Laboratory/Diagnostic Procedural Checklist

INTRODUCTION: The checklist is a basic template for all sites and types of studies; detailed information is found in the individual studies and Appendix A, Patient Preparation and Specimen Collection.
*PRETEST: Preparation begins with good communication, active listening, timely education, and organization.*
1	Obtain/review a history of the patient’s health concerns, symptoms, surgical procedures, and results of previously performed studies.	Y	N	N/A
2	Obtain/review a history of known allergens, especially allergies to latex, anesthetics, contrast medium, sedatives, or other medications.	Y	N	N/A
3	Obtain/review a list of the patient’s current medications including over-the-counter medications, dietary supplements, anticoagulants, aspirin, and other salicylates. Some may be discontinued by medical direction prior to a study. Note the last time and dose of medications taken.	Y	N	N/A
4	Note any current medications, allergies, therapies, or other procedures that might affect study results.	Y	N	N/A
5	Introduce yourself and positively identify the patient using two person-specific identifiers before services, treatments, or procedures are performed. Explain that the ID process is a safety measure, and it applies to each patient encounter.	Y	N	N/A
6	Explain how the procedure will aid in evaluation and assessment of their clinical condition.	Y	N	N/A
7	Inform the patient of any instructions regarding pretesting diet, fluid, medication, or activity.	Y	N	N/A
8	Review the details of the procedure with the patient including but not limited to a description of the procedure, what part of the body will be evaluated, whether or not the procedure is invasive, where it will take place, how long it will take, and who will be involved.	Y	N	N/A
9	Demonstrate sensitivity to cultural issues as well as concern for modesty.	Y	N	N/A
10	Address concerns about pain and explain that there may be some discomfort during the venipuncture, IV insertion, or procedure itself.	Y	N	N/A
11	Explain that sedation may be ordered for patients who are unable to cooperate (fear of medical procedures, pediatric, combative, cognitively impaired, etc.).	Y	N	N/A
12	Ensure informed, written consent has been signed and documented prior to the procedure and before administering any medications related to the procedure.	Y	N	N/A
13	Notify the individual who is performing a study where bleeding is a known complication if the patient is taking aspirin, prescribed or natural anticoagulants.	Y	N	N/A
*Diagnostic Specifics*
14	Consider whether scheduling conflicts exist. Check history of recent procedures and consult with the laboratory or imaging department regarding potential interferences.	Y	N	N/A
15	Record the date of the last menstrual period. Pregnancy testing may be indicated before exposure to radiation or anesthetics.	Y	N	N/A
16	Consider complications regarding the use of IV iodinated or GBCA contrast medium in patients with preexisting renal insufficiency (BUN, Cr, GFR with notification of abnormal results to the radiologist prior to study); taking metformin for type 2 diabetes (metformin should be discontinued on the day of the test and may continue to be withheld for 48 hours after the test); or sensitivity to contrast (administer ordered premedication of corticosteroids and diphenhydramine).	Y	N	N/A
17	Instruct the patient to remove jewelry and other metallic objects from the area to be examined before going to the procedure location.	Y	N	N/A
*Considerations for Pregnant and Breastfeeding Patients*
18	Be aware of facility guidelines regarding the use of IV iodinated, GBCA contrast medium, and radionuclides in pregnant patients or patients who are breastfeeding.	Y	N	N/A
*Pediatric Considerations*
19	Be aware of general guidelines for pretest fasting: birth to 6 months, 3 hours; 7 months to 2 years, 4 hours; 3 years and older, 6 hours.	Y	N	N/A
20	Consider the age of the child; use words they will understand to give instructions. Encourage parents to be truthful about what the child may experience or must do.	Y	N	N/A
INTRATEST: These may be performed by HCPs in other departments .
21	Positively identify the patient.	Y	N	N/A
22	Review and ensure the patient followed all pretesting instructions regarding food, fluids, medications, activity, etc.	Y	N	N/A
23	Ensure informed, written consent has been signed and documented prior to the procedure and before administering any medications related to the procedure.	Y	N	N/A
24	Communicate known allergies; avoid the use of allergenic materials if possible.	Y	N	N/A
25	Labeling of containers should be completed *after*specimen collection and include patient demographics, initials of the person collecting the specimen, date and time of collection, and laterality.	Y	N	N/A
*Diagnostic Specifics*
26	Ensure that emergency medical equipment and medications are readily available in case of complications (e.g., bleeding, allergic reaction).	Y	N	N/A
27	Insert the IV for administration of ordered contrast, radionuclides, fluids, or medications. Ensure patency.	Y	N	N/A
28	Administer ordered medications: sedatives, anesthetics, prophylactic steroids, or antihistamines (history of allergic reaction).	Y	N	N/A
29	Instruct the patient to void prior to the procedure (unless a full bladder is needed) and to change into the robe, gown, and foot coverings.	Y	N	N/A
30	Clip hair from the area immediately before the procedure per organizational policy or standards of practice.	Y	N	N/A
31	Record baseline vital signs and assess neurological status.	Y	N	N/A
32	Monitor the patient for complications during the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm, bleeding).	Y	N	N/A
POST-TEST: The patient should be monitored for any related complications, be provided the opportunity to ask questions or express concerns, and be provided education regarding their health care.
33	Observe the needle/catheter insertion site for bleeding, hematoma, and inflammation; apply direct pressure with dry gauze and secure with an adhesive bandage.	Y	N	N/A
34	Transport specimens promptly to the laboratory for processing and analysis.	Y	N	N/A
35	Inform the patient that the requesting health-care provider (HCP) will discuss the results with them.	Y	N	N/A
36	Instruct the patient to resume usual diet, fluids, medications, and activity as directed by the HCP (ensure gag reflex has returned).	Y	N	N/A
37	Complete postprocedural vital signs, assessments (venipuncture site, diagnostic study site), and neurological checks in relation to the procedure performed.	Y	N	N/A
38	Monitor the patient for related postprocedure complications (e.g., allergic reaction, anaphylaxis, bronchospasm, bleeding).	Y	N	N/A
39	Compare current findings with previous results. Evaluate test results in relation to the patient’s symptoms and other tests performed.	Y	N	N/A
40	Provide timely notification of a critical finding and related symptoms. The notification process should include: Read back to the caller of patient’s name, one other patient-specific identifier, critical finding, name of the person giving the report, time and date of the report, name of the person receiving the report. Similar documentation is made when handing off communication to the requesting HCP.	Y	N	N/A
41	Review policy regarding any delay in a timely report of a critical finding. Actions may require completion of a notification form with review by Risk Management.	Y	N	N/A
42	Provide a compassionate, reassuring environment. Recognize patient/family anxiety related to study results, and support coping strategies.	Y	N	N/A
43	Encourage questions and verbalization of concerns; provide answers and support.	Y	N	N/A
44	Provide teaching and information regarding the clinical implications of results.	Y	N	N/A
45	Explain any post-test restrictions (e.g., breastfeeding and nuclear medicine tests).	Y	N	N/A
46	Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.	Y	N	N/A
47	Explain that additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Be prepared to educate the patient regarding access to the appropriate counseling services.	Y	N	N/A
48	Discuss the implications of abnormal results on the patient’s lifestyle, and explain the patient/family role in successfully achieving expected patient outcomes.	Y	N	N/A

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Introduction