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SPECIMEN SPECIMEN COLLECTION COLLECTION
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SPECIMENSPECIMENCOLLECTIONCOLLECTION

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SPECIMEN SPECIMEN CONSIDERATIONSCONSIDERATIONS

SPECIMEN COLLECTION, SPECIMEN COLLECTION, HANDLING, AND PROCESSING HANDLING, AND PROCESSING REMAINS ONE OF THE PRIMAY REMAINS ONE OF THE PRIMAY AREAS OF PREANALYTICAL AREAS OF PREANALYTICAL ERROR.ERROR.

CAREFUL ATTENTION TO EACH CAREFUL ATTENTION TO EACH PHASE IS NECESSARY TO PHASE IS NECESSARY TO ENSURE PROPER SUBSEQUENT ENSURE PROPER SUBSEQUENT TESTING AND REPORTING OF TESTING AND REPORTING OF MEANINGFUL RESULTSMEANINGFUL RESULTS

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SPECIMEN SPECIMEN CONSIDERATIONSCONSIDERATIONS

SPECIMEN COLLECTION, SPECIMEN COLLECTION, HANDLING, AND PROCESSING HANDLING, AND PROCESSING REMAINS ONE OF THE PRIMAY REMAINS ONE OF THE PRIMAY AREAS OF PREANALYTICAL ERROR.AREAS OF PREANALYTICAL ERROR.

CAREFUL ATTENTION TO EACH CAREFUL ATTENTION TO EACH PHASE IS NECESSARY TO ENSURE PHASE IS NECESSARY TO ENSURE PROPER SUBSEQUENT TESTING PROPER SUBSEQUENT TESTING AND REPORTING OF MEANINGFUL AND REPORTING OF MEANINGFUL RESULTSRESULTS

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TYPES OF SAMPLETYPES OF SAMPLE

WHOLE BLOODWHOLE BLOOD PLASMA: centrifuge whole blood at PLASMA: centrifuge whole blood at

RCF of 1000g to 2000g for 10 RCF of 1000g to 2000g for 10 minutesminutes

ARTERIAL BLOOD: for blood gasesARTERIAL BLOOD: for blood gases SERUM:SERUM: Other body fluids: CSF, Other body fluids: CSF,

paracentesis fluids, amniotic fluidsparacentesis fluids, amniotic fluids

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OBJECTIVESOBJECTIVES

Describe and perform the venipuncture process Describe and perform the venipuncture process including:including: Proper patient identification procedures.Proper patient identification procedures. Proper equipment selection and use.Proper equipment selection and use. Proper labeling procedures and completion of Proper labeling procedures and completion of

laboratory requisitions.laboratory requisitions. Order of draw for multiple tube phlebotomy.Order of draw for multiple tube phlebotomy. Preferred venous access sites, and factors to Preferred venous access sites, and factors to

consider in site selection, and ability to differentiate consider in site selection, and ability to differentiate between the feel of a vein, tendon and artery.between the feel of a vein, tendon and artery.

Patient care following completion of venipuncture.Patient care following completion of venipuncture. Safety and infection control procedures.Safety and infection control procedures. Quality assurance issues.Quality assurance issues.

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OBJECTIVESOBJECTIVES

Identify the additive, additive function, volume, and Identify the additive, additive function, volume, and specimen considerations to be followed for each of the specimen considerations to be followed for each of the various color coded tubes.various color coded tubes.

List six areas to be avoided when performing List six areas to be avoided when performing venipuncture and the reasons for the restrictions.venipuncture and the reasons for the restrictions.

Summarize the problems that may be encountered in Summarize the problems that may be encountered in accessing a vein, including the procedure to follow accessing a vein, including the procedure to follow when a specimen is not obtained.when a specimen is not obtained.

List several effects of exercise, posture, and tourniquet List several effects of exercise, posture, and tourniquet application upon laboratory values.application upon laboratory values.

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VENIPUNCTURE VENIPUNCTURE PROCEDUREPROCEDURE

The venipuncture procedure is complex, requiring both The venipuncture procedure is complex, requiring both knowledge and skill to perform. Each phlebotomist generally knowledge and skill to perform. Each phlebotomist generally establishes a routine that is comfortable for her or him. establishes a routine that is comfortable for her or him. Several essential steps are required for every successful Several essential steps are required for every successful collection procedure:collection procedure:

Identify the patient.Identify the patient. Assess the patient's physical disposition (i.e. diet, exercise, Assess the patient's physical disposition (i.e. diet, exercise,

stress, basal state).stress, basal state). Check the requisition form for requested tests, patient Check the requisition form for requested tests, patient

information, and any special requirements.information, and any special requirements. Select a suitable site for venipuncture.Select a suitable site for venipuncture. Prepare the equipment, the patient and the puncture site.Prepare the equipment, the patient and the puncture site. Perform the venipuncture.Perform the venipuncture. Collect the sample in the appropriate container.Collect the sample in the appropriate container. Recognize complications associated with the phlebotomy Recognize complications associated with the phlebotomy

procedure.procedure. Assess the need for sample recollection and/or rejection.Assess the need for sample recollection and/or rejection. Label the collection tubes at the bedside or drawing area.Label the collection tubes at the bedside or drawing area. Promptly send the specimens with the requisition to the Promptly send the specimens with the requisition to the

laboratory.laboratory.

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ORDER ORDER FORM/REQUISITIONFORM/REQUISITION

A requisition form must accompany each sample A requisition form must accompany each sample submitted to the laboratory. This requisition form must submitted to the laboratory. This requisition form must contain the proper information in order to process the contain the proper information in order to process the specimen. The essential elements of the requisition specimen. The essential elements of the requisition form are:form are:

Patient's surname, first name, and middle initial.Patient's surname, first name, and middle initial. Patient's ID number.Patient's ID number. Patient's date of birth and sex.Patient's date of birth and sex. Requesting physician's complete name.Requesting physician's complete name. Source of specimen. This information must be given Source of specimen. This information must be given

when requesting microbiology, cytology, fluid analysis, when requesting microbiology, cytology, fluid analysis, or other testing where analysis and reporting is site or other testing where analysis and reporting is site specific.specific.

Date and time of collection.Date and time of collection. Initials of phlebotomist.Initials of phlebotomist.

Indicating the test(s) requested.Indicating the test(s) requested. An example of a simple requisition form with the essential An example of a simple requisition form with the essential

elements is shown below:elements is shown below:

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LABELING THE SAMPLELABELING THE SAMPLE

A properly labelled sample is essential A properly labelled sample is essential so that the results of the test match so that the results of the test match the patient. The key elements in the patient. The key elements in labelling are:labelling are:

Patient's surname, first and middle.Patient's surname, first and middle. Patient's ID number.Patient's ID number. NOTE: Both of the above MUST match the NOTE: Both of the above MUST match the

same on the requisition form.same on the requisition form. Date, time and initials of the phlebotomist Date, time and initials of the phlebotomist

must be on the label of EACH tube.must be on the label of EACH tube. An example of a simple requisition form An example of a simple requisition form

with the essential elements is shown with the essential elements is shown below:below:

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EQUIPMENTEQUIPMENT

THE FOLLOWING ARE NEEDED FOR ROUTINE THE FOLLOWING ARE NEEDED FOR ROUTINE VENIPUNCTURE:VENIPUNCTURE:

Evacuated Collection Tubes - The tubes are designed to fill Evacuated Collection Tubes - The tubes are designed to fill with a predetermined volume of blood by vacuum. The with a predetermined volume of blood by vacuum. The rubber stoppers are color coded according to the additive rubber stoppers are color coded according to the additive that the tube contains. Various sizes are available. Blood that the tube contains. Various sizes are available. Blood should NEVER be poured from one tube to another since the should NEVER be poured from one tube to another since the tubes can have different additives or coatings (see tubes can have different additives or coatings (see illustrations at end).illustrations at end).

Needles - The gauge number indicates the bore size: the Needles - The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore. larger the gauge number, the smaller the needle bore. Needles are available for evacuated systems and for use Needles are available for evacuated systems and for use with a syringe, single draw or butterfly system.with a syringe, single draw or butterfly system.

Holder/Adapter - use with the evacuated collection system.Holder/Adapter - use with the evacuated collection system. Tourniquet - Wipe off with alcohol and replace frequently.Tourniquet - Wipe off with alcohol and replace frequently. Alcohol Wipes - 70% isopropyl alcohol.Alcohol Wipes - 70% isopropyl alcohol.

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Povidone-iodine wipes/swabs - Used if blood Povidone-iodine wipes/swabs - Used if blood culture is to be drawn.culture is to be drawn.

Gauze sponges - for application on the site from Gauze sponges - for application on the site from which the needle is withdrawn.which the needle is withdrawn.

Adhesive bandages / tape - protects the Adhesive bandages / tape - protects the venipuncture site after collection.venipuncture site after collection.

Needle disposal unit - needles should NEVER be Needle disposal unit - needles should NEVER be broken, bent, or recapped. Needles should be broken, bent, or recapped. Needles should be placed in a proper disposal unit IMMEDIATELY placed in a proper disposal unit IMMEDIATELY after their use.after their use.

Gloves - can be made of latex, rubber, vinyl, etc.; Gloves - can be made of latex, rubber, vinyl, etc.; worn to protect the patient and the phlebotomist.worn to protect the patient and the phlebotomist.

Syringes - may be used in place of the evacuated Syringes - may be used in place of the evacuated collection tube for special circumstances.collection tube for special circumstances.

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ORDER OF DRAWORDER OF DRAW

Blood collection tubes must be drawn in a Blood collection tubes must be drawn in a specific order to avoid cross-contamination of specific order to avoid cross-contamination of additives between tubes. The recommended additives between tubes. The recommended order of draw is:order of draw is:

First - blood culture tube (yellow-black stopper)First - blood culture tube (yellow-black stopper) Second - non-additive tube (red stopper or SST)Second - non-additive tube (red stopper or SST) Third - coagulation tube (light blue stopper). If Third - coagulation tube (light blue stopper). If

just a routine coagulation assay is the only test just a routine coagulation assay is the only test ordered, then a single light blue stopper tube ordered, then a single light blue stopper tube may be drawn. If there is a concern regarding may be drawn. If there is a concern regarding contamination by tissue fluids or contamination by tissue fluids or thromboplastins, then one may draw a non-thromboplastins, then one may draw a non-additive tube first, and then the light blue additive tube first, and then the light blue stopper tube.stopper tube.

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ORDER OF DRAWORDER OF DRAW

Last draw - additive tubes in this order:Last draw - additive tubes in this order: Last draw - additive tubes in this order:Last draw - additive tubes in this order:

SST (red-gray, or gold, stopper). Contains a gel SST (red-gray, or gold, stopper). Contains a gel separator and clot activator.separator and clot activator.

Sodium heparin (dark green stopper)Sodium heparin (dark green stopper) PST (light green stopper). Contains lithium heparin PST (light green stopper). Contains lithium heparin

anticoagulant and a gel separator.anticoagulant and a gel separator. EDTA (lavender stopper)EDTA (lavender stopper) ACDA or ACDB (pale yellow stopper). Contains acid ACDA or ACDB (pale yellow stopper). Contains acid

citrate dextrose.citrate dextrose. Oxalate/fluoride (light gray stopper)Oxalate/fluoride (light gray stopper)

NOTE:Tubes with additives must be thoroughly NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the when the blood is not thoroughly mixed with the additive.additive.

NOTE:For plastic tubes, the order of draw for NOTE:For plastic tubes, the order of draw for tubes 2 and 3 is reversed.tubes 2 and 3 is reversed.

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PROCEDURAL ISSUESPROCEDURAL ISSUES

PATIENT RELATIONS AND IDENTIFICATION:PATIENT RELATIONS AND IDENTIFICATION: The phlebotomist's role requires a professional, The phlebotomist's role requires a professional,

courteous, and understanding manner in all courteous, and understanding manner in all contacts with the patient. Greet the patient contacts with the patient. Greet the patient and identify yourself and indicate the and identify yourself and indicate the procedure that will take place. Effective procedure that will take place. Effective communication - both verbal and nonverbal - is communication - both verbal and nonverbal - is essential.essential.

Proper patient identification MANDATORY. If an Proper patient identification MANDATORY. If an inpatient is able to respond, ask for a full name inpatient is able to respond, ask for a full name and always check the armband for and always check the armband for confirmation. DO NOT DRAW BLOOD IF THE confirmation. DO NOT DRAW BLOOD IF THE ARMBAND IS MISSING. An outpatient must ARMBAND IS MISSING. An outpatient must provide identification other than the verbal provide identification other than the verbal statement of a name. Using the requisition for statement of a name. Using the requisition for reference, ask a patient to provide additional reference, ask a patient to provide additional information such as a surname or birthdate.information such as a surname or birthdate.

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PROCEDURAL ISSUESPROCEDURAL ISSUES

If possible, speak with the patient during the If possible, speak with the patient during the process. The patient who is at ease will be less process. The patient who is at ease will be less focused on the procedure. Always thank the focused on the procedure. Always thank the patient and excuse yourself courteously when patient and excuse yourself courteously when finished.finished.

PATIENT'S BILL OF RIGHTS:PATIENT'S BILL OF RIGHTS: The Patient's Bill of Rights has been adopted The Patient's Bill of Rights has been adopted

by many hospitals as declared by the Joint by many hospitals as declared by the Joint Commission on Accreditation of Healthcare Commission on Accreditation of Healthcare Organizations (JCAHO). The basic patient rights Organizations (JCAHO). The basic patient rights endorsed by the JCAHO follow in condensed endorsed by the JCAHO follow in condensed form are given below.form are given below.

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The patient has the right to:The patient has the right to: Impartial access to treatment or Impartial access to treatment or

accommodations that are available or accommodations that are available or medically indicated, regardless of race, medically indicated, regardless of race, creed, sex, national origin, or sources of creed, sex, national origin, or sources of payment for care.payment for care.

Considerate, respectful care.Considerate, respectful care. Confidentiality of all communications and Confidentiality of all communications and

other records pertaining to the patient's other records pertaining to the patient's care.care.

Expect that any discussion or consultation Expect that any discussion or consultation involving the patient's case will be involving the patient's case will be conducted discreetly and that individuals conducted discreetly and that individuals not directly involved in the case will not be not directly involved in the case will not be present without patient permission.present without patient permission.

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Expect reasonable safety congruent Expect reasonable safety congruent with the hospital practices and with the hospital practices and environment.environment.

Know the identity and professional Know the identity and professional status of individuals providing service status of individuals providing service and to know which physician or other and to know which physician or other practitioner is primarily responsible for practitioner is primarily responsible for his or her care.his or her care.

Obtain from the practitioner complete Obtain from the practitioner complete and current information about and current information about diagnosis, treatment, and any known diagnosis, treatment, and any known prognosis, in terms the patient can prognosis, in terms the patient can reasonably be expected to understand.reasonably be expected to understand.

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Reasonable informed participation in decisions Reasonable informed participation in decisions involving the patient's health care. The patient involving the patient's health care. The patient shall be informed if the hospital proposes to shall be informed if the hospital proposes to engage in or perform human experimentation or engage in or perform human experimentation or other research/educational profits affecting his or other research/educational profits affecting his or her care or treatment. The patient has the right to her care or treatment. The patient has the right to refuse participation in such activity.refuse participation in such activity.

Consult a specialist at the patient's own request Consult a specialist at the patient's own request and expense.and expense.

Refuse treatment to the extent permitted by law.Refuse treatment to the extent permitted by law. Regardless of the source of payment, request and Regardless of the source of payment, request and

receive an itemized and detailed explanation of receive an itemized and detailed explanation of the total bill for services rendered in the hospital.the total bill for services rendered in the hospital.

Be informed of the hospital rules and regulations Be informed of the hospital rules and regulations regarding patient conduct.regarding patient conduct.

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VENIPUNCTURE SITE SELECTION:VENIPUNCTURE SITE SELECTION: Although the larger and fuller median cubital Although the larger and fuller median cubital

and cephalic veins of the arm are used most and cephalic veins of the arm are used most frequently, wrist and hand veins are also frequently, wrist and hand veins are also acceptable for venipuncture.acceptable for venipuncture.

Certain areas are to be avoided when choosing Certain areas are to be avoided when choosing a site:a site:

Extensive scars from burns and surgery - Extensive scars from burns and surgery - it is difficult to puncture the scar tissue it is difficult to puncture the scar tissue and obtain a specimen.and obtain a specimen.

The upper extremity on the side of a The upper extremity on the side of a previous mastectomy - test results may be previous mastectomy - test results may be affected because of lymphedema.affected because of lymphedema.

Hematoma - may cause erroneous test Hematoma - may cause erroneous test results. If another site is not available, results. If another site is not available, collect the specimen distal to the collect the specimen distal to the hematoma.hematoma.

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Intravenous therapy (IV) / blood Intravenous therapy (IV) / blood transfusions - fluid may dilute the transfusions - fluid may dilute the specimen, so collect from the opposite specimen, so collect from the opposite arm if possible. Otherwise, satisfactory arm if possible. Otherwise, satisfactory samples may be drawn below the IV by samples may be drawn below the IV by following these procedures:following these procedures:

Turn off the IV for at least 2 Turn off the IV for at least 2 minutes before venipuncture.minutes before venipuncture.

Apply the tourniquet below the IV Apply the tourniquet below the IV site. Select a vein other than the site. Select a vein other than the one with the IV.one with the IV.

Perform the venipuncture. Draw 5 Perform the venipuncture. Draw 5 ml of blood and discard before ml of blood and discard before drawing the specimen tubes for drawing the specimen tubes for testing.testing.

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Cannula/fistula/heparin lock - Cannula/fistula/heparin lock - hospitals have special policies hospitals have special policies regarding these devices. In regarding these devices. In general, blood should not be general, blood should not be drawn from an arm with a drawn from an arm with a fistula or cannula without fistula or cannula without consulting the attending consulting the attending physician.physician.

Edematous extremities - tissue Edematous extremities - tissue fluid accumulation alters test fluid accumulation alters test resultsresults..

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PROCEDURE FOR VEIN PROCEDURE FOR VEIN SELECTIONSELECTION

Palpate and trace the path of veins Palpate and trace the path of veins with the index finger. Arteries pulsate, with the index finger. Arteries pulsate, are most elastic, and have a thick wall. are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel Thrombosed veins lack resilience, feel cord-like, and roll easily.cord-like, and roll easily.

If superficial veins are not readily If superficial veins are not readily apparent, you can force blood into the apparent, you can force blood into the vein by massaging the arm from wrist vein by massaging the arm from wrist to elbow, tap the site with index and to elbow, tap the site with index and second finger, apply a warm, damp second finger, apply a warm, damp washcloth to the site for 5 minutes, or washcloth to the site for 5 minutes, or lower the extremity over the bedside lower the extremity over the bedside to allow the veins to fill.to allow the veins to fill.

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PERFORMANCE OF A PERFORMANCE OF A VENIPUNCTUREVENIPUNCTURE

Approach the patient in a friendly, calm Approach the patient in a friendly, calm manner. Provide for their comfort as much manner. Provide for their comfort as much as possible, and gain the patient's as possible, and gain the patient's cooperation.cooperation.

Identify the patient correctly.Identify the patient correctly. Properly fill out appropriate requisition Properly fill out appropriate requisition

forms, indicating the test(s) ordered.forms, indicating the test(s) ordered. Verify the patient's condition. Fasting, Verify the patient's condition. Fasting,

dietary restrictions, medications, timing, dietary restrictions, medications, timing, and medical treatment are all of concern and medical treatment are all of concern and should be noted on the lab requisition.and should be noted on the lab requisition.

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PERFORMANCE OF A PERFORMANCE OF A VENIPUNCTUREVENIPUNCTURE

Position the patient. The patient should Position the patient. The patient should either sit in a chair, lie down or sit up in either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm.bed. Hyperextend the patient's arm.

Apply the tourniquet 3-4 inches above the Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too selected puncture site. Do not place too tightly or leave on more than 2 minutes.tightly or leave on more than 2 minutes.

The patient should make a fist without The patient should make a fist without pumping the hand.pumping the hand.

Select the venipuncture site.Select the venipuncture site. Prepare the patient's arm using an alcohol Prepare the patient's arm using an alcohol

prep. Cleanse in a circular fashion, prep. Cleanse in a circular fashion, beginning at the site and working outward. beginning at the site and working outward. Allow to air dry.Allow to air dry.

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Grasp the patient's arm firmly using Grasp the patient's arm firmly using your thumb to draw the skin taut and your thumb to draw the skin taut and anchor the vein. The needle should anchor the vein. The needle should form a 15 to 30 degree angle with the form a 15 to 30 degree angle with the surface of the arm. Swiftly insert the surface of the arm. Swiftly insert the needle through the skin and into the needle through the skin and into the lumen of the vein. Avoid trauma and lumen of the vein. Avoid trauma and excessive probing.excessive probing.

When the last tube to be drawn is When the last tube to be drawn is filling, remove the tourniquet.filling, remove the tourniquet.

Remove the needle from the patient's Remove the needle from the patient's arm using a swift backward motion.arm using a swift backward motion.

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Press down on the gauze once the Press down on the gauze once the needle is out of the arm, applying needle is out of the arm, applying adequate pressure to avoid formation adequate pressure to avoid formation of a hematoma.of a hematoma.

Dispose of contaminated Dispose of contaminated materials/supplies in designated materials/supplies in designated containers.containers.

Mix and label all appropriate tubes at Mix and label all appropriate tubes at the patient bedside.the patient bedside.

Deliver specimens promptly to the Deliver specimens promptly to the laboratory.laboratory.

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PERFORMANCE OF A FINGERSTICK:PERFORMANCE OF A FINGERSTICK:

Follow the procedure as outlined above for greeting and Follow the procedure as outlined above for greeting and identifying the patient. As always, properly fill out identifying the patient. As always, properly fill out appropriate requisition forms, indicating the test(s) appropriate requisition forms, indicating the test(s) ordered.ordered.

Verify the patient's condition. Fasting, dietary restrictions, Verify the patient's condition. Fasting, dietary restrictions, medications, timing, and medical treatment are all of medications, timing, and medical treatment are all of concern and should be noted on the lab requisition.concern and should be noted on the lab requisition.

Position the patient. The patient should either sit in a chair, Position the patient. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm.lie down or sit up in bed. Hyperextend the patient's arm.

The best locations for fingersticks are the 3rd and 4th The best locations for fingersticks are the 3rd and 4th fingers of the non-dominant hand. Do not use the tip of the fingers of the non-dominant hand. Do not use the tip of the finger or the center of the finger. Avoid the side of the finger or the center of the finger. Avoid the side of the finger where there is less soft tissue, where vessels and finger where there is less soft tissue, where vessels and nerves are located, and where the bone is closer to the nerves are located, and where the bone is closer to the surface. The 2nd (index) finger tends to have thicker, surface. The 2nd (index) finger tends to have thicker, callused skin. The fifth finger tends to have less soft tissue callused skin. The fifth finger tends to have less soft tissue overlying the bone. Avoid puncturing a finger that is cold overlying the bone. Avoid puncturing a finger that is cold or cyanotic, swollen, scarred, or covered with a rash.or cyanotic, swollen, scarred, or covered with a rash.

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PERFORMANCE OF A FINGERSTICK:PERFORMANCE OF A FINGERSTICK:

Using a sterile lancet, make a skin puncture just off the Using a sterile lancet, make a skin puncture just off the center of the finger pad. The puncture should be made center of the finger pad. The puncture should be made perpendicular to the ridges of the fingerprint so that perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges.the drop of blood does not run down the ridges.

Wipe away the first drop of blood, which tends to Wipe away the first drop of blood, which tends to contain excess tissue fluid.contain excess tissue fluid.

Collect drops of blood into the collection device by Collect drops of blood into the collection device by gently massaging the finger. Avoid excessive pressure gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid into the drop of blood.that may squeeze tissue fluid into the drop of blood.

Cap, rotate and invert the collection device to mix the Cap, rotate and invert the collection device to mix the blood collected.blood collected.

Have the patient hold a small gauze pad over the Have the patient hold a small gauze pad over the puncture site for a couple of minutes to stop the puncture site for a couple of minutes to stop the bleeding.bleeding.

Dispose of contaminated materials/supplies in Dispose of contaminated materials/supplies in designated containers.designated containers.

Label all appropriate tubes at the patient bedside.Label all appropriate tubes at the patient bedside. Deliver specimens promptly to the laboratory.Deliver specimens promptly to the laboratory.

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ADDITIONAL CONSIDERATIONS:ADDITIONAL CONSIDERATIONS: To prevent a hematoma:To prevent a hematoma:

Puncture only the uppermost wall of the veinPuncture only the uppermost wall of the vein Remove the tourniquet before removing the needleRemove the tourniquet before removing the needle Use the major superficial veinsUse the major superficial veins Make sure the needle fully penetrates the upper most wall Make sure the needle fully penetrates the upper most wall

of the vein. (Partial penetration may allow blood to leak into of the vein. (Partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle the soft tissue surrounding the vein by way of the needle bevel)bevel)

Apply pressure to the venipuncture siteApply pressure to the venipuncture site To prevent hemolysis (which can interfere with many tests):To prevent hemolysis (which can interfere with many tests):

Mix tubes with anticoagulant additives gently 5-10 timesMix tubes with anticoagulant additives gently 5-10 times Avoid drawing blood from a hematomaAvoid drawing blood from a hematoma Avoid drawing the plunger back too forcefully, if using a Avoid drawing the plunger back too forcefully, if using a

needle and syringe, and avoid frothing of the sampleneedle and syringe, and avoid frothing of the sample Make sure the venipuncture site is dryMake sure the venipuncture site is dry Avoid a probing, traumatic venipunctureAvoid a probing, traumatic venipuncture

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Indwelling Lines or Catheters:Indwelling Lines or Catheters: Potential source of test errorPotential source of test error Most lines are flushed with a solution of heparin to Most lines are flushed with a solution of heparin to

reduce the risk of thrombosisreduce the risk of thrombosis Discard a sample at least three times the volume of the Discard a sample at least three times the volume of the

line before a specimen is obtained for analysisline before a specimen is obtained for analysis Hemoconcentration: An increased concentration of larger Hemoconcentration: An increased concentration of larger

molecules and formed elements in the blood may be due to molecules and formed elements in the blood may be due to several factors:several factors:

Prolonged tourniquet application (no more than 2 Prolonged tourniquet application (no more than 2 minutes)minutes)

Massaging, squeezing, or probing a siteMassaging, squeezing, or probing a site Long-term IV therapyLong-term IV therapy Sclerosed or occluded veinsSclerosed or occluded veins

Prolonged Tourniquet Application:Prolonged Tourniquet Application: Primary effect is hemoconcentration of non-filterable Primary effect is hemoconcentration of non-filterable

elements (i.e. proteins). The hydrostatic pressure causes elements (i.e. proteins). The hydrostatic pressure causes some water and filterable elements to leave the some water and filterable elements to leave the extracellular space.extracellular space.

Significant increases can be found in total protein, Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids, aspartate aminotransferase (AST), total lipids, cholesterol, ironcholesterol, iron

Affects packed cell volume and other cellular elementsAffects packed cell volume and other cellular elements

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Patient Preparation Factors:Patient Preparation Factors: Therapeutic Drug Monitoring: different Therapeutic Drug Monitoring: different

pharmacologic agents have patterns of pharmacologic agents have patterns of administration, body distribution, metabolism, administration, body distribution, metabolism, and elimination that affect the drug and elimination that affect the drug concentration as measured in the blood. Many concentration as measured in the blood. Many drugs will have "peak" and "trough" levels that drugs will have "peak" and "trough" levels that vary according to dosage levels and intervals. vary according to dosage levels and intervals. Check for timing instructions for drawing the Check for timing instructions for drawing the appropriate samples.appropriate samples.

Effects of Exercise: Muscular activity has both Effects of Exercise: Muscular activity has both transient and longer lasting effects. The transient and longer lasting effects. The creatine kinase (CK), aspartate creatine kinase (CK), aspartate aminotransferase (AST), lactate aminotransferase (AST), lactate dehydrogenase (LDH), and platelet count may dehydrogenase (LDH), and platelet count may increase.increase.

Stress: May cause transient elevation in white Stress: May cause transient elevation in white blood cells (WBC's) and elevated adrenal blood cells (WBC's) and elevated adrenal hormone values (cortisol and catecholamines). hormone values (cortisol and catecholamines). Anxiety that results in hyperventilation may Anxiety that results in hyperventilation may cause acid-base imbalances, and increased cause acid-base imbalances, and increased lactate.lactate.

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Diurnal Rhythms: Diurnal rhythms are body Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations during the day. fluid and analyte fluctuations during the day. For example, serum cortisol levels are highest For example, serum cortisol levels are highest in early morning but are decreased in the in early morning but are decreased in the afternoon. Serum iron levels tend to drop afternoon. Serum iron levels tend to drop during the day. You must check the timing of during the day. You must check the timing of these variations for the desired collection these variations for the desired collection point.point.

Posture: Postural changes (supine to sitting Posture: Postural changes (supine to sitting etc.) are known to vary lab results of some etc.) are known to vary lab results of some analytes. Certain larger molecules are not analytes. Certain larger molecules are not filterable into the tissue, therefore they are filterable into the tissue, therefore they are more concentrated in the blood. Enzymes, more concentrated in the blood. Enzymes, proteins, lipids, iron, and calcium are proteins, lipids, iron, and calcium are significantly increased with changes in significantly increased with changes in position.position.

Other Factors: Age, gender, and pregnancy Other Factors: Age, gender, and pregnancy have an influence on laboratory testing. have an influence on laboratory testing. Normal reference ranges are often noted Normal reference ranges are often noted according to age.according to age.

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SAFETY AND INFECTION CONTROLSAFETY AND INFECTION CONTROL Because of contacts with sick patients Because of contacts with sick patients

and their specimens, it is important to and their specimens, it is important to follow safety and infection control follow safety and infection control procedures.procedures.

PROTECT YOURSELFPROTECT YOURSELF Practice universal precautions:Practice universal precautions: Wear gloves and a lab coat or gown when Wear gloves and a lab coat or gown when

handling blood/body fluids.handling blood/body fluids. Change gloves after each patient or Change gloves after each patient or

when contaminated.when contaminated. Wash hands frequently.Wash hands frequently. Dispose of items in appropriate Dispose of items in appropriate

containers.containers. Dispose of needles immediately upon Dispose of needles immediately upon

removal from the patient's vein. Do not removal from the patient's vein. Do not bend, break, recap, or resheath needles bend, break, recap, or resheath needles to avoid accidental needle puncture or to avoid accidental needle puncture or splashing of contents.splashing of contents.

Clean up any blood spills with a Clean up any blood spills with a disinfectant such as freshly made 10% disinfectant such as freshly made 10% bleach.bleach.

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If you stick yourself with a contaminated If you stick yourself with a contaminated needle:needle:

Remove your gloves and dispose of them Remove your gloves and dispose of them properly.properly.

Squeeze puncture site to promote bleeding.Squeeze puncture site to promote bleeding. Wash the area well with soap and water.Wash the area well with soap and water. Record the patient's name and ID number.Record the patient's name and ID number. Follow institution's guidelines regarding Follow institution's guidelines regarding

treatment and follow-up.treatment and follow-up. NOTE: The use of prophylactic zidovudine NOTE: The use of prophylactic zidovudine

following blood exposure to HIV has shown following blood exposure to HIV has shown effectiveness (about 79%) in preventing effectiveness (about 79%) in preventing seroconversionseroconversion

PROTECT THE PATIENTPROTECT THE PATIENT Place blood collection equipment away from Place blood collection equipment away from

patients, especially children and psychiatric patients, especially children and psychiatric patients.patients.

Practice hygiene for the patient's Practice hygiene for the patient's protection. When wearing gloves, change protection. When wearing gloves, change them between each patient and wash your them between each patient and wash your hands frequently. Always wear a clean lab hands frequently. Always wear a clean lab coat or gown.coat or gown.

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IF BLOOD STOPS FLOWING INTO THE TUBE:IF BLOOD STOPS FLOWING INTO THE TUBE: The vein may have collapsed; resecure the The vein may have collapsed; resecure the

tourniquet to increase venous filling. If this is tourniquet to increase venous filling. If this is not successful, remove the needle, take care of not successful, remove the needle, take care of the puncture site, and redraw.the puncture site, and redraw.

The needle may have pulled out of the vein when The needle may have pulled out of the vein when switching tubes. Hold equipment firmly and switching tubes. Hold equipment firmly and place fingers against patient's arm, using the place fingers against patient's arm, using the flange for leverage when withdrawing and flange for leverage when withdrawing and inserting tubes.inserting tubes.

PROBLEMS OTHER THAN AN INCOMPLETE PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:COLLECTION:

A hematoma forms under the skin adjacent to A hematoma forms under the skin adjacent to the puncture site - release the tourniquet the puncture site - release the tourniquet immediately and withdraw the needle. Apply firm immediately and withdraw the needle. Apply firm pressure.pressure.

The blood is bright red (arterial) rather than The blood is bright red (arterial) rather than venous. Apply firm pressure for more than 5 venous. Apply firm pressure for more than 5 minutes.minutes.

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TROUBLESHOOTING GUIDELINES:TROUBLESHOOTING GUIDELINES: IF AN INCOMPLETE COLLECTION OR NO BLOOD IF AN INCOMPLETE COLLECTION OR NO BLOOD

IS OBTAINED:IS OBTAINED: Change the position of the needle. Move it Change the position of the needle. Move it

forward (it may not be in the lumen)forward (it may not be in the lumen) or move it backward (it may have penetrated or move it backward (it may have penetrated

too far).too far). Adjust the angle (the bevel may be against the Adjust the angle (the bevel may be against the

vein wall).vein wall). Loosen the tourniquet. It may be obstructing Loosen the tourniquet. It may be obstructing

blood flow.blood flow. Try another tube. There may be no vacuum in Try another tube. There may be no vacuum in

the one being used.the one being used. Re-anchor the vein. Veins sometimes roll away Re-anchor the vein. Veins sometimes roll away

from the point of the needle and puncture from the point of the needle and puncture site.site.

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BLOOD COLLECTION ON BABIES:BLOOD COLLECTION ON BABIES: The recommended location for blood collection on a The recommended location for blood collection on a

newborn baby or infant is the heel. The diagram newborn baby or infant is the heel. The diagram below indicates in green the proper area to use for below indicates in green the proper area to use for heel punctures for blood collection:heel punctures for blood collection:

Prewarming the infant's heel (42 C for 3 to 5 minutes) Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to obtain capillary blood blood gas is important to obtain capillary blood blood gas samples and warming also greatly increases the flow samples and warming also greatly increases the flow of blood for collection of other specimens. However, of blood for collection of other specimens. However, do not use too high a temperature warmer, because do not use too high a temperature warmer, because baby's skin is thin and susceptible to thermal injury.baby's skin is thin and susceptible to thermal injury.

Clean the site to be punctured with an alcohol Clean the site to be punctured with an alcohol sponge. Dry the cleaned area with a dry cotton sponge. Dry the cleaned area with a dry cotton sponge. Hold the baby's foot firmly to avoid sudden sponge. Hold the baby's foot firmly to avoid sudden movement.movement.

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BLOOD COLLECTION ON BABIES:BLOOD COLLECTION ON BABIES:Using a sterile blood lancet, puncture the side of Using a sterile blood lancet, puncture the side of

the heel in the appropriate regions shown above the heel in the appropriate regions shown above in green. Do not use the central portion of the in green. Do not use the central portion of the heel because you might injure the underlying heel because you might injure the underlying bone, which is close to the skin surface. Do not bone, which is close to the skin surface. Do not use a previous puncture site. Make the cut use a previous puncture site. Make the cut across the heelprint lines so that a drop of blood across the heelprint lines so that a drop of blood can well up and not run down along the lines.can well up and not run down along the lines.

Wipe away the first drop of blood with a piece of Wipe away the first drop of blood with a piece of clean, dry cotton. Since newborns do not often clean, dry cotton. Since newborns do not often bleed immediately, use gentle pressure to bleed immediately, use gentle pressure to produce a rounded drop of blood. Do not use produce a rounded drop of blood. Do not use excessive pressure or heavy massaging because excessive pressure or heavy massaging because the blood may become diluted with tissue fluid.the blood may become diluted with tissue fluid.

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BLOOD COLLECTION ON BABIES:BLOOD COLLECTION ON BABIES: Fill the capillary tube(s) or micro collection device(s) Fill the capillary tube(s) or micro collection device(s)

as needed.as needed. When finished, elevate the heel, place a piece of When finished, elevate the heel, place a piece of

clean, dry cotton on the puncture site, and hold it in clean, dry cotton on the puncture site, and hold it in place until the bleeding has stopped.place until the bleeding has stopped.

Be sure to dispose of the lancet in the appropriate Be sure to dispose of the lancet in the appropriate sharps container. Dispose of contaminated materials sharps container. Dispose of contaminated materials in appropriate waste receptacles. Remove your in appropriate waste receptacles. Remove your gloves and wash your hands.gloves and wash your hands.

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Red Top ADDITIVE None Red Top ADDITIVE None MODE OF ACTION Blood MODE OF ACTION Blood clots, and the serum is clots, and the serum is separated by separated by centrifugation USES centrifugation USES Chemistries, Immunology Chemistries, Immunology and Serology, Blood Bank and Serology, Blood Bank (Crossmatch)(Crossmatch)

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Gold Top Gold Top ADDITIVE None MODE OF ADDITIVE None MODE OF ACTION Serum separator tube (SST) ACTION Serum separator tube (SST) contains a gel at the bottom to separate contains a gel at the bottom to separate blood from serum on centrifugation blood from serum on centrifugation USES Chemistries, Immunology and USES Chemistries, Immunology and Serology Serology

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Light Green Top Light Green Top ADDITIVE Plasma ADDITIVE Plasma Separating Tube (PST) with Lithium Separating Tube (PST) with Lithium heparin MODE OF ACTION heparin MODE OF ACTION Anticoagulates with lithium heparin; Anticoagulates with lithium heparin; Plasma is separated with PST gel at the Plasma is separated with PST gel at the bottom of the tube USES Chemistries bottom of the tube USES Chemistries

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Red-Gray Top Red-Gray Top ADDITIVE Serum ADDITIVE Serum Separating Tube (SST) with clot Separating Tube (SST) with clot activator MODE OF ACTION Forms clot activator MODE OF ACTION Forms clot quickly and separates the serum with quickly and separates the serum with SST gel at the bottom of the tube USES SST gel at the bottom of the tube USES Chemistries Chemistries

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Purple Top Purple Top ADDITIVE EDTA liquid ADDITIVE EDTA liquid MODE OF ACTION Forms calcium salts to MODE OF ACTION Forms calcium salts to remove calcium USES Hematology remove calcium USES Hematology (CBC) and Blood Bank (Crossmatch); (CBC) and Blood Bank (Crossmatch); requires requires full drawfull draw - invert 8 times to - invert 8 times to prevent clotting and platelet clumping prevent clotting and platelet clumping

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Light Blue Top Light Blue Top ADDITIVE Sodium ADDITIVE Sodium citrate MODE OF ACTION Forms calcium citrate MODE OF ACTION Forms calcium salts to remove calcium USES salts to remove calcium USES Coagulation tests (protime and Coagulation tests (protime and prothrombin time), prothrombin time), full drawfull draw required required

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Dark Green Top Dark Green Top ADDITIVE Sodium ADDITIVE Sodium heparin or lithium heparin MODE OF heparin or lithium heparin MODE OF ACTION Inactivates thrombin and ACTION Inactivates thrombin and thromboplastin USES For lithium level, thromboplastin USES For lithium level, use sodium heparin use sodium heparin For ammonia level, use sodium or For ammonia level, use sodium or lithium heparin lithium heparin

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Dark Blue Top Dark Blue Top ADDITIVE Sodium ADDITIVE Sodium EDTA MODE OF ACTION Tube is EDTA MODE OF ACTION Tube is designed to contain no contaminating designed to contain no contaminating metals USES Trace element testing metals USES Trace element testing (zinc, copper, lead, mercury) and (zinc, copper, lead, mercury) and toxicology toxicology

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Light Gray Top Light Gray Top ADDITIVE Sodium ADDITIVE Sodium fluoride and potassium oxalate MODE fluoride and potassium oxalate MODE OF ACTION Antiglycolytic agent OF ACTION Antiglycolytic agent preserves glucose up to 5 days USES For preserves glucose up to 5 days USES For lithium level, use sodium heparin lithium level, use sodium heparin Glucoses, requires Glucoses, requires full drawfull draw (may (may cause hemolysis if short draw) cause hemolysis if short draw)

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Yellow Top Yellow Top ADDITIVE ACD (acid-ADDITIVE ACD (acid-citrate-dextrose) MODE OF ACTION citrate-dextrose) MODE OF ACTION Complement inactivation USES HLA Complement inactivation USES HLA tissue typing, paternity testing, DNA tissue typing, paternity testing, DNA studies studies

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Yellow - Black Top Yellow - Black Top ADDITIVE Broth ADDITIVE Broth mixture MODE OF ACTION Preserves mixture MODE OF ACTION Preserves viability of microorganisms USES viability of microorganisms USES Microbiology - aerobes, anaerobes, fungi Microbiology - aerobes, anaerobes, fungi

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Black Top Black Top ADDITIVE Sodium citrate ADDITIVE Sodium citrate (buffered) MODE OF ACTION Forms (buffered) MODE OF ACTION Forms calcium salts to remove calcium USES calcium salts to remove calcium USES Westergren Sedimentation Rate; Westergren Sedimentation Rate; requires requires full drawfull draw

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Orange Top Orange Top ADDITIVE Thrombin ADDITIVE Thrombin MODE OF ACTION Quickly clots blood MODE OF ACTION Quickly clots blood USES STAT serum chemistries USES STAT serum chemistries

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Brown Top Brown Top ADDITIVE Sodium heparin ADDITIVE Sodium heparin MODE OF ACTION Inactivates thrombin MODE OF ACTION Inactivates thrombin and thromboplastin USES Serum lead and thromboplastin USES Serum lead determination determination

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SAMPLE PROCESSINGSAMPLE PROCESSING GENERALLY, SAMPLES SHOULD BE GENERALLY, SAMPLES SHOULD BE

ANALYZED WITHIN 4 HOURS AND TO ANALYZED WITHIN 4 HOURS AND TO MINIMIZE THE EFFECT OF EVAPORATION, MINIMIZE THE EFFECT OF EVAPORATION, THEY SHOULD BE PROPERLY CAPPED, THEY SHOULD BE PROPERLY CAPPED, AWAY FROM AREAS OF RAPID AIRFLOW, AWAY FROM AREAS OF RAPID AIRFLOW, LIGHT AND HEAT.LIGHT AND HEAT.

REFRIGERATION AT 4C FOR 8h, MOST REFRIGERATION AT 4C FOR 8h, MOST ANALYTES ARE QUITE STABLE EXCEPT ANALYTES ARE QUITE STABLE EXCEPT ALP(INCREASE) AND LDH(DECREASE)ALP(INCREASE) AND LDH(DECREASE)

FROZEN AT -20CFROZEN AT -20C

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SAMPLE VARIABLESSAMPLE VARIABLES Physiologic considerationsPhysiologic considerations Proper patient preparationProper patient preparation Problems in collectionProblems in collection TransportationTransportation Processing Processing StorageStorage

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CHAIN OF CUSTODYCHAIN OF CUSTODY TESTS ARE LINKED TO CRIME OR TESTS ARE LINKED TO CRIME OR

ACCIDENTACCIDENT DOCUMENT SPECIMEN IDENTIFICATION DOCUMENT SPECIMEN IDENTIFICATION

AND PHASE OF PROCESSAND PHASE OF PROCESS TAMPER-PROOF SEALTAMPER-PROOF SEAL WITNESSWITNESS CO-SIGNCO-SIGN