CC-UC-02600 - Laboratory: Basic Flow - Provide Specimen (Blood)

Actors

• Client/Client caregiver
• Clinic administrator
• Phlebotomist

Pre-conditions

• The client is covered by provincial/territorial health care insurance.
• The client has a valid, completed, lab requisition provided by the primary care provider.
• The client has an appointment or is at a walk-in diagnostic laboratory clinic.

Step	Description	Data elements collected	Result
1	The clinic administrator registers the client. Registration may include, but is not limited to: Validating the requisition, confirming identification and health card, verification preparation instructions were followed.	Person Identifier Type Person Identifier Value Person Identifier Assigner Person Given Name Person Middle Name (if applicable) Person Surname Date of Birth Person Identifier Type Person Identifier Value Person Identifier Assigner Service Request Identifier Service Request Category Service Request Name Service Request Status (if validation status is recorded) Service Request Additional Instructions Fasting Status Flag For Specimen Collection (when fasting is a preparation requirement) Encounter Status Encounter Start Date and Time	The client is registered and confirmed to meet the requirements for the laboratory visit, and the client's medical record is updated at the diagnostic laboratory clinic. CC-UC-02601 Unable to Conduct Lab Test (e.g. did not fast, prep instructions not followed).
2	The Phlebotomist confirms the client's identification, draws and labels the blood sample.	Person Identifier Type Person Identifier Value Person Given Name Person Surname Date of Birth Specimen Collection Organization Specimen Identifier Specimen Processing Status Date and Time Specimen Lifecycle Stage Specimen Status Specimen Type Specimen Collection Period Specimen Collection Body Site Specimen Collection Procedure	The client's identification is confirmed, and blood sample is drawn and labelled, and the client's medical record is updated at the diagnostic laboratory clinic. CC-UC-02602 Unable to retrieve blood sample
3	The clinic administrator packages the sample in preparation for transfer to the lab for analysis.	Specimen Identifier Specimen Processing Status Date and Time Specimen Lifecycle Stage Specimen Status Specimen Handling Instructions Specimen Condition (if assessed) Specimen Processing Procedure (if the packaging/preparation step is recorded as specimen processing)	The sample is packaged and prepared for transfer to the lab for analysis and the client's medical record is updated at the diagnostic laboratory clinic.
4	The clinic administrator provides the client with instructions for accessing lab results.	Document Date and Time (if a handout/document is created) Document Status Document Type Document Recipient Document Content	The client receives instructions for accessing results.
5	This use case ends.	Not applicable	Not applicable

Post-conditions

• A blood sample is drawn from the client.
• The blood sample is labelled, packaged in preparation for analysis.
• The client is provided with instructions on accessing results.
• The client's medical record is updated at the diagnostic laboratory clinic.

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If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca