Labeling, Requisition and Collection Instructions

Refer to Hospital policy: 18004-Specimen Labeling for Laboratory Processing (Internal Link)

The Division of Anatomic Pathology requires the submission of a completed Anatomic Pathology Requisition (order) for each tissue specimen or group of tissue specimens submitted for evaluation.

1. Each Anatomic Pathology Requisition must be legible and include the following information:
   1. Patient Identification (either EMR-generated demographic label or legibly handwritten at top of requisition) must include at least:
      1. Patient's Full Name (Last, First).
      2. Medical Record Number/Unit Number.
   2. Name or designation of Unit/Ward/Clinic submitting specimens.
   3. Name and PI # of Attending Physician.
   4. Name and PI # of Requesting Physician/Surgeon.
   5. Name and Pager number of Requesting Physician/Surgeon.
   6. Date and Time of specimen collection.
   7. Suspected Diagnoses.
   8. Relevant clinical information.
   9. Legible, specific and concise anatomic description of each specimen.
   10. Name or designation of Unit/Ward/Clinic where written report is to be sent.
   11. Special requests or instructions, such as:
       1. Special stains or IHC requests.
       2. Molecular Genomic testing/patient enrolled in Clinical Trials.
2. Specimens submitted without requisition (order) or with incomplete information may be returned to submitting area for corrective action.
3. For telephone assistance or to schedule in-service training in completing Anatomic Pathology Requisitions, please call 916-734-2525.

The Division of Anatomic Pathology requires every tissue specimen from each patient to be properly labeled.

1. Each Anatomic Pathology specimen label must include at least the following information:
   • Patient's Full Name (Last, First)
   • Medical Record Number/Unit Number
   • Specific anatomic specimen source
2. Multiple specimens from the same operative procedure are designated as letters "A", "B"; etc. Each specimen must be listed with a precise description of the anatomic site.
3. A number/letter designation corresponding to the number/letter designation on the Anatomic Pathology Requisition (order).
4. Specimens submitted without a label or with incomplete or illegible information may be returned to submitting area for corrective action.
5. For telephone assistance or to schedule in-service training in completing Anatomic Pathology specimens labels, please call 916-734-2525.

Anatomic pathology results can be obtained by contacting AP Client Services at 916-734-2525, Monday through Friday from 8 a.m. - 4:30 p.m. . The patient's medical record number and full name are necessary in order to obtain anatomic pathology results.

All specimens must meet criteria as defined by the laboratory to be accepted for testing. As a general rule, blood and urine specimens that arrive in the laboratory unlabeled will be discarded. There will be no retrospective identification permitted. 

Specimen labelling data required:

1. Patient family name and individual name.

2. Unique patient identification number (8 digits).

3. Date and time of collection, the collector's initials.

4. For Blood Bank specimens, the collector's name is mandatory.

Requisition data required:

1. Patient family name and individual name.

2. Unique patient identification number (8 digits).

3. Ordering physician index number.

4. Ward or clinic routing or address.

5. Test requested.

6. Date and time of collection.

7. Collectors identification.

8. Gender (M/F).

9. Source or type of specimen.

UC Davis Medical Center DOE policy is acceptable as substitute.

Specimen container and test requisition must be received together and the label must match the requisition exactly.  If more than one container must be used (e.g., two jugs for a 24-hour urine collection) label as l of 2 and 2 of 2, to be sure they stay together. Labeling of specimens must be done by the person obtaining the specimen or by someone witnessing the act. 

Stool collections (24, 48, and 72 hour)

Patient Preparation:

Explain procedure to patient. Include instructions on:

a. Collecting urine separate from feces.

b. Saving all urine and feces.

c. Not mixing any foods together; only eating food provided/approved by dietician.

For specific instructions for collecting Send Out Stool Collections, call 916-734-0500.

Spot urine collection instructions

Clean Catch Instructions:

1. Instruct patient on how to best collect urine for a Urinalysis or urine culture:

Cleanse yourself with towelettes as follows:

Male:

Wipe head of penis in a single motion with first towelette. Repeat with second towelette. If not circumcised, hold foreskin back before cleansing. Urinate a small amount into toilet or bedpan. Proceed to step 4.

Female:

Separate the labia. Wipe inner labial folds front to back in a single motion with first towelette. Wipe down through center of labial folds with second towelette. Keep the labia separated and urinate a small amount into toilet or bedpan. Proceed to step 4.

4. Place cup under stream and continue to urinate into cup and collect specimen.

5. Finish voiding into toilet or bedpan.

6. Replace cap on cup. Tighten cap securely. Do not remove label from cap.

2. Provide appropriate specimen container and towelette:

a. Vacutainer Urine Collection Kit for urine culture and other miscellaneous spot urine test.

b. Urine container with cap and collection cup.

3. Avoid contamination, do not touch inside of cup or cap.

Urine collection (24 hour)

Patient Instructions:

   1. On Day 1, wake up and empty bladder into the toilet and write the date and time. Do not collect this urine.  Do record this time and date.

   2. From then on, collect all urine you pass during Day 1 and overnight into this container. Do not overfill, use a second jug if urine is more than 2900 mL (measurement lines on the side of container).

   3. Place jug in refrigerator between collections.

   4. On Day 2 you must wake up at the same time as Day 1 and try to empty your bladder into the collection container. It’s OK if your bladder is empty.  This is your stop time, It must be the same time as Step 1.

   5. Keep the urine refrigerated and return urine container to the lab on the day the collection is complete.

Example:

Bladder emptied into toilet on Jan. 1, 2023 at 5 a.m. (this is the time recorded in Step 1).  All urine collected from 5am on Day 1 until the last collection into the container at 5 a.m. on Day 2, Jan. 1, 2023 (this is the time recorded in Step 4).  After 5 a.m. on Jan. 1, 2023 empty bladder into toilet normally.

Important Notes:

• Any leaks will cause test to be cancelled. Make sure the cap is tightened to stop spills.
• Make sure to protect the label on the container, unlabeled containers may be rejected.
• Do Not fill jug to the top, use a second jug if level exceeds 2900 mL
• Any fecal matter in the collection container will result in cancellation and recollection.
• If any urine is spilled or if you do not collect all of the urine during the 24 hour period, you will need to recollect.

Instruction for patients on 24 hour urine collection:

1. Attach demographic label to 24 hour urine collection container.
   • Ask the patient if they’ve collected a 24 hour urine before. If they answer “Yes” ask if they require two collection containers.  If they answer “No” give them two collection containers.
2. Complete laboratory portion of 24 hour urine instructions
3. Explain process to patient. Be as clear and concise as possible:
   • On Day 1 of collection, wake up and empty bladder into the toilet. Write down this date and time in Step 1.
   • After the first void, collect all urine passed during day 1 into this container.
   • Place container in refrigerator between collections.
   • Do not fill jug to the top, use a second jug if liquid is more than 2900 mL
   • Continue to collect all urine overnight.
   • On Day 2, you must wake up at the same time as Day 1 and try to empty bladder into collection container. It’s ok if your bladder is empty.
   • This is your stop time. Write down the time you stopped in step 4.  It should be the same time as step 1.
   • If sample is spilled, or not all urine is collected you will have to recollect specimen.
4. Reminders to patient:
   • Avoid alcoholic beverages and vitamins for at least 24 hours before starting collection and during collection period.
   • Continue to take medications unless instructed by physician to discontinue.
   • Continue normal liquid intake and dietary habits 24 hours before and during collection unless instructed otherwise by physician.
   • Fecal matter in the collection container will result in cancellation and recollection.