Documentation Guidelines

It is vital to document phlebotomy procedure. ​
 
Minimum documentation includes date and time of the phlebotomy​
 
Location of the venipuncture​
 
Number of attempts​
 
Type of tests the specimens collected​
 
Patient’s tolerance to the procedure​
 
Destination of the laboratory or, which lab you sent the specimen​
 
Document complications, if any and follow up. Document the physician’s (whomever you contacted) with full name and title.