{"id":33243,"date":"2023-10-29T08:09:25","date_gmt":"2023-10-29T08:09:25","guid":{"rendered":"https:\/\/www.process.st\/templates\/requisition-form-for-phlebotomy\/"},"modified":"2024-03-05T14:56:39","modified_gmt":"2024-03-05T14:56:39","slug":"requisition-form-for-phlebotomy","status":"publish","type":"post","link":"https:\/\/www.process.st\/templates\/requisition-form-for-phlebotomy\/","title":{"rendered":"Requisition Form for Phlebotomy"},"content":{"rendered":"\n<section id=\"patient-identification\"> \n <h2>Patient Identification<\/h2>\n <div class=\"text-content\">\n   Verify the identity of the patient to ensure accurate record-keeping and sample collection. This task is crucial in preventing any mix-ups or errors in the phlebotomy process. Collect the patient's full name, date of birth, and contact information. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Full Name <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"date-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Date of Birth <\/label> \n   <div class=\"date-container\"> <button type=\"button\" disabled class=\"btn btn-default\"> <i class=\"fa fa-calendar btn-icon\"><\/i> Date will be set here <\/button> \n   <\/div> \n  <\/div> \n <\/div> \n <div class=\"number-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Contact Number <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"explanation-of-procedure-to-patient\"> \n <h2>Explanation of procedure to patient<\/h2>\n <div class=\"text-content\">\n   Clearly explain the phlebotomy procedure to the patient to ensure their understanding and alleviate any anxiety or concerns they may have. Provide a friendly and reassuring explanation. \n <\/div> \n <div class=\"textarea-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Explanation <\/label> <textarea placeholder=\"Something will be typed here...\" rows=\"3\" disabled class=\"form-control\"><\/textarea> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"obtain-consent-from-patient\"> \n <h2>Obtain consent from patient<\/h2>\n <div class=\"text-content\">\n   Obtain the patient's consent before proceeding with the phlebotomy procedure. Inform them about the purpose of the collection, potential risks or discomfort, and their rights to refuse or withdraw consent. \n <\/div> \n <div class=\"select-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Consent <\/label> <select disabled class=\"form-control\"> <option value=\"An option will be selected here\">An option will be selected here<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Agreed \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Not Agreed \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n<\/section> \n<section id=\"prepare-the-requisition-form\"> \n <h2>Prepare the requisition form<\/h2>\n <div class=\"text-content\">\n   Ensure all necessary details are ready on the requisition form before collecting the blood sample. This form serves as a record of the patient's information, tests to be performed, and other relevant instructions. \n <\/div> \n<\/section> \n<section id=\"complete-patient-details-on-the-form\"> \n <h2>Complete patient details on the form<\/h2>\n <div class=\"text-content\">\n   Fill in the patient's details accurately and legibly on the requisition form. Include information such as name, date of birth, contact information, and any relevant medical history. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Full Name <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"date-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Date of Birth <\/label> \n   <div class=\"date-container\"> <button type=\"button\" disabled class=\"btn btn-default\"> <i class=\"fa fa-calendar btn-icon\"><\/i> Date will be set here <\/button> \n   <\/div> \n  <\/div> \n <\/div> \n <div class=\"number-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Contact Number <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"select-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Gender <\/label> <select disabled class=\"form-control\"> <option value=\"An option will be selected here\">An option will be selected here<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Male \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Female \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Other \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Address <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"indicate-type-of-tests-to-be-performed\"> \n <h2>Indicate type of test(s) to be performed<\/h2>\n <div class=\"text-content\">\n   Specify the type of test(s) to be conducted on the collected sample. This ensures that the correct tests are performed and accurately recorded for further analysis. \n <\/div> \n <div class=\"multi-choice-content form-field-content\"> \n  <div class=\"form-group\"> <label> Test Type <\/label> <select disabled class=\"form-control\"> <option value=\"\">Multiple options can be selected from this list<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Blood Count \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Glucose \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Cholesterol \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       4 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Hormone Levels \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       5 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Liver Function \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n<\/section> \n<section id=\"prepare-the-patient-for-venipuncture\"> \n <h2>Prepare the patient for venipuncture<\/h2>\n <div class=\"text-content\">\n   Ensure the patient is prepared for the blood collection procedure. This involves cleaning the site, positioning the patient comfortably, and making necessary arrangements for the collection process. \n <\/div> \n <div class=\"multi-select-content form-field-content\"> \n  <div class=\"form-group\"> <label> Preparation Checklist <\/label> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Clean the collection site \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Provide patient with a comfortable position \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Gather necessary equipment \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       4 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Explain the procedure to the patient \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       5 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Ensure patient comfort \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n<\/section> \n<section id=\"perform-the-venipuncture\"> \n <h2>Perform the venipuncture<\/h2>\n <div class=\"text-content\">\n   Execute the venipuncture procedure to collect the blood sample. Follow sterile techniques and the appropriate blood collection method to ensure a successful and safe collection process. \n <\/div> \n <div class=\"multi-select-content form-field-content\"> \n  <div class=\"form-group\"> <label> Venipuncture Steps <\/label> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Select appropriate site \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Apply tourniquet \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Cleanse site with disinfectant \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       4 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Insert needle into vein \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       5 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Collect adequate amount of blood \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n<\/section> \n<section id=\"label-the-collected-samples\"> \n <h2>Label the collected samples<\/h2>\n <div class=\"text-content\">\n   Label each collected sample accurately to maintain traceability and avoid mix-ups. Ensure that the labels include patient identification details and collection information. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Label Text <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"record-date-and-time-of-collection-on-the-form\"> \n <h2>Record date and time of collection on the form<\/h2>\n <div class=\"text-content\">\n   Document the exact date and time of sample collection on the requisition form. This information is crucial for tracking and analyzing the samples accurately. \n <\/div> \n <div class=\"date-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Collection Date <\/label> \n   <div class=\"date-container\"> <button type=\"button\" disabled class=\"btn btn-default\"> <i class=\"fa fa-calendar btn-icon\"><\/i> Date will be set here <\/button> \n   <\/div> \n  <\/div> \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Collection Time <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"inclusion-of-any-special-instructions\"> \n <h2>Inclusion of any special instructions<\/h2>\n <div class=\"text-content\">\n   Include any special instructions or considerations for the collected sample on the requisition form. This helps laboratory personnel understand and handle the sample appropriately. \n <\/div> \n <div class=\"textarea-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Special Instructions <\/label> <textarea placeholder=\"Something will be typed here...\" rows=\"3\" disabled class=\"form-control\"><\/textarea> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"seal-sample-in-a-biohazard-bag\"> \n <h2>Seal sample in a biohazard bag<\/h2>\n <div class=\"text-content\">\n   Securely seal the collected sample in a biohazard bag to minimize the risk of contamination or leakage during transportation. Ensure the bag is properly labeled with patient details. \n <\/div> \n<\/section> \n<section id=\"handover-of-the-filled-form-and-sample-to-the-courier\"> \n <h2>Handover of the filled form and sample to the courier<\/h2>\n <div class=\"text-content\">\n   Safely hand over the filled requisition form and the sealed sample to the designated courier. Ensure proper documentation is done to track the sample's journey. \n <\/div> \n<\/section> \n<section id=\"ensure-receivers-signature-on-form\"> \n <h2>Ensure receiver's signature on form<\/h2>\n <div class=\"text-content\">\n   Obtain the signature of the receiver to acknowledge the handover of the filled requisition form. This ensures accountability and a record of the transfer. \n <\/div> \n<\/section> \n<section id=\"approval-signature-verification-from-phlebotomist\"> \n <h2>Approval: Signature Verification from Phlebotomist<\/h2>\n <div class=\"approval-content\"> \n  <div class=\"header\"> \n   <div class=\"list-title\">\n    Will be submitted for approval:\n   <\/div> \n  <\/div> \n  <div class=\"approval-rule-subject-tasks-list\"> \n   <ul class=\"list\"> \n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Label the collected samples<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li>\n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Record date and time of collection on the form<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li>\n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Inclusion of any special instructions<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li>\n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Seal sample in a biohazard bag<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li>\n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Handover of the filled form and sample to the courier<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li>\n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Ensure receiver's signature on form<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li> \n   <\/ul> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"scan-the-completed-form\"> \n <h2>Scan the completed form<\/h2>\n <div class=\"text-content\">\n   Scan the completed requisition form to create a digital copy for record-keeping and future reference. Make sure the scan is clear and legible to avoid any issues with data retrieval. \n <\/div> \n<\/section> \n<section id=\"upload-the-scanned-form-in-the-system\"> \n <h2>Upload the scanned form in the system<\/h2>\n <div class=\"text-content\">\n   Upload the scanned copy of the completed requisition form into the designated system or database. This ensures easy access to the form and maintains a digital record of the sample collection process. \n <\/div> \n<\/section> \n<section id=\"disposal-of-used-phlebotomy-materials\"> \n <h2>Disposal of used phlebotomy materials<\/h2>\n <div class=\"text-content\">\n   Properly dispose of any used phlebotomy materials in compliance with biohazard waste disposal regulations. This includes needles, gloves, and other disposable items. \n <\/div> \n<\/section> \n<section id=\"sanitize-the-workstation\"> \n <h2>Sanitize the workstation<\/h2>\n <div class=\"text-content\">\n   Thoroughly sanitize the phlebotomy workstation to eliminate any potential contamination and maintain a clean and safe environment for future procedures. Follow proper sanitization protocols and use appropriate cleaning agents. \n <\/div> \n<\/section> \n<section id=\"update-patients-record-with-collection-information\"> \n <h2>Update patient's record with collection information<\/h2>\n <div class=\"text-content\">\n   Record the collection information in the patient's medical record to ensure accurate tracking and analysis of the sample. This information helps healthcare professionals make informed decisions based on the collected data. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Medical Record Number <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n<\/section>\n","protected":false},"excerpt":{"rendered":"<p>Patient Identification Verify the identity of the patient to ensure accurate record-keeping and sample collection. This task is crucial in preventing any mix-ups or errors in the phlebotomy process. Collect the patient's full name, date of birth, and contact information. Full Name Date of Birth Date will be set here Contact Number Explanation of procedure [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"ep_exclude_from_search":false,"cover_icon_emoji":"\ud83d\udc89","cover_icon_url":"","tasks_count":"20","template_description":"","template_id":"l3--r8o1T1Od5zDKhm9Kjw","task_0":"Patient Identification","task_slug_0":"patient-identification","task_1":"Explanation of procedure to patient","task_slug_1":"explanation-of-procedure-to-patient","task_2":"Obtain consent from patient","task_slug_2":"obtain-consent-from-patient","task_3":"Prepare the requisition form","task_slug_3":"prepare-the-requisition-form","task_4":"Complete patient details on the form","task_slug_4":"complete-patient-details-on-the-form","task_5":"Indicate type of test(s) to be 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