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Run: Lab Specimen Reject and Recollection Log

Log rejected lab specimens, rejection reasons, notifications, and recollection outcomes in one clinic-ready record. Use it to track what failed, who was told...

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Specimen Identification

Date of Rejection (required)

Date the specimen was received and rejected in the lab.

Time of Rejection (required)

Time the rejection decision was made.

Accession / Lab Order Number (required)

Unique lab accession or order number assigned to this specimen.

Patient MRN (Medical Record Number) (required)

Patient MRN only — do not enter name, DOB, or SSN in this field. Minimum necessary per HIPAA §164.502(b).

Specimen Type (required)

Specify Other Specimen Type

Ordering Department / Clinic (required)

Ordering Provider (Last Name, First Initial) (required)

Rejection Reason

Rejection Reason(s) (required)

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? (required)

Collecting Staff Name / ID

Was the ordering provider notified? (required)

Notification Method

Time of Provider Notification

Was recollection ordered? (required)

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 (required)

Lab Technician Employee ID (required)

Corrective Action Taken (required)

Select all corrective actions documented for this rejection event.

Corrective Action Details

Does this rejection require supervisor review? (required)

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).

Yes No N/A

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