POLICIES AND PROCEDURES MANUAL

LABORATORY PROCEDURES
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SUBJECT: LABORATORY PROCEDURES

1. PURPOSE:

This policy will provide guidelines for the appropriate process and procedure(s) to
be used for laboratory specimen collection.

2. POLICY:

1. A physician's order is required before obtaining any laboratory specimen.

Physician order must specify date to be obtained, except random urine drug screens
for those individuals with an open problem and current treatment plan for substance
abuse.

2. All laboratory specimens shall be placed, stored, and transported in fluid

impermeable sealed plastic bags that have a biohazardous symbol on them. Lab
slips should be placed in a compartment separate from the specimen(s).

3. GENERAL INFORMATION:

In all procedures where it can be reasonably anticipated exposure to blood or

other potentially infectious material may result, personal protective equipment and
engineering controls shall be used.

A. Engineering controls are those that isolate or remove the blood borne
pathogen hazard from the workplace (e.g., sharps containers.)
B. Personal protective equipment consists of special clothing or equipment worn by
an employee for protection against a hazard. General work clothing (e.g., uniforms,
pants, shirts or blouses) not intended to function as protection against a hazard are
not considered to be personal protective equipment.
C. If refrigeration is indicated, laboratory specimens shall be stored in a specially
designated refrigerator in which no food or drugs are kept.

D. For Drug Abuse Screening, urine is the specimen of choice.

E. Registered Nurses who have demonstrated proficiency in venipuncture

technique may obtain blood specimens.
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F. Blood specimens may also be obtained at the specimen collection station by the
contractor’s phlebotomist(s) during normal working hours, (TBD)

G. All urine specimens will be collected by the “Mid-Stream Clean Catch” process,
except for the collection of “24-Hour” urine specimens.

4. PROCEDURE:

NURSING ACTION KEY POINTS

A. Check for Physician’s orders. A. Determine if individual is to be

N.P.O. for test.

B. Addressograph appropriate lab B. Be sure stamp is legible on all

slip. copies.

C. Fill out form completely. C. Include physician's name, unit,

date, diagnosis (related to reason for
obtaining specimen), and name of
person obtaining specimen.

D. Check appropriate box for required D. Include essential information.

test and write in source of specimen. Such things as STAT or CALLBACK
must be included on the request or it
will be handled as a routine. Verify
test with doctor’s orders.

E. Hand hygiene before and after E. Use appropriate protective

procedure. equipment and engineering controls if
it is reasonably anticipated exposure
to blood or other potentially infectious
material may result.

F. Collect specimens and label with G. Each specimen must be labeled

individual's name, CSH number, test separately. Use two (2) forms of
required, physician's name, and any identifying each individual before
other pertinent information. collecting specimen(s).

H. When collecting urine specimens, H. All surfaces shall be

be sure the cap fits the container decontaminated after completion of
snugly to reduce spillage. procedure if contamination occurs.
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I. Place all specimens in leak-proof
plastic bag provided by the
contractor's specimen collection
station at Coalinga.
J. Any specimens obtained after
early morning pick-up, must be
delivered to the specimen
collection site by the unit staff.
K. Document in chart and on the
MAR.
5. AFTER HOURS PROCEDURE:
NURSING ACTION
A. Contact NOD/ACNS when
Physician's Order is written.
B. Addressograph appropriate lab slip
and fill out completely.
C. Collect specimen in usual manner
and deliver to Central Sally Port for
pick-up by contracting laboratory.
D. Document in chart.
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I. Place specimen in lab specimen
Refrigerator in the program for early
morning pick-up.
J. If there is any delay in delivery of
the specimen, place in specimen
refrigerator. DO NOT LEAVE ON
COUNTER.
K. Type of specimen, time, date, and
name of person, obtaining
specimen and test requested.
KEY POINTS
A. NOD/ACNS will expedite delivery
to contracting laboratory.
B. Mark STAT or CALL BACK on lab
slip. The lab slip is to accompany
the specimen.
C. Place specimen(s) in refrigerator,
sign “log sheet”, and call ACNS
Office at ext.
D. Type of specimen, time, date, and
name of person obtaining specimen
and test requested.