What information must be documented on the requisition and label to ensure traceability?

What information must be documented on the requisition and label to ensure traceability?

• A. Patient identifiers (name, DOB/MRN), date/time of collection, test(s) ordered, specimen type, and collector initials.
• B. Patient diagnoses, physician license number, lab room number, specimen color.
• C. Date of birth only, test cost, handling instructions, device serial.
• D. Allergies, caregiver, sample color, collection method.

Answer: (A)

Traceability in the lab hinges on linking the specimen to the right patient, the correct tests, and the exact collection event. The information you document on the requisition and the label must include patient identifiers (name with date of birth or MRN), the date and time of collection, the tests ordered, the specimen type, and the collector’s initials. These elements together ensure you can accurately match the specimen to the patient, know which assays to perform, verify that the sample type is appropriate for those tests, and identify who collected the specimen if any questions arise later. Other details like diagnoses, license numbers, lab room numbers, or arbitrary data such as specimen color or device serials don’t establish this linkage. They may be useful in other contexts, but they don’t provide the necessary accountability and traceability between patient, sample, and test workflow.

Traceability in the lab hinges on linking the specimen to the right patient, the correct tests, and the exact collection event. The information you document on the requisition and the label must include patient identifiers (name with date of birth or MRN), the date and time of collection, the tests ordered, the specimen type, and the collector’s initials. These elements together ensure you can accurately match the specimen to the patient, know which assays to perform, verify that the sample type is appropriate for those tests, and identify who collected the specimen if any questions arise later.

Other details like diagnoses, license numbers, lab room numbers, or arbitrary data such as specimen color or device serials don’t establish this linkage. They may be useful in other contexts, but they don’t provide the necessary accountability and traceability between patient, sample, and test workflow.