Lab Specimen Reject and Recollection Log

Document rejected specimens, rejection reasons, corrective actions, and recollection outcomes in the clinic laboratory setting.

Specimen Identification

• Date of Rejection
  Date the specimen was received and rejected in the lab.
• Time of Rejection
  Time the rejection decision was made.
• Accession / Lab Order Number
  Unique lab accession or order number assigned to this specimen.
• Patient MRN (Medical Record Number)
  Patient MRN only — do not enter name, DOB, or SSN in this field. Minimum necessary per HIPAA §164.502(b).
• Specimen Type
• Specify Other Specimen Type
• Ordering Department / Clinic
• Ordering Provider (Last Name, First Initial)

Rejection Reason

• Rejection Reason(s)
  Select all reasons that apply. Multiple reasons may be selected.
• Specify Other Rejection Reason
• Additional Rejection Details / Observations
  Provide specific, observable details to support the rejection decision and assist in corrective action.
• Specimen Photo (Optional)
  Attach a photo documenting the rejection condition (e.g., hemolysis, broken container). Ensure patient identifiers are not visible in the image.

Notification and Communication

• Was the collecting staff / phlebotomist notified?
• Collecting Staff Name / ID
• Was the ordering provider notified?
• Notification Method
• Time of Provider Notification
• Was recollection ordered?
• Reason Recollection Was Waived or Not Possible

Recollection Tracking

• Recollection Date
• Recollection Time
• New Accession Number (Recollected Specimen)
  Enter the accession number assigned to the replacement specimen.
• Recollection Outcome
• Recollection Notes

Lab Staff and Supervisor Review

• Lab Technician / MLT Name
• Lab Technician Employee ID
• Corrective Action Taken
  Select all corrective actions documented for this rejection event.
• Corrective Action Details
• Does this rejection require supervisor review?
  Supervisor review is required for repeat rejections from the same collector, critical specimen types, or patient safety concerns.
• Supervisor / Lab Manager Name
• Supervisor Review Date
• Supervisor Electronic Signature
  Supervisor signature confirms review of this rejection record.
• Flag for QA Trend Analysis
  Check if this rejection should be included in monthly QA trend reporting (e.g., repeat rejection from same unit, same reason code ≥3 times this month).