Specimen tracking

A specimen record connects to the encounter that prompted collection. It carries a specimen type, collection date, accession number and processing status. That gives the clinician and reviewer a way to distinguish an order from a collected specimen, one received for testing and one already tested. A rejected specimen remains visible for follow-up.

An eye care clinic may collect material as part of a patient visit. The team can record that event here and use the accession number to reconcile with the lab’s own result and handling process. The lab’s result system is a connection to plan during implementation when results need to move between teams.

• Encounter origin. Every specimen belongs to the patient visit that led to the order.
• Collection and receipt. The status changes as handling milestones occur; the collection date records the clinical event.
• Accession reference. The accession number gives staff a practical value to match with an external lab record or paper report.

Agree the specimen types that the clinic will record and who assigns the accession number. Define when a specimen becomes received, how the clinic learns that testing is complete and who marks a rejection. Decide how the care team contacts the patient or orders a repeat specimen after a rejection. If a separate lab handles testing, agree its identification convention before the first transfer.

The team should also decide which status changes can be made by the Licensed Clinician and which require an external acknowledgement. A local status should represent evidence the clinic actually has, including the accession reference and collection date where relevant.

During a visit, the clinician orders a lab specimen and links the record to the current encounter. At collection, the clinician records the specimen type and date. Once a receiving lab identifies it, the accession number helps the team match its receipt. The clinician or reviewer can then see whether the record is still ordered, collected, received, tested or rejected.

If the specimen is rejected, the care team does not mark it as tested simply to clear the queue. The coordinator can assign a care task to contact the patient or arrange another collection. The original specimen record continues to explain why the follow-up was needed.

• Specimens in process — Ordered, collected and received specimens with their encounter and accession reference.
• Encounters awaiting review — Visits where specimen handling may be part of the review evidence.

See care documentation and follow-up coordination.