Specimen Submission

Test Requisitions

Specimens for laboratory testing must be submitted with a written request (requisition) for testing or an electronic order (barcoded label). The following requests are acceptable:

1. Customized paper requisition form with pre-printed client information for submissions from providers outside Stanford Health Care
2. Approved, general-use paper requisition for a specific testing specialty
3. Printed copy of test order from Stanford Health Care or Stanford Children’s Health EPIC systems
4. Stanford Health Care EPIC-barcoded laboratory label affixed to the specimen container

Verbal Orders, Standing Orders and Add-On-Tests

Regulations require that all verbal orders for tests must be confirmed by a written signed requisition within 30 days of the request. This includes standing orders, add-on requests, and verbal orders for all patients. The laboratory will provide the request form to be used, either via fax, mail or download here to confirm the request. No official results will be sent out until written confirmation is received from the physician.

Patient Identification

All patients from whom clinical specimens are obtained must be positively identified prior to specimen collection with two identifiers. Positive identification and proper labeling ensure accurate patient identification throughout the testing process from collection to results. Positive identification is the responsibility of the person collecting the sample.  Specimens may be rejected if positive patient identification cannot be confirmed by the laboratory.

Specimen Labeling

Stanford Health Care and Stanford Children’s Health – EPIC Labeling:

Barcoded labels with accession numbers generated by the Stanford Health Care or Stanford Children’s Health EPIC systems are recommended for affiliated providers. These labels must be affixed to the specimen in an irreversible fashion. Specimens without affixed labels will not be tested. The date, time and identification of collector must be recorded in EPIC after the specimen has been drawn and after verifying that the patient name and a secondary unique identifier (such as a Medical Record Number) on the label matches with that on the order. This is the single most important factor in preventing errors in patient specimen identification.

Non-EPIC Labels and EPIC Downtime Labeling:

If a non-barcoded label is used, the following information must be legibly recorded on the label affixed in an irreversible fashion to the specimen container:

• Patient's full name (avoid nicknames and abbreviations). The label on the specimen container must match the patient's name on the accompanying requisition or test request
• Medical Record Number or other unique identifier (date of birth may be used as a unique identifier, except for specimens collected for pre-transfusion testing)
• Date and time of collection
• Signature or initials of person who identified the patient, collected the specimen and labeled the specimen
• Specimen source (if indicated, based on the test requested)

Avoid Specimen Labeling Pitfalls:

• Use of a request form wrapped around the container or packaged with the container is not acceptable as a specimen label. A label must be irreversibly affixed to each container submitted to the laboratory.
• Use one label per specimen. Avoid affixing multiple labels to one container when possible.
• The label should be affixed directly to the specimen container and not to the bag.
• Specimens with labels that do not contain all required information (or for which the information is not legible or does not match an accompanying test requisition) will be considered improperly identified and may result in specimen rejection or delay of testing pending confirmation of positive patient identification.

Rejection of Specimens

Proper specimen collection and handling are essential to obtaining valid, timely test results. All test requisitions and specimens must meet the established criteria for identification, collection, volume, and testing in order to be processed. The laboratory will not process unlabeled, mislabeled, or misidentified specimens. When such a specimen is received, the laboratory will contact the submitter. The nurse or physician will be informed that the specimen is improperly identified, and a new specimen may need to be obtained if clinically indicated. 

Safety Precautions

All specimens should be regarded as potentially hazardous or infectious. Universal Blood and Body Substance Techniques should be observed when handling and transporting specimens. Specimen tubes and containers should be tightly capped to prevent leakage. Specimen bags should be closed securely to prevent leakage.

Shipping Instructions

Place the labeled specimen in a leak-proof plastic biohazard bag and securely seal. Place any accompanying paperwork or requisitions in the outside pouch of the bag as needed. Arrange for transportation to the laboratory as soon as possible.  

When delivery to the laboratory cannot be accomplished immediately, refer to specific tests in the test directory for temperature requirements, special handling instructions, and specimen stability information to preserve the integrity of the sample during transport.

When shipping Infectious Substances, the contents must be packed by personnel who are trained in accordance with the provisions contained in the United States Department of Transportation (DOT) and/or International Air Transportation Association (IATA) regulations for shipping Infectious Substances. Please refer to Regulatory Links on the Compliance page of the Test Directory.

The shipper is required to comply with the rules and guidelines for transport of medical specimens as set forth by the United States government, the government of the country of origin and international regulatory agencies. Failure to follow instructions for packaging and shipping specimens can result in the delay, loss or destruction of your specimens. Stanford Health Care will not be held responsible for any liability attributable to the shipper’s improper actions or failure to comply with federal, state, and local regulations.

Venipuncture Collection

Specimen collection is the first step in the process of acquiring quality results. Improper collection methods or techniques can result in erroneous results. Patients from whom clinical specimens are obtained must be positively identified prior to specimen collection. Follow your institution’s policies and procedures for the safe collection and handling of blood specimens for diagnostic testing.

NOTE: Blood of all patients are considered potentially infectious for hepatitis B virus (HBV) and other blood-borne pathogens, and universal precautions must be followed. Please refer to OSHA 1910.1030 - Bloodborne pathogens for more information.

To prevent the rejection of specimens, the following information must be legibly recorded on each irreversibly affixed label for specimens submitted to Stanford Health Care.

• Patient full first and last name
• Medical Record Number (or other unique identifier such as date of birth)
• Date and time of collection
• Initials or name of the person who identified the patient, collected, and labeled the specimen

NOTE: For Stanford Health Care or Stanford Children’s Health providers collecting specimens using EPIC, the date/time of collection and the collector identification may be electronically recorded.

After collection, mix the tubes by gentle inversion 8 to 10 times. Centrifuge at 3,000 – 3500 rpm for 10 to 15 minutes if indicated. Proper centrifugation is critical for proper separation of cells from serum or plasma. Store and transport specimen upright to maintain separation. Refer to the Test Directory webpages for specific collection and handling instructions for each test.

Some tests require plasma or serum to be separated and refrigerated or frozen within a defined time frame to preserve the integrity of the specimen. If a specimen is frozen for storage or for transport before arriving to the laboratory, do not allow it to thaw. Keep frozen on ice or dry ice as needed during transport. Store separated specimens upright in the refrigerator unless otherwise specified by the test requirements. Please refer to the Test Directory for specific information for specimen handling for each test.

Tips

• Avoid Hemolysis and stasis due to prolonged application of the tourniquet which can occur after 1 minute of application. When hemolysis occurs, red blood cells are lysed, and hemoglobin is released. When the serum is separated, the color will appear pink or red. Hemolysis can cause falsely increased results for many analytes, including potassium, magnesium, iron, lactate, phosphorous, ammonia, and total protein.
• Use a butterfly needle for pediatric patients and for patients for which venipuncture may be more difficult.
• Central lines. Avoid collecting specimens from veins where administration of fluids will cause abnormal levels of electrolytes, glucose, or drugs. Avoid contamination from heparin locks for coagulation tests.
• Use the correct tube and draw tubes in the proper sequence.  Collect the specimen into the proper tube or container using the correct sequence of draw. This avoids cross contamination of anticoagulants in some tubes which can interfere with certain test results.

Order of Specimen Containers for Blood Draw

A. Obtain blood specimens in the following order:

• Blood Culture bottles
• Non- Additive tube (Red-top tube) (Plain)
• Coagulation tube (Light blue-top tube). A Light blue-top tube (Sodium citrate) tube is never the first tube drawn when using a butterfly. If a coagulation assay is the only test ordered, draw 1-2cc’s into a non-additive tube (red-top) first and then draw the Light blue-top tube.
• Red top tubes with clot activator
• SST Gold-top tube
• Last- Additive tubes in this order:
• Heparin: Green-top tube (Sodium heparin) or Gel- mint-top tube (Lithium heparin). Mint-top tubes must never be used to draw cytogenetics samples
• Lavender- top tube (EDTA)
• Gray-top-tube (Oxalate/fluoride)
• Other additive tubes
• Special instructions for collecting specimens for metal analysis apply. Please refer to the Test Directory for these tests.

Urine Specimen Collection

Random Urine Collection for Routine Urinalysis or Urine Culture  

All urine specimens should be collected as clean catch urine specimens, unless otherwise indicated. Please refer to the Test Directory for specific tests. The first voided morning specimen is preferred. Urine specimens for Urinalysis require immediate refrigeration or transfer to a urine preservative/or growth inhibitor transport tube for urinalysis or culture as applicable for optimal results.

The BD 364957 Vacutainer® Complete Urine Collection System with Preservative Tube is the preferred collection system for most urine testing. However, sterile, screw-cap containers may also be used for collection.

Patient Instructions: Male

• The hands are to be thoroughly washed with soap and water and dried with a paper towel.
• The initial portion of urine is passed into the toilet bowl. A portion of the remaining urine should be passed into a sterile, screw-cap plastic cup.
• Aliquot a portion to a urine transport tube (contains preservative) for routine urinalysis or special urine culture transport tube for Microbiology testing.
• Transport the specimen to the laboratory immediately or refrigerate if transport is delayed.

Patient Instructions: Female

• The hands are to be thoroughly washed with soap and water and dried with a paper towel.
• With one hand the patient should spread her labia and keep them continuously apart until the urine is voided into a sterile screw-cap container.
• The patient should cleanse the urethral meatus from front to back.
• The patient should void the urine and after the first portion of the urine is passed, a specimen should be caught in the sterile container without stopping the stream. The sterile container should be held in such a way that contact with the legs, vulva, or clothing is avoided.
• Aliquot a portion to a urine transport tube (contains preservative) for routine urinalysis or special urine culture transport tube for Microbiology testing.
• Transport the specimen to the laboratory immediately or refrigerate if transport is delayed.

24 hour Urine Collection – For Patients

Instructions for Patients: 24 Hour Timed Urine Collection

Your doctor has ordered a test which requires a 24-hour timed urine collection. It is most important that you make sure that all urine voided during the time period is collected. If you plan to go out and about, you should take the collection container with you. Please deliver the collection container and the requisition to the laboratory as soon as possible after completion of the collection period.

Instructions for Day of Test

• To complete a 24-hour collection, follow the instructions below for Day 1 and Day 2 collections.  
• Do not void directly into container.  Collect urine each time in a disposable clean plastic or paper cup and carefully pour into the 24-hour container.
  • When adding a specimen to the container, add slowly to avoid splatter to skin and eyes and avoid spilling the urine. If splatter occurs, wash off with cold water.
• Refrigerate during and after collection.

Day 1: Discard the first morning specimen and record time. Collect ALL specimens during the remainder of the day and night.

• Record on label: START DATE AND TIME:______________

Day 2: Collect the first morning specimen and then STOP Collection.

• Record on label: STOP (FINISH) DATE AND TIME:_______________
• Tighten lid securely. Keep upright during storage and transport. Transport in a refrigerated container with the order from your doctor as soon as possible after completion.
• If the amount of specimen exceeds capacity of the 24-hour urine container, use a similar sealable clean plastic container such as a clean and rinsed milk or juice container to collect additional urine and refrigerate as in the original process. Label as container number 2 and note on the requisition that 2 containers submitted.

24 hour Urine Collection – For Providers

General Information for Health Care Professionals:

Containers and/or preservatives are available from the Central Supply department or from a local Patient Service Center.  If you need a collection container, request a 24-hour Urine Collection Container and specify for which test.

For most collections, preservatives are not added to the container with the exception of testing for metanephrines, which require 10 grams of Boric Acid to be added at the start of collection. However, all specimens should be refrigerated during the collection process.  When collection is completed, specimens must be delivered to the laboratory immediately for processing and addition of preservatives if applicable.

• If applicable chemical preservatives are added in the laboratory as soon as the specimen is delivered.
• In order to calculate body surface area for Clearance test, Height and Weight must be given and a blood specimen is required.
• Write information on the attached Request Form.
• If multiple tests are ordered, more than one method of preservation may be required and additional specimen collection periods at a different time will be necessary.
  • Dietary restrictions may apply. See specific test for information.
  • Some specimens require protection from light.
  • Patient Instruction forms are available upon request.

Consult the Individual test in the Test Directory for specific collection instructions, preservative, storage, temperature and transport information.

To submit aliquot, mix specimen well by inverting container several times (be sure lid is securely tightened), measure total volume and submit aliquot as indicated in Test Directory/ Laboratory Guide or submit entire specimen container. Note amount & name of preservative if added.

Be sure to write on the label and on the Test Request form the:

• Patient name
• Test name
• Date of collection
• Timed Interval of collection
• Total Volume or Submit entire specimen collected in original collection
• Check urine specimen containers to be sure lids are secured.
• Keep specimens in an upright position
• Prepare specimen for submittal promptly to the laboratory
• Keep refrigerated during transport.