Laboratory evidence

A specimen record identifies its type and investigation. Its processing state moves through Ordered, Collected, Received and Tested, with Rejected available for a specimen that cannot proceed. The collection date and accession number help the Licensed Clinician and Clinical Reviewer distinguish one specimen from another. Multiple specimens can belong to the same investigation without losing their separate states.

Measured observations record a metric, numeric value, unit, observation date and person who entered the measurement. The observation is linked to its investigation. A reviewer can therefore read a measurement alongside the investigation notes and the specimen states for that episode. The unit and date are essential to interpreting a value; the number alone is not enough.

• Specimen identity. Record specimen type and accession number so processing refers to the intended item.
• Processing status. Update the specimen as collection and receipt occur, and mark rejected items explicitly.
• Observation context. Keep the measured value, unit, date and recorder attached to the investigation.

For a case with two investigations, a specimen collected during the second visit must link to that second episode. The case remains the common identity, but each evidence record follows the investigation where it was produced.

Agree when an accession number is entered and who updates each specimen status. Decide how a rejected specimen is handled in the team’s follow-up work. The lab’s own result system may be a connection to set up; the investigation record here holds the specimen and observation information the care team uses. Agree which measurements belong in metric observations and how units are written consistently.

A Clinical Reviewer should inspect the evidence in sequence: investigation dates, specimen collection and processing state, observation date, then the clinician’s note. If a specimen is only Received, that status should remain visible during the review rather than being treated as a completed test.

Create an ordered specimen for an active investigation, then record its collection date and accession number. Move it to Received and later Tested. Add a measured observation with value, unit, date and recorder. Ask the reviewer to find the specimen and observation under the same investigation. Rehearse a rejected specimen and confirm the status remains distinct from Tested; add a follow-up action if the case requires another collection.

• Specimen queue — Ordered, collected and received items needing the next processing step.
• Investigation review inbox — Episodes awaiting a review of their notes and laboratory evidence.

Use specimen processing to rehearse collection and investigation review for the evidence decision.