LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 354.03 Phlebotomy Venipuncture and Phlebotomist Responsibilities
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, MD, Chief Medical Officer, on Dec 08, 2023
 
I.  PURPOSE
 
This policy establishes phlebotomist responsibilities and the procedure for the correct collection of blood by venipuncture to avoid pre-analytical errors, client care complications and to ensure client safety during the procedure. 
 
II.  DEFINITIONS
 

Clinic: Any DMH directly operated facility or program
 

Authorized personnel: Phlebotomist 
 
III.  POLICY
 
Phlebotomists shall follow all departmental policies and procedures and unit procedures.
 
Phlebotomists shall report to assigned work location, ready to work at the start time of each phlebotomy session and notify supervisor or supervisor’s designee upon arrival.
 
Prior to the beginning of each phlebotomy session, phlebotomists shall notify supervisor or supervisor’s designee when supplies are low and request for restock of supplies ahead of time.
 
Phlebotomists shall use universal precaution guidelines for infectious materials in handling and disposing of specimens and used materials. 
 
Clinical competency shall be demonstrated to and deemed satisfactory by Chief of Nursing or designee on annual bases.
 
Besides venipuncture procedures, phlebotomists will also perform Clinical Laboratory Improvement Amendments (CLIA) waived point-of-care tests.
 
IV.  PROCEDURES
 
V.  AUTHORITIES
 
VI.  ATTACHMENT
 
No attachments are associated with this policy.