standard Precautions
outlined by the Centers For Disease Control and
Prevention (CDC), blood and other bodily fluids
should be considered as potentially infectious. To
protect medical personnel from direct contact with
blood during phlebotomy (blood collection), gloves
are required to be worn. Gloves should be disposed of
after each patient.
Needles and sharps used in the blood collection
process should be handled with extreme caution and
disposed of in biohazard sharps containers. Sharps
containers should be conveniently located near
phlebotomy work sites.
Absorbent materials, such as cotton 2 x 2s used to
cover blood extraction sites, normally contain only a
small amount of blood and can be disposed of as
general waste. However, if a large amount of blood is
absorbed, the absorbent material should be placed in a
biohazard waste container and treated as infectious
waste.
Clean phlebotomy work site equipment and
furniture daily with a disinfectant.
FINGER PUNCTURE
The finger puncture method is used when a patient
is burned severely or is bandaged so that the veins are
either covered or inaccessible. Finger puncture is also
used when only a small amount of blood is needed.
Materials Required for Finger Puncture
Procedure
To perform a finger puncture, the following
materials are required:
Sterile gauze pads (2" x 2")
7-3