Clinical SOP • Laboratory Operations
Laboratory Handling
Collect, identify, label, process, store, and transport patient specimens safely and accurately while preserving specimen integrity and protecting patients and employees from preventable exposure.
Purpose
Accurate laboratory results begin with correct patient identification, specimen collection, labeling, handling, storage, and transportation.
Employees must follow the requirements for the specific test, specimen, collection device, laboratory, and courier. When instructions conflict or are unclear, stop and contact the receiving laboratory before collecting or processing the specimen.
Before Specimen Collection
Confirm the Order
Verify the requested test, ordering provider, diagnosis information, specimen type, laboratory destination, and any special instructions.
Identify the Patient
Ask the patient to state their full name and date of birth and compare both identifiers with the order and RXNT record.
Review Patient Preparation
Confirm fasting, medication, timing, dietary, hygiene, or other preparation requirements when applicable.
Gather Correct Supplies
Select the correct collection device, tube, swab, container, preservative, labels, requisition, transport bag, and PPE.
Inspect Supplies
Confirm containers are intact, clean, appropriate, and not expired. Do not use damaged or contaminated supplies.
Explain the Procedure
Tell the patient what will be collected, how it will be collected, and what they need to do during or after the procedure.
Standard Specimen Handling Procedure
Review the Laboratory Instructions
Confirm the correct specimen type, container, collection method, volume, timing, processing, storage, and transport requirements.
Perform Hand Hygiene and Apply PPE
Clean hands and select PPE based on the anticipated exposure to blood, body fluids, respiratory secretions, chemicals, or contaminated materials.
Verify the Patient
Use two patient identifiers immediately before collection. Never rely only on the patient’s location, room number, or appearance.
Collect the Specimen
Follow the approved collection technique and obtain the required amount without contaminating the specimen, container, or surrounding area.
Secure the Container
Close the container completely and confirm it will remain leak-resistant during handling, storage, and transport.
Label in the Patient’s Presence
Label the specimen immediately after collection while remaining with the patient. Match the label with the patient and order before moving to another task.
Confirm Label Information
Verify all required information, including patient identifiers, collection date, collection time, specimen source when applicable, and collector identification when required.
Process the Specimen
Mix, allow to clot, centrifuge, separate, preserve, refrigerate, freeze, or maintain at room temperature only as directed by the receiving laboratory.
Place in a Transport Bag
Place the closed specimen container in the designated leak-resistant biohazard transport bag. Keep paperwork in the separate outer document pouch.
Document Collection
Record the collection in RXNT and complete the laboratory order, requisition, tracking process, or electronic interface as required.
Store Correctly
Place the specimen in the designated storage area at the required temperature and protect it from unauthorized access, contamination, and delay.
Prepare for Transport
Confirm the specimen, order, destination, packaging, pickup time, and any special transport requirements before releasing it.
Clean the Work Area
Dispose of waste correctly, disinfect applicable surfaces and equipment, remove PPE safely, and perform hand hygiene.
Specimen Labeling Standard
Every specimen must be labeled immediately after collection while the collector remains with the patient. The label must match the patient, order, specimen, and receiving laboratory requirements.
Common Specimen Types
Blood
Use the correct collection tubes, order of draw, fill volume, mixing, clotting time, processing method, and storage conditions for the tests ordered.
Urine
Provide the correct container and collection instructions. Confirm whether the order requires clean-catch, random, timed, culture, or another collection method.
Swabs
Use the correct swab and transport medium. Collect from the required anatomical source without touching unintended surfaces.
Stool
Provide the required container and instructions. Prevent contamination with urine, toilet water, tissue, or cleaning products.
Wound or Drainage
Confirm the collection method, specimen source, transport medium, and whether cleaning or preparation is required before collection.
Other Specimens
Follow the receiving laboratory’s instructions for tissue, body fluid, pathology, cytology, molecular testing, cultures, or specialty kits.
Storage and Temperature Control
Room Temperature
Keep only specimens approved for room-temperature storage in the designated secure area and transport them within the required timeframe.
Refrigerated
Place specimens requiring refrigeration in the designated specimen refrigerator. Do not store patient food, staff food, or medication in the same area unless specifically authorized and separated.
Frozen
Freeze specimens only when specifically required. Follow instructions for preparation, temperature, packaging, and avoidance of repeated freeze-thaw cycles.
Protected From Light
Use the required protective wrapping or container for light-sensitive specimens.
Timed Specimens
Record the exact collection time and ensure processing and courier transfer occur within the required timeframe.
Temperature Monitoring
Maintain and review temperature records for specimen storage equipment according to clinic requirements.
Transport and Courier Handoff
Confirm the Destination
Verify which laboratory will perform the test and confirm the specimen is packaged for the correct courier or pickup process.
Inspect the Specimen
Confirm the container is closed, labeled, intact, and free of external contamination or leakage.
Match the Order and Specimen
Confirm patient identifiers, requested tests, specimen type, specimen source, and laboratory destination.
Package Correctly
Use the required leak-resistant transport packaging and separate paperwork from the specimen container.
Maintain Required Conditions
Maintain required temperature, light protection, upright positioning, and transport timeframe.
Document the Handoff
Complete the clinic’s specimen tracking, pickup log, courier manifest, electronic process, or other required documentation.
Potential Specimen Rejection Issues
Missing or Incorrect Label
The specimen is unlabeled, mislabeled, incompletely labeled, or does not match the laboratory order.
Wrong Container
The collection tube, preservative, swab, transport medium, or container is not acceptable for the ordered test.
Insufficient Quantity
The amount collected is below the minimum required for testing or the tube was not filled correctly.
Leaking or Damaged Container
The container is open, cracked, leaking, externally contaminated, or otherwise unsafe to process.
Improper Storage or Delay
The specimen was stored at the wrong temperature, transported late, exposed to light, or processed outside the allowed timeframe.
Compromised Specimen
The specimen is clotted, hemolyzed, contaminated, improperly mixed, or otherwise unsuitable for the requested test.
Spills, Leaks, and Exposure
Restrict access to the affected area, obtain the appropriate spill supplies and PPE, and follow the clinic’s blood and body-fluid spill procedure. Report occupational exposure immediately.
Do and Do Not
Always Do
- Verify the order before collecting.
- Use two patient identifiers.
- Follow test-specific collection instructions.
- Use the correct container and supplies.
- Label the specimen in the patient’s presence.
- Secure specimens in leak-resistant packaging.
- Maintain required temperature and timing.
- Document collection and courier handoff.
- Perform hand hygiene before and after handling.
- Report spills and exposures immediately.
Never Do
- Pre-label an empty specimen container.
- Leave a collected specimen unlabeled.
- Guess which tube or transport medium to use.
- Place paperwork inside the specimen compartment.
- Transport a leaking or unsecured specimen.
- Store specimens with food or personal items.
- Change collection times or patient information.
- Relabel a questionable specimen independently.
- Ignore an expired or damaged collection device.
- Delay reporting an occupational exposure.
RXNT Documentation
Detailed screenshots belong in the RXNT Center. Use the following documentation standard for laboratory workflows.
Confirm the Correct Patient
Review the patient name, date of birth, provider, location, and encounter before documenting collection.
Review the Laboratory Order
Confirm the tests, diagnosis information, laboratory destination, and any collection instructions.
Document Collection
Enter the collection date, time, specimen type, source, collector, and other required information.
Record Collection Issues
Document patient refusal, unsuccessful collection, insufficient specimen, delay, contamination, recollection, or other relevant issue.
Track Laboratory Status
Confirm the order was transmitted, printed, collected, sent, or otherwise moved to the correct workflow status.
Route Results Correctly
Ensure incoming results are associated with the correct patient and routed to the ordering provider according to clinic workflow.
Quality-Control Expectations
Staff must maintain organized laboratory supplies and monitor collection devices, transport materials, storage areas, expiration dates, and required logs according to assigned responsibilities.
Employee Competency
The employee should demonstrate each skill during onboarding or competency validation.