clinical patient care
Specimen Collection and Labeling
Collecting a nonblood specimen well means the right patient, the right method for that specimen type, a closed leakproof container, a label made at the patient's side, and delivery to the lab the way the lab asks.
14 steps3 criticalLimit 5 minAlways tested
Steps
- 1Perform hand hygiene and put on gloves
- 2Critical stepCheck the provider's order and the lab's collection instructions for this specimen type
- 3Identify the patient by comparing two identifiers with the order; a room number is not an identifier
- 4Explain the procedure and how the patient will collect the specimen, and ask if they have questions
- 5For a clean-catch urine, have the patient wash hands, open the cup without touching the inside, and cleanse the urinary opening with the towelette (front to back for females)
- 6Have the patient pass a small amount of urine into the toilet, then fill the cup about halfway in the stream, and finish in the toilet
- 7For stool, swab or sputum specimens, collect the specimen as the lab's or kit manufacturer's instructions say
- 8Critical stepClose the container tightly so it cannot leak
- 9Critical stepLabel the container in front of the patient, before leaving the room, with their full name, a second identifier, the collection date, and the time and source if the lab asks
- 10Check that the label matches the order and requisition, and send the requisition with the specimen
- 11Place the closed container in a leakproof, labeled or color-coded biohazard bag or container as your facility requires
- 12Store and deliver the specimen as the lab instructs for that test, including any time limit
- 13Remove gloves and wash your hands
- 14Document the collection: date, time, specimen source, and anything unusual about the specimen
What graders are watching for
Tips
- Label with the patient present: one hospital lab compares the identifiers against the order at collection and labels before leaving the room, and does not accept room or bed number as an identifier.
- Storage and delivery rules differ by test and lab (one hospital lab asks for refrigeration and return within a stated time for urine); always check the lab's own collection guide for the test you are collecting.
- If the patient touches the inside of the cup or contaminates it, get a new container rather than using it.
Common mistakes
- Labeling the specimen later, away from the patient, from memory.
- Using a room number or bed number as an identifier.
- Touching the inside of the cup or lid, then still using it.
- Assuming one storage rule fits every specimen type instead of checking the lab's instructions.
Practice this skill
Practise the sequence with critical-step highlighting and a rationale for each step.
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Sources and how we check them: How we verify.