2.0 Specimen Submission Criteria


Title of Manual: Specimen Collection

Version No: 1.1

Title: Specimen Submission Criteria

Effective Date: 11/01/09
Revised Date: 01/02/14

Document #: GPA.SPC.2.0


I. PURPOSE

This section is intended for clinicians who collect, prepare, and submit specimens for testing. In order to ensure quality testing, it is imperative to submit quality, accurately prepared and identified specimens. Only specimens collected by licensed health care providers will be accepted for processing in the pathology laboratory.

Results will be reported only to those authorized to receive them. The patient's attending physician must authorize exceptions to these policies. If testing is canceled after the specimen has been processed, a report will still be issued, but the patient will not be charged. Documentation of canceled test(s) will be notated on the final report.

II. MATERIALS

Reagents

Supplies

Equipment


III. PROCEDURE

GENERAL SPECIMEN SUBMISSION CRITERIA

• A properly completed Greensboro Pathology Associates test requisition must accompany all specimens.
• The requisition must state the patient’s full first and last name, source/site of the specimen, patient’s date
  of birth, ICD-9 code, and social security number (optional).
• If the requisition does not include the date of birth, the client office will be contacted.
• If the requisition does not include the diagnosis code (ICD-9), the client office may be contacted to
  obtain this information. We are unable to bill third party carriers without this information.
• Two patient identifiers are required on all specimens. Specimens must be labeled with at least the
  patient name and unique requisition identifier number. Specimens received without the required labeling
  will be rejected and the client office contacted for further clarification.
• If a container or slide is submitted without the patient’s name, the client office will be contacted. A control
  sticker from the requisition must be affixed to the container.
• The patient name (& other patient identifier) on the container and the requisition must match and be legible.
• For tissue specimens, the number part (equivalent to the body site) must be listed on the container and
  the requisition. The body site is not required on the container – only the number part is required.
• If the requisition states there is a number part for which we don’t have the container with specimen
  inside, all specimen containers with the requisition may be rejected and the client office contacted for
  further clarification.
• If no tissue is found in a specimen container, the case will be accessioned with a statement that no tissue
  was found or reported. The client office will be notified.
• Federal regulations require that the laboratory maintain written documentation of all tests ordered, including   verbal orders. A Verbal Order Authorization form will be sent to the clinician who placed a verbal order.
  The Verbal Order Authorization form should then be signed and returned to the laboratory.

NOTE: If the above requisition information cannot be obtained by telephone, the specimen and requisition will be returned to the office.

Pap Specimen Submission Criteria:

• The use of lubricants should be minimized prior to Pap specimen collection due to increased risk
  of contaminating the alcohol based transport medium or obscuring the cervical cellular sample.
  NCCLS guidelines recommend that no lubricant be used during Pap testing but suggests lukewarm
  water be used to lubricate and warm the speculum. ACOG recommends that care be taken not to
  contaminate the specimen with lubricant because this may lead to an unsatisfactory result. If a lubricant
  must be used due to patient discomfort or other circumstances, take care not to contaminate the cervix
  or collection devices with lubricant. A tiny amount of lubricant may be used, just enough to sparingly
  coat the speculum, avoiding the tip of the speculum.

• Removal of excess mucus, inflammatory exudate, or other discharge before taking the Pap sample is just
  as important. The excess cervical mucus and exudate is essentially devoid of meaningful cellular material
  and when present in the sample vial may yield little or no diagnostic material present. It should be
  gently removed from the cervical canal with forceps and a gauze pad.

• The cervix should not be cleaned by washing with saline or it may result in relatively acellular Pap
  specimen. Also the sample should be obtained before the application of acetic acid. Improper collection
  techniques such as excess lubricant and mucus, cervical washing, and use of the wrong collection devices,
  can adversely affect slide presentation. The Pap slide remains a representative of what the clinician has
  collected and rinsed into the vial.

IV. QUALITY CONTROL

V. CALCULATIONS/CALIBRATION

VI. INTERPRETATIONS

VII. METHOD PERFORMANCE SPECIFICATIONS

VIII. REFERENCES

IX. RELATED DOCUMENTS

• Collection Guide E:12/9/13
• GPA Directory of Service E:1/10/10 R:1/2/14

X. DOCUMENT HISTORY

MINOR REVISION
(Laboratory Director’s Signature on Original Subsequent Document Attached)

X - MAJOR REVISION
(Requires Laboratory Director & Department Director Signature - where applicable)

Reason for Change

1/02/14 New Document Control Forma and
updated Related Documents Section to include
GPA Directory of Service revision.



Laboratory Director

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Date

Natalie Depcik-Smith, MD
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Department Director

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Date


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Designee

Date

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(Signature)

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(Signature)

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(Signature)

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