What is the proper procedure for writing a lab order?

Proper Procedure for Writing a Lab Order

Laboratory orders must be written in a standardized format with complete information to ensure patient safety, accurate testing, and proper interpretation of results. 1 Written lab orders should follow a structured approach that includes patient identifiers, clinical information, and specific test details.

Essential Components of a Lab Order

Patient Information

• Patient's full name and a second identifier (e.g., medical record number, date of birth) 1
• Patient's date of birth 1
• Patient's location (inpatient unit, outpatient clinic)

Order Details

• Date and time of order 1
• Diagnosis or reason for testing 1
• Test name using standardized nomenclature 1
• Specific testing protocol or regimen name if applicable 1
• Specimen source when appropriate 1
• Priority level of testing (routine, urgent, STAT) 2

Provider Information

• Name and contact information of the ordering provider 1
• Provider's signature
• Provider's National Provider Identifier when required 1

Best Practices for Lab Order Writing

Use Standardized Forms and Systems

• Utilize standardized, preprinted or electronic forms for test ordering 1
• Follow institutional protocols for test ordering procedures 1
• Use computerized provider order entry systems when available to reduce errors
• Use full generic names and avoid unapproved abbreviations 1

Prioritization of Tests

• Implement a priority system for test ordering (e.g., color-coded system) 2
  • STAT/emergent: Immediate processing (e.g., cardiac enzymes, arterial blood gases)
  • Urgent: Process within 1-2 hours
  • Routine: Standard processing time

Specimen Considerations

• Include specific instructions for specimen collection if needed
• Note any special handling requirements (e.g., "keep on ice," "protect from light")
• Document timing requirements for serial specimens or timed collections

Important Safeguards and Pitfalls to Avoid

Avoid Common Errors

• Never use verbal orders except to hold or stop testing 1
• Avoid handwritten labels; use computer-printed labels when possible 1
• Do not use ambiguous abbreviations or non-standard test names 1
• Prevent duplicate ordering of tests within inappropriate timeframes 2, 3

Documentation Requirements

• For specialized testing, include supporting references or justification 1
• Document any dose modifications or exceptions with clear reasoning 1
• For genetic or specialized testing, include relevant family history when appropriate 1

Communication Considerations

• Ensure timely transmission of orders to the laboratory 1
• Include contact information for critical result notification
• Provide adequate clinical information to guide test interpretation 1

Special Situations

Send-out Testing

• Process and send specimens to reference laboratories within 3 working days 1
• Include an accurate sample list with volumes and locations 1
• Provide a pictorial illustration of sample arrangements when helpful 1
• Inform receiving laboratory ahead of time to ensure proper handling 1

Research or Protocol-Based Testing

• Include protocol name and number when applicable 1
• Document informed consent for specialized testing 1
• Note if test is part of a research protocol or clinical trial

By following these standardized procedures for writing laboratory orders, clinicians can ensure accurate testing, reduce errors, and improve patient care outcomes while minimizing unnecessary testing and associated costs.