Medical Dictionary for Phlebotomy

Saddleback College Phlebotomy Program

Chapter 1: Fundamentals of the Clinical Laboratory

Category 1: The Profession

1. Clinical Laboratory Testing

The process of collecting, examining, analyzing, and reporting results of specimens to detect, diagnose, and treat diseases. Laboratory professionals communicate test results to physicians and other primary care providers to support patient care decisions.

• Specimen

A sample of body tissue or fluid (such as blood, urine, or tissue) collected from a patient for laboratory testing and analysis.

• Laboratory Professionals

Trained healthcare workers who collect specimens, perform laboratory tests, analyze results, and communicate findings to physicians. This includes medical laboratory scientists, medical laboratory technicians, and phlebotomists.

• Detection

The process of discovering or identifying the presence of a disease, condition, or abnormality through laboratory testing.

• Diagnosis

The identification of a specific disease or condition based on laboratory test results, symptoms, and other clinical findings.

• Treatment

Medical care and procedures provided to cure or manage a disease or condition. Laboratory results help guide treatment decisions.

• Primary Care Provider

A physician or healthcare professional who provides initial and ongoing medical care to patients, including ordering laboratory tests and making treatment decisions based on results.

Category 2: History of the Profession

• ASCP (American Society for Clinical Pathology)

A professional organization founded to establish standards and certification for laboratory professionals. ASCP created the Board of Registry in 1928 to certify medical technologists.

• Board of Registry (BOR)

The certification board created by ASCP in 1928 to test and certify laboratory professionals. Passing the registry exam allows professionals to use credentials such as MT(ASCP).

1. Medical Technologist (MT)

The original title for laboratory professionals who passed the Board of Registry examination. The designation MT(ASCP) indicated certification by the American Society for Clinical Pathology. This title was later changed to Medical Laboratory Scientist (MLS) in 2009.

1. Credentialing

The process of verifying and documenting that a professional has met specific educational requirements, passed examinations, and maintains competency in their field through certification.

1. Registry Exam

A comprehensive examination administered by the Board of Registry to test knowledge and competency of laboratory professionals seeking certification.

1. ASCLS (American Society for Clinical Laboratory Science)

A professional organization originally formed in 1933 as the American Society of Clinical Laboratory Technicians (ASCLT). This organization represents and supports clinical laboratory professionals.

1. Medical Laboratory Technician (MLT)

A category of laboratory professional developed in the 1960s requiring a 2-year associate degree. MLTs perform laboratory tests under supervision and use the credential MLT(ASCP) when certified.

1. Associate Degree

A two-year college degree program. Medical Laboratory Technicians typically complete an associate degree before taking their certification examination.

1. Specialist

A laboratory professional with focused expertise in a specific area such as chemistry, microbiology, hematology, blood banking, cytotechnology, histotechnology, laboratory safety, or molecular pathology.

1. Chemistry (Clinical Chemistry)

A specialty area of the laboratory that analyzes chemical components in body fluids such as blood and urine to assess organ function, detect diseases, and monitor treatment.

1. Microbiology

A specialty area of the laboratory that identifies bacteria, viruses, fungi, and parasites that cause infections. Microbiologists culture specimens and perform sensitivity testing to determine appropriate antibiotics.

1. Hematology

A specialty area of the laboratory that studies blood cells, including red blood cells, white blood cells, and platelets. Hematology testing helps diagnose anemia, infections, bleeding disorders, and blood cancers.

• Blood Banking (Transfusion Medicine)

A specialty area of the laboratory that types blood, tests for compatibility, and manages blood products for transfusions. This includes testing for ABO blood type, Rh factor, and antibody screening.

• Cytotechnology

A specialty that examines cells under a microscope to detect cancer, precancerous conditions, and other diseases. Cytotechnologists analyze Pap smears and other cellular specimens.

• Histotechnology

A specialty that prepares tissue samples for microscopic examination. Histotechnologists process, embed, section, and stain tissue specimens for pathologists to diagnose diseases.

• Molecular Pathology / Molecular Biology

A specialty that uses molecular and genetic techniques to diagnose diseases at the DNA and RNA level. This includes genetic testing, infectious disease detection, and cancer diagnostics.

• Phlebotomy Technician / Donor Phlebotomist

A trained professional who specializes in collecting blood specimens from patients or blood donors. Phlebotomists are certified members of the laboratory team.

• Pathologist’s Assistant

A specialty certification for professionals who assist pathologists in examining tissues, performing autopsies, and handling surgical specimens.

• Diplomat in Laboratory Management (DLM)

A specialty certification available for laboratory professionals with expertise in managing laboratory operations, personnel, budgets, and compliance.

• Licensure

Legal permission granted by a state or territory to practice as a laboratory professional. Requirements vary by state and specialty. States requiring licensure include California, Florida, Georgia, Hawaii, Louisiana, Montana, Nevada, New York, North Dakota, Rhode Island, Tennessee, West Virginia, and territories such as Guam.

• Medical Laboratory Scientist (MLS)

The updated professional title (as of 2009) for generalist laboratory professionals, replacing the term Medical Technologist. MLSs hold a bachelor’s degree and use the credential MLS(ASCP) when certified.

• Continuing Education

Ongoing learning and training activities required for certified professionals to maintain their certification. This ensures professionals stay current with new technologies, methods, and standards.

• DCLS (Doctorate in Clinical Laboratory Science)

A postbaccalaureate doctoral degree approved in 2012, representing the terminal advanced-practice degree in the laboratory profession. The DCLS focuses on patient care management, education, research applications, health care policy development, and health care services delivery.

• Terminal Degree

The highest academic degree available in a particular field of study. For clinical laboratory science, the DCLS is the terminal degree.

• NAACLS

National Accrediting Agency for Clinical Laboratory Sciences. The organization that accredits educational programs in clinical laboratory sciences and defines professional responsibilities and competencies.

Category 3: Clinical Laboratory Functions

• Clinical Decision-Making

The process physicians use to evaluate patient information, including laboratory test results, to make diagnoses and treatment decisions. Laboratory results provide crucial objective data for this process.

• Test Results

The findings or values obtained from laboratory analysis of a specimen. Results are reported to physicians to support patient diagnosis and treatment.

• Healthcare Provider

A licensed professional who provides medical care to patients, including physicians, nurse practitioners, physician assistants, and other qualified clinicians.

• Laboratory Assay

A specific laboratory test or procedure used to measure or detect a substance, organism, or condition in a specimen. Also simply called a test.

• Routinely Ordered Tests

Laboratory tests that are commonly requested by physicians for standard patient care. Typically, only a small percentage of available tests are routinely ordered.

Category 4: Staffing in the Clinical Laboratory

• Pathologist

A medical doctor (MD or DO) who specializes in diagnosing diseases by examining tissues, cells, and body fluids. Pathologists often serve as laboratory directors.

• PhD (Doctor of Philosophy)

A doctoral degree holder with advanced training in a scientific field. PhDs may serve as laboratory directors, particularly in specialized areas such as clinical chemistry or molecular diagnostics.

• Laboratory Director

The person with overall responsibility for the laboratory, typically a pathologist or PhD. The director ensures quality, compliance with regulations, and oversees all laboratory operations.

• Laboratory Supervisor / Manager

The person responsible for the technical aspects of managing laboratory operations, including personnel supervision, quality control, and ensuring compliance with federal, state, and local regulations.

• Business Manager

An administrative professional who handles non-technical aspects of laboratory operations such as budgeting, billing, purchasing, and human resources.

• Federal Regulations

Rules and requirements established by the United States government that laboratories must follow. The primary federal regulation is CLIA (Clinical Laboratory Improvement Amendments).

• State Regulations

Rules and requirements specific to each state that laboratories must follow in addition to federal regulations. These may include licensure requirements and reporting mandates.

• Local Regulations

Rules and requirements established by county or city governments, including building codes, fire prevention codes, and local health department requirements.

• Regulatory Mandate

A required standard, rule, or regulation that must be followed by law. Laboratories must follow regulatory mandates at federal, state, and local levels.

• Technologist

A laboratory professional, typically with a bachelor’s degree, who performs complex laboratory tests, supervises staff, interprets results, and may participate in teaching or research. Also known as Medical Laboratory Scientist (MLS).

• Technician

A laboratory professional, typically with an associate degree, who performs routine laboratory tests under supervision. Also known as Medical Laboratory Technician (MLT).

• Methodology

The specific procedures, techniques, and processes used to perform a laboratory test. Understanding methodology is essential for troubleshooting and interpreting results.

• Instrumentation

The equipment and machines used in the laboratory to perform tests. Laboratory professionals must understand how instruments work to operate them properly and identify problems.

• Correlate and Interpret Data

The ability of laboratory professionals to analyze test results in context, compare results to reference ranges, identify patterns, and understand clinical significance. This requires in-depth knowledge of testing principles.

• Process Specimens

To prepare specimens for testing by activities such as centrifuging, labeling, sorting, and distributing them to appropriate laboratory departments.

• Phlebotomist

A healthcare professional specially trained to collect blood specimens from patients. In larger hospitals, phlebotomists perform most blood collections, though MLSs and MLTs may also collect blood.

Category 5: Clinical Laboratory Improvement Amendments (CLIA) of 1988

• CLIA (Clinical Laboratory Improvement Amendments)

Federal regulations passed in 1988 to ensure high quality laboratory results. CLIA establishes standards for laboratory testing, including personnel qualifications, quality control, and proficiency testing.

• CLIA Personnel Requirements

Standards that define the education, training, and experience required for employees performing moderate or high complexity laboratory tests. These requirements are more stringent for highly complex tests.

• Waived Tests

Simple laboratory tests that have been cleared by the FDA for home use, use simple methodologies, are unlikely to produce incorrect results, and pose no reasonable risk of harm if performed incorrectly. Examples include dipstick urinalysis and blood glucose testing. No CLIA personnel requirements apply to waived testing sites.

• Moderately Complex Tests

Laboratory tests that require some judgment and interpretation but are less complex than highly complex tests. Personnel performing these tests must meet specific CLIA education and training requirements.

• Highly Complex Tests

Laboratory tests that require significant expertise, judgment, and interpretation. Personnel performing these tests must meet the most stringent CLIA education and experience requirements.

• Test Complexity Criteria

Factors used to classify tests as waived, moderate, or high complexity, including: risk of harm to the patient, risk of erroneous result, type of testing method, degree of independent judgment needed, and availability for home use.

• FDA (Food and Drug Administration)

The federal agency responsible for protecting public health by regulating food, drugs, medical devices, and laboratory tests. The FDA clears tests for home use and waived status.

• Simple Methodology

Testing procedures that are straightforward, easy to perform, and unlikely to produce errors. Tests with simple methodology may qualify for waived status under CLIA.

• Erroneous Result

An incorrect or inaccurate test result. CLIA classifies tests based on the likelihood and potential harm of erroneous results.

• Dipstick Urinalysis

A simple test using a reagent strip dipped into urine to detect substances such as glucose, protein, blood, and pH. This is classified as a waived test.

• Blood Glucose

A measurement of the amount of sugar (glucose) in the blood. Point-of-care blood glucose testing using a glucometer is classified as a waived test.

• PPM (Provider-Performed Microscopy)

A CLIA category for microscopic examinations personally performed by a physician, midlevel practitioner, or dentist. Requirements include: categorized as moderately complex, microscope is the primary instrument (brightfield or phase-contrast only), specimen is labile (unstable), control materials are not available, and specimen handling is limited.

• Practitioner

For PPM purposes, defined as a physician, midlevel practitioner under physician supervision, or dentist who is authorized to perform microscopy procedures.

• Midlevel Practitioner

A healthcare provider such as a nurse practitioner or physician assistant who works under the supervision of a physician. Midlevel practitioners may perform provider-performed microscopy.

• Microscope

An optical instrument that magnifies small objects for detailed examination. For PPM, only brightfield or phase-contrast microscopy is allowed.

• Brightfield Microscopy

The most common type of light microscopy where specimens appear dark against a bright background. This is one of the two types of microscopy allowed for provider-performed microscopy.

• Phase-Contrast Microscopy

A type of microscopy that enhances contrast in unstained transparent specimens by converting phase shifts in light into brightness changes. This is one of the two types of microscopy allowed for provider-performed microscopy.

• Labile Specimen

A specimen that is unstable and deteriorates quickly, requiring immediate examination. Labile specimens are characteristic of provider-performed microscopy procedures.

• Control Materials

Specimens with known values used to verify that a test is working correctly. For PPM procedures, control materials are typically not available, which is one reason these tests must be performed by practitioners.

Category 6: Laboratory Departments

• Departmentalized Laboratory

A laboratory organizational structure where separate physical areas are designated for different testing divisions such as hematology, chemistry, microbiology, etc. Common in larger laboratories.

• Core Laboratory

An open laboratory design where hematology, urinalysis, hemostasis/coagulation, and clinical chemistry share workspace. This configuration allows for cross-training and efficient workflow. Also called an integrated laboratory.

• Cross-Training

Training laboratory personnel to perform tests in multiple departments or specialties. Cross-training is especially important in core laboratory configurations and helps provide coverage during absences.

• Cytogenetics

A specialized laboratory division that studies chromosomes to detect genetic abnormalities, birth defects, and certain cancers. Found in larger laboratories.

• Toxicology

A specialized laboratory division that tests for drugs, poisons, and toxic substances in body fluids. Used for therapeutic drug monitoring, drug screening, and forensic investigations.

• Flow Cytometry

A specialized laboratory technology that uses laser-based instruments to analyze cells and particles. Used for cancer diagnosis, immune system disorders, and transplant monitoring.

• Molecular Diagnostics

A specialized laboratory division that applies principles of molecular biology to detect and analyze genetic material (DNA and RNA) for disease diagnosis, monitoring, and predicting treatment response. Applications include gene therapy, genetic screening, and infectious disease detection.

• Transfusion Medicine

Another term for blood banking; the laboratory specialty concerned with blood typing, compatibility testing, and managing blood products for transfusions.

• Hemostasis / Coagulation

The laboratory specialty that tests blood clotting function. Hemostasis refers to the body’s process of stopping bleeding, while coagulation tests measure how well blood clots. Important for managing patients on blood thinners and diagnosing bleeding disorders.

• Immunology and Serology

A laboratory specialty that tests for antibodies, antigens, and immune system function. Used to diagnose infections, autoimmune diseases, allergies, and monitor transplant recipients.

• Urinalysis

The laboratory analysis of urine, including physical examination (color, clarity), chemical testing (pH, protein, glucose, blood), and microscopic examination (cells, crystals, bacteria). Used to detect kidney disease, urinary tract infections, diabetes, and other conditions.

• Central Testing Area

A cluster of automated instruments in one location devoted to processing high volumes of test samples. Common in medium to large laboratories for efficiency.

• High Volume Testing

Laboratory tests that are performed frequently on many patients, such as complete blood counts and basic metabolic panels. Automated instruments handle high volume testing efficiently.

• Biotechnology

The use of living organisms, cells, or biological molecules to develop products and technologies for medical and research purposes. Molecular diagnostics is an application of biotechnology.

• Molecular Genetics Research

Scientific study of genes at the molecular level to understand genetic diseases and develop new diagnostic and therapeutic approaches.

• Gene Therapy

A treatment approach that involves inserting, altering, or removing genes to treat or prevent disease. Molecular diagnostics provides information to support gene therapy applications.

• Genetic Screening

Testing to identify genetic disorders or predisposition to diseases in individuals or populations. Can be used for newborn screening, prenatal testing, or carrier detection.

• Stem Cell Research

Scientific investigation of undifferentiated cells that can develop into many different cell types. Molecular diagnostics provides information relevant to stem cell applications.

• Cloning

A molecular biology technique to create identical copies of genes, cells, or organisms. Used in research and production of therapeutic proteins.

• Cell Culture

Growing cells in a controlled laboratory environment. Used for research, drug testing, and production of biological products. Some laboratory specialties such as microbiology and molecular diagnostics utilize cell culture.

Category 7: Health Care Organizations

• Health Care Organization

An institution that provides medical services, ranging from large teaching hospitals to community hospitals to small specialty clinics or phlebotomy drawing stations.

• Tertiary Care Hospital

A large hospital that provides specialized advanced medical care and complex treatments. Often includes teaching facilities, research programs, and comprehensive laboratory services.

• Teaching Hospital

A hospital affiliated with a medical school where medical students, residents, and other healthcare professionals receive clinical training. Often provides tertiary care and has extensive laboratory facilities.

• Community Hospital

A local hospital that provides general medical and surgical care to a specific geographic area. Typically smaller than tertiary care hospitals but offers essential laboratory services.

• Freestanding Specialty Clinic

A healthcare facility not attached to a hospital that provides focused medical services in specific areas such as cardiology, orthopedics, or urgent care. May have limited on-site laboratory testing.

• Phlebotomy Drawing Station

A freestanding facility where patients go specifically to have blood drawn for laboratory testing. Specimens are then transported to a main laboratory for analysis.

• Chief Executive Officer (CEO)

The highest-ranking executive in a healthcare organization who has overall responsibility for operations and works with the board of trustees to set organizational direction.

1. Board of Trustees

A group of individuals who have legal responsibility for governing a healthcare organization, setting policies, and ensuring the organization fulfills its mission.

1. Chief Operating Officer (COO)

The executive responsible for implementing policies and managing daily operations of the healthcare organization. Reports to the CEO.

1. Chief Financial Officer (CFO)

The executive responsible for managing the financial operations of the healthcare organization, including budgeting, financial planning, and reporting.

1. Chief Information Officer (CIO)

The executive responsible for information technology systems, including laboratory information systems, electronic medical records, and computer networks.

1. Chief Technology Officer (CTO)

The executive responsible for technological innovation and implementation of new technologies in the healthcare organization.

1. Vice President (VP)

A senior executive who oversees major divisions of a healthcare organization. Common VP positions include nursing, clinical services, general services, and human resources.

1. VP of Nursing

The executive responsible for all nursing services and nursing personnel throughout the healthcare organization.

1. VP of Clinical Services

The executive who oversees clinical departments such as the clinical laboratory, radiology, and pharmacy. Laboratory managers typically report to this VP.

1. VP of General Services

The executive responsible for support services such as facilities management, housekeeping, security, and maintenance.

1. VP of Human Resources

The executive responsible for recruitment, hiring, employee relations, benefits, training, and personnel policies throughout the organization.

1. Radiology

A clinical department that uses imaging technologies such as X-rays, CT scans, MRI, and ultrasound to diagnose and treat diseases. Like the laboratory, radiology reports to the VP of Clinical Services.

1. Pharmacy

A clinical department that prepares and dispenses medications. Pharmacy works closely with the laboratory to monitor drug levels and drug interactions.

Category 8: Primary Accrediting Organizations

1. Accreditation

A voluntary process where a laboratory is evaluated by an external organization to verify it meets established quality standards. Accreditation demonstrates commitment to quality and is often required for reimbursement.

1. COLA (Commission on Office Laboratory Accreditation)

One of the three primary laboratory accrediting organizations in the United States. COLA focuses on physician office laboratories and provides education-based accreditation.

1. CAP (College of American Pathologists)

An internationally recognized laboratory accreditation program that uses teams of practicing laboratory professionals as inspectors. CAP is considered the gold standard for laboratory accreditation.

1. Inspector

A trained professional who evaluates laboratories during accreditation surveys. CAP uses practicing laboratory professionals as inspectors, providing peer review of laboratory operations.

1. TJC (The Joint Commission)

One of the three primary accrediting organizations. The Joint Commission has been evaluating and accrediting hospital laboratory services since 1979 and freestanding laboratories since 1995.

1. Freestanding Laboratory

A laboratory that is not part of a hospital, operating as an independent facility. Freestanding laboratories can be accredited by organizations like TJC or CAP.

1. AABB (American Association of Blood Banks)

A specialty organization that accredits blood banks, transfusion services, and cellular therapy facilities. AABB sets standards for blood collection and transfusion practices.

1. ASHI (American Society of Histocompatibility and Immunogenetics)

A specialty organization that accredits laboratories performing tissue typing for organ transplantation and immune system testing.

1. AOA (American Osteopathic Association)

An organization that accredits osteopathic hospitals and their associated laboratories, ensuring quality standards are met.

Category 9: External Government Laboratory Accreditation and Regulation

1. Chemical Waste Disposal

Proper methods for disposing of hazardous chemicals used in laboratory testing. Laboratories must follow federal, state, and local regulations for safe disposal to protect the environment and public health.

1. Hazardous Chemicals

Chemical substances that pose risks to health or safety. Laboratories must follow regulations regarding the use, storage, labeling, and disposal of hazardous chemicals.

1. Laboratory Safety

Practices and regulations designed to protect laboratory workers from hazards including biological agents, chemicals, sharps, and fire. Includes proper use of personal protective equipment and safety procedures.

1. Biohazardous Materials

Biological substances that pose a risk of infection or disease, including blood, body fluids, tissues, and cultures of infectious agents. Must be handled using Standard Precautions and disposed of properly.

1. Standard Precautions

A set of infection control practices used to prevent transmission of diseases through blood and body fluids. Standard Precautions assume all blood and body fluids are potentially infectious and require use of appropriate protective equipment.

1. External Controls

Regulations and standards imposed on laboratories by outside agencies at federal, state, and local levels to ensure quality, safety, and compliance.

1. Public Health Laws

Laws designed to protect and improve the health of communities. Laboratories must report certain test results (such as infectious diseases) to public health authorities as mandated by these laws.

1. Reporting Requirements

Obligations for laboratories to report specific test results to health authorities. For example, positive tests for reportable infectious diseases must be reported to the Centers for Disease Control and Prevention (CDC) or state health departments.

1. CDC (Centers for Disease Control and Prevention)

The federal agency responsible for protecting public health and safety through disease prevention and control. Laboratories report certain infectious disease results to the CDC.

1. Certification

Official recognition that a laboratory or individual meets specific standards. Laboratories must obtain CLIA certification to perform testing, and individuals obtain certification through professional organizations like ASCP.

1. Medicaid

A joint federal and state program that provides health coverage for low-income individuals. Medicaid agencies regulate laboratories that serve Medicaid beneficiaries through state-specific requirements.

1. State Environmental Laws

State regulations governing waste management, chemical disposal, and environmental protection. Laboratories must comply with both federal and state environmental requirements.

1. Building Codes

Local regulations that specify standards for construction, ventilation, plumbing, and electrical systems in laboratory facilities to ensure safety.

1. Fire Prevention Codes

Local regulations designed to prevent fires and ensure safe evacuation. Laboratories must follow fire prevention codes regarding storage of flammable materials, fire extinguishers, and emergency exits.

Category 10: Alternate Sites of Testing

1. Central Laboratory Testing

Testing performed in a main hospital or reference laboratory where specimens are transported for analysis. Offers the most comprehensive testing menu and specialized expertise.

1. Point-of-Care Testing (POCT)

Laboratory testing performed near or at the site of patient care, such as at the bedside, in a clinic, or emergency department. Provides rapid results but with a limited test menu. Also called bedside testing or near-patient testing.

1. Decentralization of Laboratory Testing

The trend of moving some laboratory testing away from central laboratories to point-of-care locations for faster turnaround times and improved patient care.

1. Reference Laboratory

A specialized laboratory that performs complex, unusual, or rarely ordered tests that smaller laboratories cannot perform. Specimens are sent to reference laboratories when specialized expertise or equipment is needed.

1. Physician Office Laboratory (POL)

A small laboratory located in a doctor’s office that performs simple tests such as urinalysis, blood glucose, and rapid strep tests. POLs typically perform only waived or moderately complex tests.

1. Turnaround Time

The time from when a specimen is collected until the test result is reported. Point-of-care testing typically has faster turnaround times than central laboratory testing.

1. Test Menu

The list of laboratory tests that a facility can perform. Central laboratories have comprehensive test menus, while point-of-care and physician office laboratories have limited test menus.

Category 11: Medical-Legal Issues

1. Informed Consent

The patient’s voluntary agreement to a medical procedure or test after being fully informed about what will be done, why it is being done, potential risks, and how results will be used. Patients must understand and agree before testing proceeds.

1. Confidentiality

The legal and ethical obligation to keep patient information and test results private. Any information about patients and their test results must be kept strictly confidential and shared only with authorized individuals.

1. HIPAA (Health Insurance Portability and Accountability Act)

A federal law passed in 1996 that protects patient privacy by setting national standards for the security of health information. HIPAA requires strict confidentiality of patient records and test results.

1. Patient Access Regulations

Rules established by the Centers for Medicare and Medicaid Services (CMS) that give patients the right to directly access their laboratory test results. Laboratories are not required to interpret results but may refer patients to their healthcare providers with questions.

1. CMS (Centers for Medicare and Medicaid Services)

The federal agency that administers Medicare and Medicaid programs and enforces CLIA regulations. CMS establishes rules for laboratory testing and patient access to results.

1. Ordering Provider

The physician or healthcare provider who requests laboratory tests for a patient. Under patient access regulations, laboratories refer patients with questions about results back to their ordering or treating providers.

1. Treating Provider

The healthcare provider currently caring for and treating the patient. May or may not be the same as the ordering provider.

1. Chain of Custody

A documented process that tracks specimens from collection through testing to result reporting, ensuring the specimen’s integrity and admissibility as legal evidence. Required for forensic and medicolegal cases such as drug testing, paternity testing, and criminal investigations. Every person who handles the specimen must document their role.

1. Medicolegal

Relating to both medicine and law. Medicolegal specimens include those used in legal proceedings such as criminal investigations, workers’ compensation cases, or paternity determinations.

1. Evidence

Material or information presented in legal proceedings to support claims or allegations. Laboratory test results may serve as evidence in court cases if proper chain of custody is maintained.

1. Admissible Evidence

Evidence that meets legal requirements and can be presented in court. For laboratory results to be admissible, proper chain of custody must be documented from specimen collection through result reporting.

1. Specimen Transport

The process of moving specimens from the collection site to the laboratory for testing. For chain of custody specimens, transport must be documented by each person handling the specimen.

1. Standard of Care

The degree of care, skill, and diligence that a reasonable healthcare professional would provide under similar circumstances. Healthcare organizations and their employees are legally obligated to meet the accepted standard of care to prevent harm to patients.

1. Reasonable Person

A legal concept describing how an average, prudent person would act in similar circumstances. The standard of care is defined by how a reasonable healthcare professional would act.

1. Injury Prevention

Actions taken to avoid harm to patients. Healthcare providers have a legal duty to take reasonable measures to prevent injury during specimen collection and testing.

Category 12: Medical Ethics

1. Personal Ethics

Values, ideals, and moral principles that guide an individual’s behavior and decisions. Personal ethics are based on what a person or group considers right and wrong.

1. Ethics

Principles of conduct and moral values that guide behavior in professional and personal contexts. Ethics encompasses concepts of right and wrong, justice, fairness, and responsibility.

1. Values

Core beliefs and principles that individuals or groups consider important and use to guide decisions and actions. Professional values include integrity, honesty, and patient welfare.

1. Professional Ethics

Moral principles and standards of conduct that apply to members of a profession. Laboratory professionals follow professional ethics regarding patient care, colleague relationships, and society.

1. Code of Ethics

A written set of ethical principles and professional conduct standards adopted by an organization. ASCLS has a Code of Ethics that defines laboratory professionals’ responsibilities toward patients, colleagues, the profession, and society.

1. ASCLS Code of Ethics

The ethical guidelines established by the American Society for Clinical Laboratory Science that outline professional responsibilities in four areas: duties to patients, duties to colleagues and the profession, duties to society, and duties to maintain personal competence.

1. Responsibility

The duty or obligation to fulfill commitments and be accountable for actions. Laboratory professionals have responsibilities to patients, colleagues, the profession, and society.

1. Proper Conduct

Behavior that follows ethical principles and professional standards. Includes honesty, integrity, respect for patients and colleagues, and commitment to quality.

1. Patient (Patient Care)

An individual receiving healthcare services. Laboratory professionals have an ethical duty to provide quality testing, maintain confidentiality, show respect, and act in the patient’s best interest.

1. Colleagues

Fellow professionals working in the laboratory or healthcare field. Laboratory professionals have ethical responsibilities to treat colleagues with respect, collaborate effectively, and support professional development.

1. Society

The community and public at large. Laboratory professionals have ethical responsibilities to society including promoting public health, advancing the profession, and serving the community.

1. Pledge to the Profession

A formal commitment statement endorsed by ASCLS where laboratory professionals promise to uphold professional standards, pursue excellence, maintain competence, and contribute to the advancement of clinical laboratory science.

1. Integrity

Adherence to moral and ethical principles; honesty and strong moral character. Laboratory professionals demonstrate integrity by being truthful, maintaining quality standards, and doing what is right even when no one is watching.

1. Competence

The ability to perform job duties effectively with required knowledge and skills. Laboratory professionals have an ethical obligation to maintain and improve their competence through continuing education and staying current with new developments.

End of Medical Dictionary

This dictionary is intended as a study aid for students in the Saddleback College Phlebotomy Program. Terms are organized by category as they appear in Chapter 1: Fundamentals of the Clinical Laboratory.

About the Author

admin

Administrator

Visit Website View All Posts