41.0 Completing and Verifying Requistions


Title of Manual: Specimen Collection

Version No: 1.0

Title: Completing and Verifying Requisitions

Effective Date: 12/20/10
Revised Date: 06/23/14

Document #: GPA.SPC.41.0


I. PURPOSE

To provide specific guidelines for all phlebotomist in completing and verifying manual and computer generated requisitions.

This is to be performed by all personnel who are trained on ordering / completing clinical requisitions.

II. MATERIALS

Reagents

Supplies

Equipment

• Requisition
• Clinician’s
written/electronic orders


III. PROCEDURE

Preprinted requisitions are provided to all clients and they include the client name, client code, address, telephone number, fax number, and list of physicians in practice. The preprinted requisition form may
include a short list of customized or frequently used client specific test(s) in the lower right corner.

A. Completing Requisition (Manual):
    1. Patient Section requires the following:
        a. Patient’s Full Name
        b. Patient’s Address
        c. Patient’s Telephone Number
        d. Patient’s Date of Birth
        e. Patient’s Sex
        f. Patient’s Social Security Number (optional)
        g. Patient’s chart number (if required by physician)
    2. Billing Section requires:
        a. Bill to (office, patient/other) box checked with appropriate documentation attached to requisition.
        b. Medicare / Medicaid number with documentation attached to requisition.
        c. Responsible party (if other than patient)
        d. Insurance Company
        e. Policy number
        f. Group number
    3. Specimens require:
        a. Collection Date
        b. Collection Time
        c. Fasting Status
        d. Urine Volume (if submitting a 24 hour urine)
    4. ICD-9 Code (s) must be provided and marked in the appropriate boxes in this section.
    5. Individual Test and Panels – select appropriate test requested by the client and verify tube type.
    6. Additional Test /Panels / Comments – handwrite additional test not listed on the requisition or
        any comment needed by the physician.
B. Completing Requisition (Psych/Outreach)
    1. Patient Information
        a. Patient demographics (full name, DOB, SSN (optional), and Sex) must match exactly as printed or
            written on the original order from the encounter form, script, or manual requisition provided by
            the client.
        b. Patient address and telephone must be provided.
2. Requesting Location
        a. This will be the physical address and phone number for the client.
3. Billing Information – Insurance Billing
        a. Primary – this will include the patient’s insurance carrier group and policy number.
4. Order Information
        a. Must match exactly the ordering physician listed on the encounter form, script or manual requisition.
        b. ICD-9 codes match exactly as provided by the client.
5. Test(s) Ordered
        a. Must match exactly the test requested from the provider.
        b. Phlebotomist must include the phlebotomy code.

IV. QUALITY CONTROL

N/A

V. CALCULATIONS/CALIBRATION

N/A

VI. INTERPRETATIONS

N/A

VII. METHOD PERFORMANCE SPECIFICATIONS

N/A

VIII. REFERENCES

N/A

IX. RELATED DOCUMENTS

N/A

X. DOCUMENT HISTORY

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

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

Reason for Change

2/10/14 New Document Control Format.
Updated supply list.

6/23/14 Moved procedure to
Specimen Collection Manual.



Laboratory Director

(Signature)

Date

Natalie Depcik-Smith, MD
(Print)



Department Director

(Signature)

Date

Robert M. Gay, M.D.
(Print)



Designee

Date

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)



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