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76. [LO 6.4] What type of blood cells have
hemoglobin?
a. Erythrocytes
b. Leukocytes
c. Thrombocytes
d. All of these
7 7. [LO 6.4] Mononuclear leukocytes include all of
these except
a. B lymphocytes (B-cells).
b. monocytes.
c. neutrophils.
d. T lymphocytes (T-cells).
78. [LO 6.4] Various types of granulocytes exhibit
these colors when stained except
a. blue-black.
b. red-orange.
c. tan-pink.
d. yellow-green.
79. [LO 6.4] A person develops an allergy. What
type of blood cells may be elevated when he is
exposed to the cause of his allergy?
a. Basophils
b. Eosinophils
c. Macrophages
d. Plasma cells
80. [LO 6.4] While on vacation, a person acquires
a parasitic infection. What blood cells may be
elevated as a result of this infection?
a. Basophils
b. Eosinophils
c. Monocytes
d. Neutrophils
81. [LO 6.4] A function of T lymphocytes (T-cells) is
to
a. fight bacterial infections.
b. mediate cellular interactions.
c. phagocytize microorganisms.
d. produce antibodies.
82. [LO 6.4] Serum differs from plasma mainly
because it contains no
a. electrolytes.
b. fibrinogen.
c. nutrients.
d. water.
83. [LO 6.6] A woman who is pregnant is concerned
that her blood type may not match that of her
baby’s and might harm either her or her baby.
Which red blood cell antigen should be of most
concern to her and her physician?
a. A
b. B
c. O
d. Rh
84. [LO 6.5] When platelets clump together to form
a platelet plug, this is known as
a. thrombinolysis.
b. fibrinolysis.
c. hemolysis.
d. hemostasis.
Enhance your learning by completing these exercises and more at
connect.mheducation.com.
References
Harmening, D. (2009). Clinical hematology and fundamentals of hemostasis. Philadelphia, PA: F. A. Davis.
Hoffman, R., Benz, E. J., Shattil, S. J., Cohen, J., & Silberstein, L. E. (1995). Hematology: Basic principles and practice (2nd ed.).
New York, NY: Churchill Livingstone.
Kaushansky, K., Lichtman, M., Beutler, E., Kipps, T., Prchal, J., & Seligsohn, U. (Eds.). (2010). Williams hematology (8th ed.).
New York, NY: McGraw-Hill.
National Accrediting Agency for Clinical Laboratory Sciences. (2012). NAACLS entry-level phlebotomist competencies. Rosemont, IL: Author.
Owen, R. (2000). Karl Landsteiner and the first human marker locus. Genetics, 155, 995–998. Retrieved May 31, 2011, from
www.genetics.org/content/155/3/995.full
Shier, D., Butler, J., & Lewis, R. (2010). Hole’s human anatomy and physiology (12th ed.). New York, NY: McGraw-Hill.
Wilson, D. (2008). McGraw-Hill manual of laboratory and diagnostic tests. New York, NY: McGraw-Hill.
Design Elements: Law & Ethics icon (marble columns) ©Nice_Media/Shutterstock.com RF; Life Span Considerations icon (baby holding hand) ©Lerche&Johnson/Shutterstock.com RF; Communicate & Connect icon (patient and doctor) ©Rocketclips, Inc./Shutterstock.com RF; Safety & Infection Control icon (samples in hand) ©motorolka/
Shutterstock.com RF.
Chapter The Cardiovascular System
Copyright © 2019 by McGraw-Hill Education
Patient and Specimen
7
accession number
ambulatory
analyte
ASAP
assault
basal state
battery
bedside manner
code of ethics
confidentiality
diurnal variation
essentialterms
electronic health record
(EHR)
electronic medical record
(EMR)
ethics
fasting
Health Insurance
Portability and
Accountability Act
(HIPAA)
Requirements
hemoconcentration
hemodilution
informed consent
interfering
substances
law
lipemic
peak level
postprandial
rapport
respondeat
superior
sedentary
STAT (ST)
therapeutic
drug
monitoring
(TDM)
trough level
Learning Outcomes
. Identify the parts and functions of a
laboratory requisition.
. Identify the professional communication
techniques of the phlebotomist.
. Comply with ethical and legal standards for
professional communication.
. Carry out proper patient
identification.
. Define the legal/ethical importance of
specimen identification.
. Recognize patient factors that may affect
specimen quality and test results.
. Explain the phlebotomist’s role in
maintaining accurate and secure blood
collection documentation.
©McGraw-Hill Education/Take One Digital Media, photographer
Related NAACLS Competencies
. Demonstrate understanding of the
importance of specimen collection and specimen
integrity in the delivery of patient care.
. Describe the legal and ethical importance of
proper patient/sample identification.
. Define the phlebotomist’s role in collecting
and/or transporting these specimens to the
laboratory.
. List the general criteria for suitability of a
specimen for analysis, and reasons for specimen
rejection or re-collection.
. Explain the importance of timed, fasting, and
STAT specimens, as related to specimen integrity
and patient care.
. Demonstrate understanding of requisitioning,
specimen transport, and specimen processing.
. Describe the process by which a request for a
laboratory test is generated.
. Communicate (verbally and nonverbally)
effectively and appropriately in the workplace.
. Maintain confidentiality of privileged
information on individuals, according to federal
regulations (e.g., HIPAA).
. Interact appropriately and professionally.
. Demonstrate an understanding of the major
points of the American Hospital Association’s
Patient’s Bill of Rights and the Patient’s Bill of
Rights from the workplace.
Introduction
This chapter explains how orders for laboratory tests are generated, the skills
needed for professional communication with the patient, and the identification required for both the patient and the specimen. The chapter also offers
insights into the effect of certain patient situations on the laboratory results
and describes how specimen collection is documented and tracked in the electronic health record.
. Comply with the American Hospital
Association’s Patient’s Bill of Rights and the
Patient’s Bill of Rights from the workplace. (Patient
Care Partnership)
. Define and use medicolegal terms and
discuss policies and protocol designed to avoid
medicolegal problems.
. Demonstrate ability to use computer
information systems necessary to accomplish job
functions. (Patient Care Partnership)
.
The phlebotomy procedure begins when a physician or other qualified
healthcare practitioner orders blood tests to be performed. The order may
be entered on an inpatient’s chart, electronic medical record (EMR), or
electronic health record (EHR), which may interact with facility-wide
computer systems (see Figure 7-1). Many inpatient facilities require that
the healthcare practitioner enter laboratory test requests directly into the
hospital information system (HIS) or laboratory information system (LIS).
In most facilities, this is called computerized physician order entry, or
CPOE.
If the patient is an outpatient, the order for laboratory tests may be written
as a prescription requested on an official requisition form (see Figure 7-2),
telephoned to the laboratory by the physician or office staff, or faxed to the
Figure - Patient information may be
maintained in a hard copy file or entered
into a computer system, or both.
©Arthur Tilley/Getty Images RF
Laboratory Requisitions
laboratory from the physician office. In addition, some laboratories have provided physician offices with access to the LIS for the
purpose of ordering tests and accessing results. In this case, the
physician offices are called clients.
In many healthcare facilities, when a laboratory test is ordered
it is entered into a computer at the patient care station (part of
the HIS). The computer in the laboratory (part of the LIS) receives
the order and provides an accession number (a number assigned
sequentially in the order received). This accession number is usually a Julian date (the day of the year) followed by the test number.
The LIS then prints the requisition, in the form of labels, for the
phlebotomist to use. Figure 7-3 shows the Julian date as the fourth
day of the year (004) in the year 2011 (11-). The Julian date is followed by the number 002085, which indicates that this test is the
2,085th test ordered on that day.
Copyright © 2019 by McGraw-Hill Education
Chapter Patient and Specimen Requirements
Figure - Physician office staff may use a laboratory requisition form to order tests for their patients. All required patient
and specimen information must be included as well as billing information.
Copyright © 2019 by McGraw-Hill Education
Chapter Patient and Specimen Requirements
A
B
C
D
E
G
H
M
I
J
K
F
Figure - A laboratory test requisition may
take the form of a computer-generated label and
must contain the following: (A) patient’s name,
(B) patient’s medical record number, (C) patient’s
location, (D) bar code, (E) laboratory accession
number, (F) requesting physician, (G) blood
volume and tube type, (H) test status, (I) test to
be performed, (J) patient’s age and gender, (K)
patient’s date of birth, (L) date and time the test
is to be performed, and (M) laboratory section to
which the specimen should be delivered.
©Lillian Mundt
L
specimen or before drawing blood from a patient. All requisitions must contain certain basic information to ensure that the specimen drawn and the
reported test results are for the correct patient. Every requisition should contain the following information:
●
Patient’s name
●
Patient’s date of birth
●
Patient’s medical record number
●
Patient’s location (if inpatient)
●
Ordering physician’s name
●
Type of test to be performed
●
Test status (timed, fasting, STAT, ASAP)
●
Date and time the test is to be performed
Some laboratories require separate requisitions for each
department. These requisitions may be color-coded or
numbered to identify the laboratory to which the specimen
will be transported for analysis. The phlebotomist must be
able to read and interpret requisition labels quickly and
accurately.
Physician orders for laboratory tests will indicate the
type of specimen and the time or priority of collection.
Some specimens are ordered as STAT (ST), which means
they must be collected and transported immediately. Specimens may also be referred to as ASAP (as soon as possible)
or routine (RT), with collection times determined by the
facility. Some laboratory tests require specific times for collection; these are referred to as timed tests, which will be
discussed later in this chapter.
The phlebotomist is responsible for examining all requisitions carefully before leaving the laboratory to collect the
In special testing conditions, additional information should be included. Special testing conditions include fasting (no food or liquids except water) prior to
the draw and situations in which blood must be drawn at an exact time. These
requirements are also included on the requisition form.
Other information may also appear on computer-generated requisitions
because they are often used as specimen labels (see Figure 7-3). Additional
information may include the following:
●
Computerized bar code
●
Laboratory accession number
●
Type of anticoagulant tube required
●
Volume required
●
Laboratory section performing the test
The requirements for specimen labeling are discussed later in this chapter.
Chapter Patient and Specimen Requirements
Checkpoint
Questions .
1. What information must requisitions for laboratory tests include?
2. Define the following: EHR, CPOE, and LIS.
Copyright © 2019 by McGraw-Hill Education
.
Professional Communication
The phlebotomist must exhibit a certain level of confidence when working
with patients. Just knowing how to perform the proper technique may not be
sufficient. The patient may be anxious, combative, or have veins that are difficult to access. In such instances, self-confidence combined with experience
in dealing with all kinds of patients provides the mind-set required to successfully obtain the specimen on even the most difficult draws.
Greeting the Patient
The phlebotomist sets the tone for the venipuncture procedure when greeting the patient. Always smile and address the patient in a calm, pleasant tone
of voice to gain the patient’s confidence and trust. Behave as a professional.
Show courtesy and respect for the patient. This is called bedside manner
or rapport. Be aware of cultural differences that might make communication awkward. For example, direct eye contact may be considered disrespectful by individuals of certain cultures or backgrounds. Cultural diversity and
professionalism are discussed further in the chapter Practicing Professional
Behavior.
A pleasant and confident manner will help put the patient at ease and
may help divert the patient’s attention from the phlebotomy procedure.
When greeting a patient, you should always identify yourself. In most cases,
it is appropriate to state your first name only. A patient may become upset
about treatment or become affectionate toward you and attempt to contact
you outside the facility. For these reasons, many facilities recommend that
phlebotomists simply identify themselves as from the lab. Check the policy
of the facility where you are employed. In any case, after identifying yourself,
be certain to state why you are there and what you will be doing. Remember,
phlebotomists represent the laboratory profession.
Greeting the patient properly is
important for both inpatients and outpatients. Outpatient situations occur
in hospitals and clinics, patients’
homes, long-term healthcare facilities, and physician offices, among
others. In an outpatient situation,
the first few seconds are even more
critical than with an inpatient. If a
patient is in a hospital, it is not a surprise for a phlebotomist to arrive to
collect a specimen. When a patient is
not in a traditional hospital or clinic
setting, a person arriving to collect a
blood sample may not be expected.
Your arrival may cause the patient
to become anxious, so conducting
yourself in a professional manner is
essential in an outpatient setting.
Inpatients present different circumstances (see Figure 7-4). The
doors to most patients’ rooms are
Copyright © 2019 by McGraw-Hill Education
usually open. Whether a patient’s
Figure - Greeting the patient in a pro-
fessional manner instills confidence in the
patient concerning phlebotomy skills.
©Plush Studios/Blend Images LLC RF
Chapter Patient and Specimen Requirements
door is closed or open, knock and wait for a response before entering.
Some patients cannot respond, especially if they are asleep, have been
sedated, or have a medical appliance covering or inserted into their mouth.
After waiting for a few seconds, open the door slowly and greet the patient
before proceeding into the room. Even if the door is slightly ajar or open, it
is still a good idea to knock lightly to make the patient aware that you are
about to enter.
Life Span
Considerations
Special Considerations for Children
In the healthcare field, discretion and common sense must be used at all
times, but especially when dealing with children. The phlebotomy procedure
usually frightens children. Never lie to patients (children or adults) by telling
them, “This will not hurt.” Even the most smoothly performed phlebotomy procedure will cause momentary discomfort. For children, it is best to keep them talking to distract them and then quickly proceed with the procedure. If they ask if it
will hurt tell them the truth saying something like, "You will feel a little quick sting."
Usually, a parent is present and can assist with the phlebotomy procedure and
reassure the child. However, in some cases the parent will be anxious and may
need to be comforted as well.
Because an adult usually accompanies the child in an outpatient setting, phlebotomists may approach identifying the child as they would an adult. If the child
is too young or unable to respond to questions, ask the adult to verify the child’s
identity.For most purposes, the consent of a parent is enough informed consent
to proceed with the procedure.
Sometimes the curtain is pulled around the patient’s bed. Treat this situation in a similar manner. Talk to the patient through the curtain before pulling
it back and entering. Taking this small extra step before entering the patient’s
room can save you and the patient embarrassment in the event the patient is
undergoing a procedure or is using a bedpan or urinal. Following these steps
will make the patient feel respected and will help create a positive setting for
the phlebotomy procedure.
Life Span
Considerations
Chapter Patient and Specimen Requirements
Special Considerations for Geriatric Patients
Just as there are certain details to keep in mind when dealing with children
in the phlebotomy setting, there are also special considerations for geriat-
ric patients. Elderly patients may exhibit sensory impairment, such as loss
of hearing or vision, that requires further patient preparation. However, do not
assume that older adult patients cannot hear by automatically raising your voice.
Hearing loss may require the phlebotomist to repeat questions and instructions.
Phlebotomists may also encounter patients who are confused about where they
are or why they are in the hospital or may need special assistance. In many cases,
such as in a long-term care facility, the phlebotomist should inquire about recommendations for assistance or restrictions at the nursing station before entering.
In an outpatient setting, a patient’s loss of eyesight may require you to carefully
guide the patient to the phlebotomy chair. Being patient and compassionate will
make it easier to communicate with elderly patients.
Copyright © 2019 by McGraw-Hill Education
Wake the Patient Gently
At any time of the day, but especially during early morning blood collections, the patient may be asleep. Gently wake the patient without startling
him or her and explain why you are there (see Figure 7-5). Nudge the bed,
instead of touching the patient. Talk in a soft manner and avoid turning on bright
lights. Give the patient the opportunity to shield his or her eyes before turning
on a light. Never attempt to collect a specimen from a sleeping patient. The
patient may wake suddenly and jerk the arm. This could potentially harm the
patient or injure you.
Responding to Patient Questions
Patients often want to know the purpose of the blood tests requested by the
healthcare provider and how much blood will be drawn. The best response
is to state that the tests are routine tests ordered by the physician.
If the patient needs more information about the tests, suggest
that she speak with the physician
directly.
The phlebotomist should not discuss the tests with the patient. For
example, if the phlebotomist were to
tell a pregnant woman that a test for
syphilis (a sexually transmitted infection) was to be drawn, and this was
the first she had heard of it, imagine
the anxiety and panic this woman
might feel, not to mention the doubt
created toward her husband or significant other. It is the physician’s
responsibility, not the phlebotomist’s, to discuss this information
with the patient. In such cases, the
phlebotomist might respond by saying, “You will need to ask your physician about these tests or results. I
cannot discuss them with you.”
Figure - Gently waken sleeping patients
of any age before beginning procedures.
©Purestock/Getty Images RF
Communicate
& Connect
Patient Interaction
Patients often do not feel well. They may be angry or scared about their
medical condition, and, as a result, they may attempt to take out their
frustration or anger on the phlebotomist. Regardless of what the patient
says or how the patient acts, the phlebotomist must remain polite and professional. Whatever happens or whatever is said to you, do not take it personally.
Being polite and as kind as possible is the easiest way to improve an unpleasant
situation. However, phlebotomists should be aware of situations that are unsafe
for them. For example, if a patient becomes hostile or attempts intimate physical contact, the phlebotomist should leave the room as quickly and calmly as
possible.
Copyright © 2019 by McGraw-Hill Education
Chapter Patient and Specimen Requirements
Communicate
& Connect
Checkpoint
Questions .
1. Why is it important to maintain a pleasant, professional attitude while
working with patients?
2. Describe how you should let an inpatient know you are entering his or
her room.
.
Healthcare Ethics and Law
As a phlebotomist, you need to know how law and ethics apply to your profession. This knowledge will help you
●
function at the highest possible professional level
●
provide competent, compassionate healthcare to patients
●
avoid legal entanglements
Code of Ethics
Ethics is a moral philosophy that varies by individual, religion, social status, or
heritage. A code of ethics is a set of written or unwritten rules, procedures, or
guidelines that specify values, actions, and choices to help us determine right
from wrong. Following a code of ethics is a key part of being a phlebotomist.
Acting morally toward others requires putting yourself in their place. If you
were a patient requiring blood tests to rule out a disease or other condition,
you may not want other people to know, so neither would your patient. As a
phlebotomist, you must respect the patient’s rights and keep information confidential. This is just part of the phlebotomist’s code.
Healthcare and the Law
A law is a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority. You may think of laws as rules necessary to keep society functioning. If a law is violated, a civil or criminal case
may be brought to trial. In a lawsuit, there is a plaintiff (the person bringing
the lawsuit) and a defendant (the person against whom the suit is brought). If
the defendant is found liable and convicted, a fine, imprisonment, or revocation (taking away) of her license may be the penalty.
Respondeat superior is Latin for “Let the master answer.” This doctrine
states that an employer is responsible for the acts of his employees, if such acts
are performed within the scope of the employees’ duties.
Many lawsuits that are brought against phlebotomists involve civil law,
which includes wrongful acts against a person. If a phlebotomist intentionally
harms another, the plaintiff may seek remedy in a civil suit. These types of
cases may involve
●
assault—the threat of bodily harm or “reasonable apprehension of bodily
harm”
●
battery—an action that causes bodily harm to another or bodily contact made
without permission, such as drawing blood without the patient’s consent
Negligence is usually the basis for professional malpractice claims. Negli-
gence means that a professional neglects to perform in the manner expected
by the profession. Four elements—known as the four Ds—must all be present
for a malpractice case:
●
Duty—the professional owes a duty of care to the accuser. (The healthcare
provider is expected to care for the patient. For example, a phlebotomist is
expected to perform venipunctures.)
Copyright © 2019 by McGraw-Hill Education
Chapter Patient and Specimen Requirements
●
Derelict—the professional breaches the duty of care to the patient.
(The healthcare provider acts outside the standards expected
of his profession. For example, if the phlebotomist repeatedly
explores with the needle [probes] when drawing blood.)
●
Direct cause—the breach of the duty of care to the patient is a
direct cause of the patient’s injury. (The care outside the standards of the profession causes the patient’s injury. For example,
repeated probing causes nerve damage to the patient.)
●
Damages—there is a legally recognizable injury to the patient.
(The injury is deemed severe enough to warrant compensation.
For example, nerve damage caused by repeated probing is severe
enough to cause the patient not to be able to use her computer
and her job requires 8 hours a day of computer use.)
In malpractice cases, the burden of proof is on the plaintiff (the
patient, or the person who is making the case). (See Figure 7-6.)
Phlebotomists can prevent malpractice cases by following these
guidelines:
●
Caring—as a phlebotomist, caring about your patients is your most
important job.
●
Communication—the more clearly you communicate, the more
likely you are to earn your patient’s trust.
●
Competence—know your professional duties well, including your limitations, scope of practice, and standards of care. Participate in job-related
continuing education. These parts of competence are discussed in detail in
the chapter Practicing Professional Behavior.
Figure - Malpractice cases are settled
in a court of law.
©Guy Cali/Getty Images RF
Patient’s Rights and Informed Consent
Patient’s Rights
The issue of patient’s rights is not new, and it has been clearly defined by
the American Hospital Association in a document called the Patient Care Part-
nership: Understanding Expectations, Rights and Responsibilities (formerly the
Patient’s Bill of Rights). In addition to the right to refuse care, patients have
the right to be treated with respect, to have all records and information classified as confidential, to be informed about the purpose and expected results of
treatments, and to have access to their medical records.
Informed Consent
Consent is an important legal aspect of phlebotomy. As a part of informed
consent, it is the phlebotomist’s responsibility to inform the patient of the
pending procedure. After formally identifying the patient, as described later
in this chapter, the phlebotomist must explain to the patient in nonmedical
terms, using simple language, what he can expect to happen during the procedure. The phlebotomist must ensure that the patient understands what is
about to take place. Most people have had a blood test before, so the explanation “I’m here to draw your blood” should be sufficient.
If the patient does not understand English, the phlebotomist must use
hand gestures, a demonstration of a venipuncture, or some other means to
get the idea of the venipuncture procedure across to the patient. Most hospitals require a translator be present at the facility or at least a translator phone
service be available. Family should not be used to translate except for extreme
Copyright © 2019 by McGraw-Hill Education
emergency situations because they may not correctly interpret the information
Chapter Patient and Specimen Requirements