TEST REQUEST MINIMUM REQUIREMENTS - Alberta Health …

1 AHS Laboratory Services Laboratory Quality Manual Laboratory Policy Acceptance of Laboratory Samples and Test Requests Policy - Appendix A Document Number:PQMPMJ00004A. Effective Date: 22 November 2018 Version: TEST REQUEST MINIMUM REQUIREMENTS . SAMPLE MAJOR MINOR ADDITIONAL. TYPE REQUIREMENTS PREFERRED. OTHER REQUIRED INFORMATION INFORMATION. CLINICAL NAME IDENTIFIER UNIQUE IDENTIFIER SAMPLE SPECIFIC. Patient's full first and At least one (preferably two) of - Body site/sample type (if - Date of Birth (DOB) - Priority status if other last name the following assigned applicable)* than routine - Gender - Collector ID.

2 General identifiers: (in order of priority): - Relevant clinical history (if (or coded name for applicable)* - **Collection date and time - Phone/ fax number of Laboratory 1. ULI (Unique Lifetime confidential / - Patient location(for patients in care requester and recipient Identifier) - Reason for REQUEST (for research patients or facilities) - Physician identification 2. Personal Health Number# qualitative toxicology testing)* number ( study name ( PHN) - Patient phone number for non- or temporary ID for practitioner ID). 3. Government Issued inpatients only unknown patients). - Referral laboratory's Identification Number ( - Exact site ( laterality, lobes, - Test(s) /procedure(s) ordered accession number (if Federal, Military, RCMP, quadrants, etc), organ of origin - Full first and last name of requester available).)

3 pathology , Refugee, Immigration, and procedure type Therapeutic Drug - Report location or full address of Cytology, Passport, Driver's License, Monitoring (TDM). - Relevant clinical history requester Microbiology, etc) Samples: ** Time tissue removed & time - Full first and last name of recipient, Genetics 4. Medical Record Number tissue in fixative copy to recipient(s) and/or program - Time of last dose ( Hospital # / Clinic #/ - Time of next dose **Collection date and time, if name(s). Unit # / Account # / - Length of time on Accession # / Research #/ applicable - Location / full address of recipient, current dosing Subject ID/initials) copy to recipient(s) and/or program regimen - EI Number (if applicable in outbreak - Transfusion Service situations)* Transfusion Medicine Identification Number (TSIN).

4 When testing is for the purpose Notifiable communicable diseases as - Identifier (witness) ID. of transfusing must be per Public Health Act be documented when recorded on the REQUEST or -Infected persons full name, personal testing is for the collection information and must Health number, date of birth, age, purposes of Transfusion transfusing a patient correlate with sample TSIN gender, full address and telephone Medicine - Required blood number - Collector name, initials or component / product computer identification code -The name of the disease of infecting agent and volume/ dosage must be documented when - Date and time of testing is for the purpose of -The name of the physician who REQUEST transfusing the patient ordered the laboratory test - Date and time of - Special REQUIREMENTS and -The name of the reporting intended transfusion relevant clinical history laboratory * Refer to and choose Lab Test Directory for additional information.

5 Documentation of the identity of the collector on the requisition, collection slip, collection tube or electronically is acceptable. Refer to the Public Health Act for additional information. ** Must appear on the sample and/or test REQUEST /requisition. When information appears on both the information must correlate. Minor test REQUEST discrepancies may be corrected if correct information can be confirmed at the point of service with patient/healthcare card. Printed copies are UNCONTROLLED unless signed by an authorized lab personnel below. (Authorized individuals are: lab personnel designated in their zone/program or provincial role to produce print copies).

6 Initials: Site: Date Printed: Page 1 of 10. AHS Laboratory Services Laboratory Quality Manual Laboratory Policy Acceptance of Laboratory Samples and Test Requests Policy - Appendix A Document Number:PQMPMJ00004A. Effective Date: 22 November 2018 Version: TEST REQUEST MINIMUM REQUIREMENTS CONTINUED. SAMPLE MAJOR MINOR ADDITIONAL. TYPE REQUIREMENTS OTHER REQUIRED PREFERRED. CLINICAL NAME IDENTIFIER UNIQUE IDENTIFIER SAMPLE SPECIFIC INFORMATION INFORMATION. Newborn Metabolic Screening &. Biochemical In addition to identifiers In addition to identifiers Genetics above, above First AND. AND. Trimester Sonographer's operator Sonographer's full first Prenatal code (indicating a valid and last name Screening in-date license).

7 Newborn Metabolic Use name identity at If ULI pending ( Screening - Date and time of birth time of sample adoption, home birth). - Date and time of collection collection use date of birth. (continued on next page). Printed copies are UNCONTROLLED unless signed by an authorized lab personnel below. (Authorized individuals are: lab personnel designated in their zone/program or provincial role to produce print copies). Initials: Site: Date Printed: Page 2 of 10. AHS Laboratory Services Laboratory Quality Manual Laboratory Policy Acceptance of Laboratory Samples and Test Requests Policy - Appendix A Document Number:PQMPMJ00004A.

8 Effective Date: 22 November 2018 Version: TEST REQUEST MINIMUM REQUIREMENTS . SAMPLE MAJOR MINOR. TYPE ADDITIONAL. REQUIREMENTS . PREFERRED. NON OTHER REQUIRED INFORMATION INFORMATION. NAME IDENTIFIER UNIQUE IDENTIFIER SAMPLE SPECIFIC. CLINICAL. Foods and Foods: Type of food ( Lot number, if - Collection date and time - Priority status if animal testing chicken, pizza) applicable - Tests /procedure ordered other than routine Sample Source Expiry date, if - Full first and last name of requester - Phone/ fax number Restaurant name, name applicable of requester and of family (if from private - Location/full address of requester family) Brand, if applicable recipient - Full first and last name of recipient, copy to recipient(s) and/or program name(s).

9 Animals: - Location / full address of recipient, Type of animal copy to recipient(s) and/or program Name of animal owner Sample source: - *EI Number (if applicable in outbreak feces situations). - Sample storage details ( refrigerated, frozen). Infection Name of submitter Sample source / type *Relevant history (if - Collection date and time - Priority status if Control, ( : name of agency/ applicable) - Tests /procedure ordered other than routine ( drug name). Pharmaceutical business) - Full first and last name of requester - Phone/ fax number , etc. - Location/full address of requester of requester and recipient - Full first and last name of recipient, copy to recipient(s) and/or program - Physician name(s) identification number - Location / full address of recipient, ( practitioner ID).

10 Copy to recipient(s) and/or program Referral laboratory's - *EI Number (if applicable in outbreak accession number (if situations) available). * Refer to and choose Test Directory for additional information. Printed copies are UNCONTROLLED unless signed by an authorized lab personnel below. (Authorized individuals are: lab personnel designated in their zone/program or provincial role to produce print copies). Initials: Site: Date Printed: Page 3 of 10. AHS Laboratory Services Laboratory Quality Manual Laboratory Policy Acceptance of Laboratory Samples and Test Requests Policy - Appendix A Document Number:PQMPMJ00004A.