The patient’s identifying information is one of the most crucial aspects of the report.
All specimens submitted to the laboratory for testing must be appropriately labeled. This is consistent with the CAP Laboratory General Checklist (CAP GEN.40491), which requires that all primary specimen containers must be labeled with two identifiers at the time of collection to provide unique identification. It is also consistent with The Joint Commission National Patient Safety Goals (NPSG.01.01.01), which requires at least two patient identifiers when collecting blood samples and other specimens for clinical testing. If the medical record number is not available, the patient's date of birth is used as an acceptable substitute.
The first paragraph of the gross dictation always documents the specimen's state upon receipt and proper identification on the container label and the requisition form.
For example:
The specimen is received fresh, labeled with the patient’s name, and designated on the requisition as “[ ].”
