c3-REVIEW OF REQUISITION, IDENTIFICATION, AND CONSENT.docx

CHAPTER 3 ========= Patient Preparation =================== OVERVIEW -------- Before beginning the blood collection procedure, you must review the laboratory requisition form. This is a form the provider generates to request specific laboratory tests. Reviewing this form helps you determine whet...

CHAPTER 3 ========= Patient Preparation =================== OVERVIEW -------- Before beginning the blood collection procedure, you must review the laboratory requisition form. This is a form the provider generates to request specific laboratory tests. Reviewing this form helps you determine whether the documentation is complete, and assists in prioritizing specimen collection based on the ordered tests. Patient identification and explanation of the procedure are essential before performing any medical procedure. Failing to properly identify a patient can lead to a misdiagnosis or incorrect treatment plan, as providers often base treatments on the results of laboratory tests. Misidentification can also result in unnecessary delays in treatment and additional venipunctures. You must be able to evaluate the patient\'s ability to understand the procedure being performed. In addition, you must review potential complications using terminology the patient easily comprehends. It is essential to obtain the patient\'s consent before beginning any procedure and confirm adherence to any instructions about preparing for the blood collection, such as fasting. Phlebotomists are responsible for determining the appropriate site for collection based on factors such as overall condition and age. This process is necessary to minimize risks and offer the best chance for successful blood collection. You will also need to position the patient in a way that facilitates a successful venipuncture and maximizes patient safety. It is important to know the essentials of preparing a patient for a blood collection. The order of these steps can vary or even occur simultaneously. For example, you might confirm patient identity while also positioning the patient for the procedure. The goal is to find your own professional approach to the process as you gain experience, while also making sure to include every step, every time, for optimal patient preparation. Objectives ---------- Upon completion of this chapter, you should be able to: - Review the requisition form for testing requirements and patient identity. - Conduct an appropriate introduction to the patient. - Accurately identify the patient. - Obtain implied, informed, or expressed consent from the patient. - Verify the patient\'s adherence to testing requirements. - Identify any specific considerations that could affect specimen collection. - Explain the phlebotomy procedure to the patient. - Position the patient to maximize comfort and safety and optimize specimen collection. - Identify an acceptable site for sample requirements that minimizes risk. - Instruct patients about collecting nonblood specimens. REVIEW OF REQUISITION, IDENTIFICATION, AND CONSENT ================================================== Requisition review ------------------ Physicians, physician assistants, and nurse practitioners are responsible for ordering laboratory tests. Chiropractors can also request laboratory orders in some states. Do not accept orders from any other health care professional without first determining if they are authorized to order testing. The laboratory order (requisition) form lists the specific tests the provider wants completed, along with the provider\'s information. It should also include the following information: - Patient\'s full name - Patient\'s date of birth - Patient\'s sex - Specific identification numbers (can include a medical record number) Social Security numbers can appear on a registration form, but due to concerns about identity theft, this practice is not as common as it used to be. The requisition form can include specific precautions or concerns (latex allergy, tendency to faint, excessive bleeding, sites to avoid). In addition, the form will have a space to document the date and time of the collection, billing information, and diagnostic coding. Examine the requisition form to verify the tests ordered comply with appropriate testing times. Review the requisition for discrepancies, which can include duplicate test orders or missing information. Note any specific preparations or restrictions to address prior to the collection (fasting, basal state). It is also important to determine the priority of the blood collection. The terms stat, medical emergency, and as soon as possible (ASAP) indicate that the provider needs the test completed and the results relayed immediately. A routine blood collection is essential for determining a diagnosis or a baseline value, but it does not indicate urgency. If any information is missing, contact the provider for clarification before performing the blood collection. You need to understand which tubes the blood will be collected in and then determine the correct order of draw. Not doing this could lead to preanalytical errors, skewed test results, and unnecessary venipunctures. If you are unfamiliar with any of the tests ordered, consult the facility\'s laboratory manual or ask another laboratory technician or supervisor. Specimen labels are typically printed at the laboratory reception area and should accompany the requisition form. These electronically generated labels contain the patient\'s identifying information to place on the blood samples. Peel the labels off the paper to expose the adhesive side that attaches to the blood collection tubes. Depending on the facility, some labels have bar codes. If no labels are available, write the date and time of the collection, your initials, and the patient\'s full name, date of birth, and other specific identifiers. This is important to do immediately after collection, before the patient leaves the collection area or before you leave the patient\'s bedside. With the implementation of electronic records, it is uncommon to have paper-based requisitions. However, some facilities still use them, so you should understand the requirements of a paper requisition. These forms usually have multiple parts or copies and require handwritten documentation. They usually have perforations for easy detachment of parts or copies. There might also be a handwritten blood collection log on which you must record the blood collection. Even facilities that generate requisition forms electronically might have these paper forms as a backup in case of computer failure or power outages, or as a temporary requisition in an emergency prior to electronic data entry. You must be familiar with these forms and know where to store or send the various copies. Patient identification ---------------------- The phlebotomist is often the first clinical person a patient interacts with at a health care facility. Always treat patients as unique individuals, displaying a caring and compassionate demeanor. Although many patients are having routine blood testing, others are preparing for surgery or coping with a life-altering diagnosis. Treat all patients with respect, individual attention, and professionalism. Use therapeutic communication techniques to convey caring and understanding, as well as reduce patients\' stress. Before beginning a blood collection, greet the patient warmly. Tell the patient your name, that you are a phlebotomist in the laboratory department, and that you are going to collect a blood sample. Make sure your professional identification badge is always visible. Phlebotomy students should let the patient know that they are students. Follow this process with every encounter. Never assume that a patient remembers a phlebotomist. In inpatient settings, knock discreetly on the patient\'s door or door frame. If the door is open, enter quietly and greet the patient prior to the procedure. Use sensitivity and consideration when adjusting room lights and speaking to patients who have been sleeping. Keep in mind that hospitalized patients are especially vulnerable, as they are often dealing with major health issues. The Joint Commission (an agency that accredits health care facilities) mandates using two identifiers to verify each patient\'s identity before performing any procedure. This is crucial for making sure that you collect blood from the right patient for the right tests. Ask the patient to state at least two of the following acceptable identifiers: the patient\'s full name, date of birth, home address, telephone number, or Social Security number (if the medical facility policy requires it on the requisition form). Compare what the patient says to the information on the requisition form. The patient can also produce a photo identification card (driver\'s license, passport, student badge, employment card or badge), and you can compare it with the corresponding information on the form. Refer to the study guide addendum on the NHA website for details on CLSI guidelines for patient identification specific to specimen collection. It is also important to adhere to the guidelines of the Health Insurance Portability and Accountability Act (HIPAA), which mandates maintaining the patient\'s privacy and confidentiality. Mandatory compliance with HIPAA\'s Privacy Rule ensures that patient information is confidential. It also gives patients control over their personal information and who has access to it. HIPAA originally required written consent for disclosure of all patient information, but because this sometimes delayed care, the act\'s revision requires that health care professionals notify patients of their privacy policy and make a reasonable effort to obtain written acknowledgment of this notification. Because of HIPAA\'s Privacy Rule, you should use judgment and discretion in preventing anyone who is not involved in the patient\'s care from overhearing any of the patient\'s protected health information (PHI). For example, when calling a patient in the waiting room into the blood collection area, you should call only the patient\'s name. Do not mention any clinical information that others could overhear, such as, \'\'Lester Moore for a hepatitis B test.\" In inpatient settings, you can compare the information the patient says with the hospital wristband and cross-check it with the requisition form. Barcode scanners can also confirm a match from the patient\'s wristband to the requisition form or labels. It is also essential to compare facility identification numbers, because it is possible to have two patients who have similar names. Do not use the patient\'s room and bed number as an identifier. Whenever possible, ask patients to state their personal information. If you state the information and ask for confirmation, a patient might nod in agreement but have been distracted or not fully processed the information. Some patients cannot state their name and identifying information because of diminished consciousness, cognitive deficits, sedating medications, psychological conditions, or inability to speak (due to a stroke or mechanical ventilation, for example). In situations such as these, you can confirm identity by viewing the patient\'s wristband and asking a family member, acquaintance, or hospital staff member who knows the patient to confirm their identity. If there are language barriers, use a medical interpreter. If you are unsure about how to identify patients-including children, who are not legally able to identify themselves-follow the facility\'s protocol. Next are the preliminary steps of blood collection. Issues that would stop this process include inability to identify the patient, discrepancies on the requisition form or patient wristband, or information that the patient shares verbally. Report discrepancies immediately to the supervisor. In inpatient settings, surgery centers, and rehabilitation facilities, if the patient is not wearing an identification band, do not conduct the procedure until the band is on the patient. Obtaining consent ----------------- Before collecting blood from a patient, it is essential to obtain consent. Without it, deliberately touching the patient might constitute battery, which is a criminal offense. Types of consent include the following: - **Informed consent:** The patient has received full information about the procedure in a language with understandable terminology. An informed consent form is often required for high risk, invasive, and surgical procedures. - **Expressed consent:** The patient gives explicit consent to a procedure orally or in writing on a consent form. - **Implied consent:** The patient\'s actions indicate that they are giving consent for the procedure. This is the most common form of consent for phlebotomy. For example, a patient extends an arm to a phlebotomist for venipuncture. This form of consent is adequate for low-risk procedures (measuring vital signs, collecting blood). It can also be necessary in emergency medical situations, with the understanding that the patient would receive full information and sign an informed consent document if time and their condition allowed them to do so. - **Consent for minors:** In most cases, the child\'s parent or guardian must give consent for phlebotomy procedures. There are some exceptions for teenagers, such as those who are married, in the military, emancipated by a court order, or otherwise self-supporting and independent. Any patient may refuse to give consent for any reason. Whether for personal choice, cultural, religious, or other reasons, the patient has the right to refuse blood collection and does not have to offer an explanation. When a patient refuses, you usually must obtain written proof of this refusal to protect both yourself and the patient. Inform the provider of the refusal. Sometimes refusal comes from a patient not understanding what is being done and why. This can require more investigation to solve.