Specimen Collection & Phlebotomy
Accurate laboratory results begin with proper specimen collection. Correct patient identification, collection technique, specimen labeling, and handling are essential to maintaining specimen integrity and ensuring reliable diagnostic testing.
Purpose
This SOP establishes standardized procedures for collecting, labeling, handling, and preparing patient specimens for laboratory testing while ensuring patient safety, specimen integrity, and regulatory compliance.
Only trained and competency-validated personnel should collect laboratory specimens. Every specimen must be accurately identified, handled appropriately, and transported according to laboratory requirements.
Responsibilities
Medical Assistants
Verify patient identity, collect specimens safely, label specimens immediately, prepare laboratory paperwork, and ensure proper transport.
Providers
Order appropriate laboratory testing, interpret results, and communicate the plan of care with the patient.
Leadership
Maintain competency validation, monitor quality standards, and ensure required supplies remain available.
All Clinical Staff
Support infection prevention practices and protect specimen integrity throughout the collection process.
Standard Specimen Collection Workflow
Verify the Laboratory Order
Confirm the provider's laboratory order and review any patient preparation requirements before specimen collection.
Identify the Patient
Verify the patient's identity using two approved identifiers before collecting any specimen.
Prepare Supplies
Gather the required collection supplies, specimen containers, laboratory tubes, labels, PPE, and requisitions before beginning the procedure.
Perform Hand Hygiene & Don PPE
Complete hand hygiene and apply appropriate personal protective equipment before initiating specimen collection.
Collect the Specimen
Collect blood or other laboratory specimens using approved techniques while maintaining patient comfort, safety, and specimen quality.
Label the Specimen Immediately
Label every specimen in the presence of the patient immediately after collection using clinic and laboratory identification requirements.
Specimen Handling & Transport
Proper specimen handling preserves specimen integrity and helps ensure accurate, timely laboratory results. Follow laboratory-specific collection and transport requirements for every specimen.
Immediately after labeling, inspect each specimen for accuracy, verify the appropriate collection container, and prepare the specimen for transport according to laboratory guidelines.
• Patient identifiers are correct.
• Collection date and time are documented when required.
• Correct collection tube or container was used.
• Specimen volume is adequate.
• Laboratory requisition is complete.
• Transport requirements have been met.
Collection Considerations
Patient Preparation
Verify any required fasting, medication restrictions, or special preparation before specimen collection.
Order of Draw
When collecting multiple blood specimens, follow the laboratory's approved order of draw to minimize cross-contamination between collection tubes.
Specimen Quality
Inspect specimens for clotting, hemolysis, contamination, or insufficient volume before transport.
Special Handling
Certain specimens require refrigeration, protection from light, or expedited transport. Follow laboratory instructions for each ordered test.
Difficult Collections & Patient Reactions
Patient Discomfort
Pause when necessary, reassure the patient, and communicate clearly throughout the collection process.
Vasovagal Response
If the patient becomes pale, dizzy, or feels faint, discontinue the collection, ensure patient safety, notify the provider, and monitor the patient until fully recovered.
Unsuccessful Collection
Follow clinic policy regarding repeat attempts and request assistance from another qualified team member when appropriate.
Specimen Rejection
If a specimen is rejected by the laboratory due to labeling or quality issues, notify the provider when appropriate, document the issue, and recollect the specimen following clinic policy.
RXNT Documentation
Laboratory Order
Verify the provider order before documenting specimen collection.
Collection Documentation
Document the date, time, specimen type, collection status, and any collection issues within RXNT.
Patient Tolerance
Document significant patient reactions, unsuccessful attempts, or other notable events during specimen collection.
Transport Status
Verify the specimen has been prepared for transport according to laboratory requirements.
Biohazard Safety
Treat every specimen as potentially infectious and follow Standard Precautions throughout the collection and transport process.
Sharps Disposal
Dispose of needles and lancets immediately into approved sharps containers without recapping.
Biohazard Waste
Discard contaminated collection materials into designated biohazard containers.
Hand Hygiene
Perform hand hygiene immediately after glove removal and specimen handling.
Do & Don't
✔ Always
• Verify two patient identifiers.
• Label specimens immediately.
• Follow laboratory collection requirements.
• Maintain specimen integrity.
• Document collection promptly.
• Dispose of sharps safely.
✖ Never
• Label specimens away from the patient.
• Use damaged or expired collection supplies.
• Ignore patient symptoms during collection.
• Send unlabeled specimens to the laboratory.
• Leave used sharps unattended.
Employee Competency
- Verifies patient identity before specimen collection.
- Collects specimens using approved techniques.
- Maintains specimen integrity throughout the collection process.
- Labels specimens accurately and immediately.
- Recognizes patient reactions and responds appropriately.
- Prepares specimens for laboratory transport.
- Documents collection accurately in RXNT.
- Maintains OSHA, CLIA, and infection prevention standards.