Version 1.1 Sept 2018
Phlebotomy
Target Audience
Who Should Read This Policy
All Clinical Staffs
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Ref. Contents Page
1.0 Introduction 4
2.0 Purpose 4
3.0 Objectives 4
4.0 Process 4
5.0 Procedures connected to this Policy 8
6.0 Links to Relevant Legislation 8
6.1 Links to Relevant National Standards 9
6.2 Links to other Key Policies 9
6.3 References 9
7.0 Roles and Responsibilities for this Policy 10
8.0 Training 11
9.0 Equality Impact Assessment 11
10.0 Data Protection and Freedom of Information 12
11.0 Monitoring this Policy is Working in Practice 12
Appendices
1.0 Training Needs Analysis 13
2.0 Phlebotomy Clinical Practice Competencies 14
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Explanation of terms used in this policy Phlebotomy - the drawing of blood from a vein by the insertion of a needle.
Antecubital fossa - triangular cavity of the elbow that contains a tendon of the biceps, the median nerve, and the brachial artery.
Tourniquet - a disposable single use device that promotes vein distension for insertion of a needle.
Vacutainer - blood collection sterile glass or plastic tube with a closure that is evacuated to create a vacuum inside the tube facilitating the draw of a predetermined volume of liquid.
BBV - Blood borne virus e.g. Hepatitis B & C, HIV/Aids.
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1.0 Introduction The Black Country Partnership NHS Foundation Trust (hereafter called the Trust) recognises the relationship between physical health/illness and mental illness. It is only in recent times that physical health issues have been raised and risk factors and assessment priorities identified to provide clinical insight into how best to ensure patients health is assessed and improved. In their report “Your Choice” (September 2008) Rethink reported that only 49% of patients stated that they had ever been offered a physical health check. Nash (2005) expressed concern that the physical health of patients under mental health services was not only poor but a largely unaddressed area of need. Patients with mental illness often have other co-morbid conditions such as diabetes, ischaemic heart disease, hypertension and hyperlipidaemia. Poor physical health directly affects mental well-being and can adversely impair the rate of recovery. The Trust standard requires that all patients admitted into hospital are offered a physical health assessment and an important part of this is a blood test. A blood test can be seen as the first step in the diagnosis of a physical health related condition.
2.0 Purpose The purpose of the policy is to ensure that the Trust has a standardised approach to obtaining blood samples from patients for analysis in the laboratory while establishing safe criteria for the process. The policy recognises the health practitioner must provide a high standard of practice at all times in line with NMC and WHO guidelines for drawing blood, must have received training and have their knowledge and skills up to date. The health practitioner will work closely with other professionals to ensure that the patient’s care is co-ordinated, of a high standard and has the best possible outcome.
3.0 Objectives The policy is applicable to all staff who under-take phlebotomy as part of their duties on behalf of the Trust. Although phlebotomy /venepuncture can be seen as a relatively simple procedure, all staff undertaking phlebotomy duties should be trained in the procedure to prevent unnecessary risk of exposure to blood and reduce adverse events for patients. Objectives are:-
To improve knowledge and awareness of the risks associated with phlebotomy
Promote safe practice
Improve patient comfort and confidence
Work within the boundaries of trust policies
Ensure all equipment is checked, maintained and ready for use at all times
Ensure the quality and validity of the blood samples for laboratory analysis.
4.0 Process Phlebotomy is performed to provide diagnostic or therapeutic monitoring information, including the provision of compatible samples for blood transfusion. It is essential that samples obtained are accurate and representative of the patient’s true condition and free from artefacts. Correctly matching patient details to the blood sample(s) is absolutely vital.
Only TWO attempts should be made to obtain a blood sample from the patient, using new equipment on each occasion. If unsuccessful obtain support from another member of staff qualified to perform phlebotomy. Failed attempts should be documented in the patient notes.
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The recommended site for phlebotomy is the ante-cubital fossa. If this site is not available, refer to professional who carries out venepuncture from other sites.
Identify the clinical need for phlebotomy.
Identify the patient by surname, first name, date of birth, address and/or NHS number.
Explain the procedure to the patient, discuss the need for the blood sample to be taken, obtain informed consent for the procedure, establishing whether the patient has any known allergies.
If the patient is anxious or expresses that they are needle phobic, or any other condition that might make phlebotomy difficult, they may benefit from a topical anaesthetic. This requires a prescription.
Two possible phlebotomy sites should be chosen for application of the topical anaesthetic to give the person obtaining the blood sample a choice of site. These areas should be covered with a transparent film dressing and left on for 45-60 minutes as per prescription advice. Prior to obtaining samples the cream must be removed from the sites.
When taking blood, health workers should wear well-fitting non-sterile gloves and should also carry out hand hygiene before and after each patient procedure before putting on gloves and after removing them.
As a professional, you are “personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” Code of Professional Conduct (2008) Nursing Midwifery Council (NMC).
The trained nurse has the right to delegate this procedure to a health care support worker who has completed training and has been deemed as competent to practice or phlebotomist. The trained nurse must ensure the health care support worker or phlebotomist has received Trust phlebotomy training and has successfully completed the competency, and is confident and competent to perform the procedure.
The Health Care Professional (Health Care Support Worker) has the right to refuse to insert a needle to obtain a sample of venous blood if they have concerns about the patient’s veins or the patient’s condition, or do not feel confident to undertake the procedure.
All record keeping must adhere to standards set out by the NMC Record Keeping Guidance for Nurses and Midwives (2009).
Restraint When considering using restraint there must be objective reasons to justify that restraint is necessary. It should be a multidisciplinary decision making process, and will require assessment for mental capacity to consent to phlebotomy. Staff should be able to identify that the person being cared for is likely to suffer harm should the blood test not be performed. Proportionate restraint should be used. A carer or professional must not use restraint just so that they can do something more easily. The recording of the decision making process and the rationale must be documented in the patients notes. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest amount of time possible. Patients who require phlebotomy, who are detained under the Mental Health Act (2007), may require restraint to obtain the blood sample. Staffs are advised to consult the Restrictive Physical Intervention policy, section 4.4.15 Clinical Holding Interventions for further advice.
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Paediatrics
Venepuncture should only offered to children as agreed by the Trust and should be undertaken by experienced phlebotomists/nursing staff who have received training specifically for children.
All children under the age of 4 should be referred to the GP or District General Hospital.
Children will require help to cope with the procedure and this should be done by: - Establishing the child’s perception of pain. - Offering an explanation to the parent/carer in advance of any conversations
with the child. - Establishing a rapport with the child to gain the child’s confidence and give
necessary reassurance prior to carrying out the procedure. - Consider the use play and/or distraction techniques. - Consider involving a play specialist and psychologist to prepare the child for
the procedure. - Consider the use of local anaesthetic preparations prior to the procedure.
For very young children (under 12) a butterfly needle should be used, in order to limit the risk of venous collapse or unexpected movement causing collapse of the vein.
For Children over 12 the blood collection system used for adult should be used unless there is a defined clinical need for a butterfly to be used.
Informed consent should be obtained from the child and/or parent/legal guardian prior to the procedure. Informed consent is obtained from the parent/legal guardian or next of kin if a child is under the age of consent (16 years) or if the child does not have the cognitive ability to understand or make an informed decision. Preferences in relation to the venepuncture site should be identified such as dominant hand, clothing worn thumb sucking hand etc.)
Minimal restraint and holding should be used for the venepuncture procedure. If used it should be appropriate to age, cognitive ability and behaviour of the child.
Equipment required for venous blood sampling
Specimen request form signed by medical practitioner.
Single use disposable tourniquet.
Single use non sterile gloves and disposable apron.
Alcohol wipes.
Vacuum system components and appropriate sampling tubes.
Gauze swabs.
Appropriately labelled Sharps box.
Tape or adhesive plaster.
Procedure
Action Rationale Within the inpatient and outpatient setting,
lighting, ventilation, privacy and position must
be checked and optimized where possible.
To ensure that the patient and the operator are
both comfortable. Having adequate lighting is also beneficial as it illuminates the procedure, ensuring
the operator has a good view of the vein and
equipment (Dougherty and Lister 2008).
Approach the patient, introduce yourself and
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check patient identity – forename, surname,
date of birth - against the blood form and
obtain information regarding allergies.
To ensure that you have the correct patient and the
correct blood form. understands the procedure and
gives his/her consent.
Give explanation and rationale for
venepuncture to the patient including the
reason for the blood test.
Information giving is a vital aspect of informed
consent to a procedure and the patient has a right
to a full explanation of care.
Information giving must include post-procedure
care including the requirement to report pain, swelling, discomfort.
Venepuncture is an anxiety provoking procedure so it is important to reassure the patient and ensure
they understand their care needs and how/when to report problems.
Ask if patient has had the procedure done
before and respond appropriately to the
patient’s questions and anxieties
To check whether the patient has had any
vasovagal (fainting) episodes with the procedure
before and be prepared for this possibility.
Ascertain whether the patient has been
requested to attend for a fasting blood test.
Check whether the patient is prescribed
anticoagulants.
The result of the blood test is compromised and a wrong diagnosis could be made if incorrect
information is given.
Anticoagulants prolong bleeding time.
Ensure patient is comfortable and consents to
the procedure.
Patient comfort will prevent movement and so facilitate the procedure.
Consent to treatment is a legal requirement.
Examine both arms and select the most
suitable site. Make the patient comfortable and place the chosen arm on a pillow with the arm
fully extended downwards.
The patient should feel as comfortable and relaxed as possible.
Observe the area of the arm and palpate for a
suitable vein. The vein should feel springy
when depressed and refill immediately when
released. Avoid nodules in the veins and junctions where veins meet.
To facilitate a suitable choice for taking blood.
Apply a single use tourniquet above the elbow
ensuring it does not obstruct arterial flow. To prevent damage to tissue.
Decontaminate hands and put on apron and
gloves. To minimise the risk of infection.
Give the patient an explanation of what is
going to happen while their blood is being
taken.
To reduce anxiety.
Clean the patient’s skin using an Isopropyl
Alcohol 70% swab and allow the skin to dry.
To maintain asepsis and reduce the risk of infection.
Action Rationale
Stabilise the vein below the chosen entry site
without contaminating the cleaned area. To prevent movement of the vein and increase the likelihood of success.
Remove the needle shield and with the bevel of
the needle pointing upwards insert the needle
into the vein at an angle of 15-30⁰. Reduce the angle of the needle as soon as you
feel the resistance change or flash back is seen
along the tubing of the venepuncture device.
The bevel needs to be upwards to facilitate smooth transition through the skin and vein.
To prevent advancing the needle too far into the vein wall.
Slightly advance the needle into the vein. To secure the device and prevent displacement.
Firmly connect the blood container to the hub
of the vacutainer and allow the bottle to fill with blood to the required level.
As soon as blood is flowing the tourniquet can
be loosened.
It is no longer necessary and prolonged tourniquet
usage may lead to inaccurate blood test results.
Hold the vacutainer holder securely while
changing the bottles and collecting the blood.
To prevent the equipment from becoming
dislodged.
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Use correct order of draw with the blood
bottles. To prevent contamination of tubes without additives from the tubes that contains additives.
Immediately engage the sharp safety
mechanism and discard in the sharps bin.
To meet health and safety requirements by
preventing sharps injuries.
Ask the patient to press gently on the puncture
site and avoid bending the arm. Apply an appropriate dressing.
To prevent and/or minimise bleeding and haematoma at puncture site.
Carefully label the bottles and place in the
specimen transport bag for laboratory samples. NB use biohazard labels if patient known to
have a BBV.
To ensure the bloods are correctly labelled and
prevent identification errors & reduce the risks of cross infection.
Ensure the patient is comfortable and does not
have any symptoms or questions. Complete any necessary documentation.
To be able to recognise and/or treat problems
before the patient leaves.
Dispose of all sharps and soiled equipment. To adhere to the health and safety and infection
control policies.
Remove and dispose of apron and gloves and
wash hands.
To adhere to the infection control policies & reduce the risk of infection.
5.0 Procedures connected to this Policy
Children Community Nursing SOP 02 – Blood Specimens http://luna.smhsct.local/documents/policies-a-z/c/4368-children-community-nursing-sop-02-blood-specimens/file
Children Community Nursing SOP 02 - Transport of Microbiology Specimens http://luna.smhsct.local/documents/policies-a-z/c/4373-children-community-nursing-sop-07-transport-of-specimens/file Infection Prevention and Control Assurance - SOP 1 - Standard Infection Control Precautions http://luna.smhsct.local/documents/policies-a-z/i/4394-infection-control-assurance-sop-1-standard-infection-prevention-and-control-precautions/file Waste Management SOP 2 - Sharps Waste http://luna.smhsct.local/documents/policies-a-z/w/4336-waste-management-sop-2-sharps-waste/file 6.0 Links to Relevant Legislation
CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staffs have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
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Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety and welfare. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people 6.1 Links to Relevant National Standards Care Quality Commission (CQC) NHS Litigation Authority (NHSLA) National Institute for Health & Clinical Excellence (NICE) World Health Organisation (WHO)
6.2 Links to other Key Policies
Infection Control Policy
Physical Health Policy
Deterioration Patient Policy
Hand Hygiene Policy
Restrictive Physical Intervention Policy 6.3 References
Dougherty, L. Lister, S (Ed) (2011). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth Edition. Lindon. Wiley Blackwell
Nash, M (2005). Physical Care Skills: A training need analysis of inpatient and community mental health nurses. Mental Health Practice. 9(4): P 24-27
Nursing and Midwifery Council. (2008) The Code. London. NMC Publications.
Nursing and Midwifery Council (2009). Record Keeping: Guidance for nurses and midwives. London. NMC Publications.
Rethink (200). Your Choice Report. www.rethink.org/nice. [Accessed May 2104]
The World Health Organisation (WHO). (2010). Best Practice in Phlebotomy. Switzerland. WHO Document Production Services.
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7.0 Roles and Responsibilities for this Policy
Title Role Key Responsibilities
Chief Executive
(Accountable)
Accountable - The Chief Executive is responsible for assuring that this policy is implemented within the Trust. Operational responsibility has been delegated.
Trust Board (Strategic)
Strategic - The role of the Trust Board is to have a strategic overview and final responsibility for safe and high quality care within
service areas across the Trust in accordance with its Assurance Framework and strategic priorities.
Executive Committee (Accountable)
Accountable - A sub-committee of the Trust Board has delegated responsibility for ensuring that this policy is efficient and effective in accordance with the Board’s Assurance Framework and Strategic priorities.
Care Governance
(Responsible)
Responsible - The Care Governance Committee is responsible for overseeing the implementation of a systematic and consistent approach to this policy. The group is chaired by the medical Director and provides exception and progress reports to
the Executive Committee.
Service Managers,
Deputy Modern
Matrons, Ward Managers and Lead
Nurses
Operational The above named are responsible for ensuring that:-
- They are familiar with this policy and are responsible for adhering to the procedures.
- Staffs attend training applicable to their role and for implementing the guidance across their areas of responsibility.
- Staff work to the standards set out in this policy.
Medical Staff
Adherence The above named are responsible for ensuring that:-
- They are familiar with the policy and are responsible for adhering to the procedures.
- Complete blood sample request forms as required for the patients.
- Are able to obtain blood samples from patients themselves and if not, to seek further training in order to gain competence.
- Should direct what blood samples need to be taken and complete specimen request forms accordingly.
- Access results and take appropriate action when any abnormalities are detected.
Clinical Staff
Adherence - All clinical staffs are responsible for ensuring that they are familiar with the policy and for adhering to the procedures referred to within the policy.
- Only staff who have completed venepuncture training and have been assessed as competent can take blood samples.
- Staff to maintain competency by an annual update of skills and regular practice of phlebotomy.
- Staff to adhere to NMC and WHO guidelines.
- Appropriately trained staff to ensure that bloods are collected as requested by the medical team.
- Ensure that bloods are transported to the laboratory promptly and are accurately labelled.
- Staff to ensure all equipment used is sterile and all equipment including the blood sample bottles are within date.
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8.0 Training
Phlebotomy training must be attended prior to any phlebotomy procedures being undertaken unless staff have received training in a previous position or with another Trust, and can provide evidence of this. (Please see Appendix 1: Training Needs Analysis).
Prior to undertaking any phlebotomy procedure, all staff must be able to demonstrate clinical competence and have a clear understanding of the underlying principles of practice. This will be achieved by:
Successful completion of the clinical practice framework. (Appendix 2). Staffs who have been trained in phlebotomy must complete a period of supervised practice. Staff who have been trained and practiced in a previous post may be allowed to demonstrate an equivalent level of competency through a period of supervised practice and the completion of the competency framework.
All staff who takes blood samples as part of their job description should attend a three yearly update as recommended by WHO 2010. Any staffs that are not competent or confident should attend a phlebotomy course prior to their practice and have successfully completed a period of supervised practise and competency.
What aspect(s)
of this policy will require staff
training?
Which staff groups require this
training?
Is this training covered in the Trust’s Mandatory and Risk
Management Training Needs Analysis document?
If no, how will the training be delivered?
Who will deliver the training?
How often will staff require
training
Who will ensure and monitor that staff have
this training?
Phlebotomy All clinical staff as appropriate
No, Staff will receive specific training where it is identified
in their individual training
needs analysis or part of their development for their
particular role and responsibilities
Theory/Practical Trust approved training provider
Refresher training every 3
years
Service area Matrons/ Physical Health Strategy
Group
9.0 Equality Impact Assessment
Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]
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10.0 Data Protection and Freedom of Information
Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.
11.0 Monitoring this Policy is Working in Practice
The Trust Care Governance Group is responsible for monitoring of compliance with this policy.
What key elements will be monitored?
(measurable policy objectives)
Where described in
policy?
How will they be monitored?
(method + sample size)
Who will undertake this
monitoring?
How Frequently?
Group/Committee that will receive and
review results
Group/Committee to ensure actions
are completed
Evidence this has happened
How staff are assessed for competency in phlebotomy
8.0 Training Competency assessment and sign off
Service Area Matrons,
Managers
On going Quality and Safety Steering Group
Quality and Safety Steering Group
Competency Documentation
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Appendix 1
Training Needs Analysis
Training Topic
Objective of training
Brief summary of key training content required
Staff Groups
applicable
to (including
numbers)
Delivery method Frequency Monitoring & Reporting
Phlebotomy theory course
To equip nurses and health care
support workers the knowledge
and skill in order
to practise phlebotomy in a
safe and competent
manner
Review of anatomy of the arm
Infection control and health & safety
Reasons for and complications of this invasive procedure
Vein selection and
demonstration of correct technique, choice of
equipment and procedure
Practical skills technique
workshop
Legal and professional
responsibilities
Identified Band 6, 5, 4
and 3 nursing staff
(inpatient
and community)
½ day theoretical training followed by a
period of supervised practice in clinical
area with a
competent practitioner
Training to be
provided externally by HEST Training
One off initial training
Followed by update
every 3 years
Attendance to be recorded by Service Area Matrons and
Professional Practice Development Nurse.
This information will be reported via the physical health monthly
dashboard and annually within physical health annual report
Evidence of
competence for staff who
are joining the
Trust and are already
practising phlebotomy
To ensure that
staff who have worked in
organisations
outside of BCPFT are competent
and safe to practice
phlebotomy
Evidence of training from
previous role/Trust. If not able to provide evidence or if
their training was over three
years ago they should follow the training pathway above.
Clinical Staff
from a previous or
from another
Trusts
If able to provide
evidence they should complete a period of
supervised practice
until the identified assessor is satisfied
they are competent to practice
independently.
One off followed by
update every 3 years as above
If not able to provide evidence or if their
training was over three years ago they
will need to complete
training as above.
Attendance to be recorded by
Service Area Matrons and Professional Practice Development
Nurse.
This information will be reported via
the physical health monthly dashboard and annually within
physical health annual report
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Appendix 2
Phlebotomy Clinical Practice Competencies
Assessment Strategy The process of developing competence follows the stages below:- 1. Observation The nurse observes a competent practitioner practicing the skill and adheres to local policies, guidelines/protocols for the procedure of venepuncture on a minimum of two occasions. 2. Supervision A period of supervised practice is undertaken. Any medical/nurse practitioner who is competent in this procedure may act as supervisor. The supervisor gives guidance and feedback for the development of competence and agrees with the assistant when competence has been achieved. This aspect will incorporate supervision on a minimum of five occasions which means that the nurse may request additional supervision to achieve competency. If the supervisor does not agree competency with the nurse, then he/she should give the reasons in order that the nurse can rectify deficits in his/her knowledge and skills. 3. Assessment When the nurse assesses him/herself to have acquired the necessary knowledge and skills for the procedure of venepuncture without supervision, then he/she arranges to be assessed in the procedure by the appropriate medical/nursing personnel. Failure in the assessment If competence is not achieved in the assessment, then further periods of supervised practice with specific guidance for improvement in practice are given and reassessment undertaken. It is the nurse’s responsibility to forward a copy of their competency record to their Manager for retention in their personnel file.
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Phlebotomy Clinical Practice Competencies
Name
Ward Department
OBSERVATION RECORD
Date
Signature of Staff Member
Signature of Assessor
1
2
3
SUPERVISED PRACTICE RECORD
Date
Signature of Staff Member
Signature of Assessor
1
2
3
4
5
6
7
8
9
10
11
12
A copy should be retained in the staff members’ personal file
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Phlebotomy Clinical Practice Competencies
Name
Ward Department
Payroll Number
Trust
The above named nurse has attended training on Venepuncture held by the Trust
Name of Tutor
Date of training
The training has been followed by a period of Observation and Supervised Practice of the procedure for Venepuncture and competence has been assessed.
Signature of assessor
Date
Clinical Staff Statement of competence I feel that I am competent in carrying out the procedure of Venepuncture and agree to carry out this procedure in accordance with Trust Policy
Signature
Date
A copy should be retained in the staff members’ personal file
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Policy Details
* For more information on the consultation process, implementation plan, equality impact assessment,
or archiving arrangements, please contact Corporate Governance
Review and Amendment History
Version Date Details of Change
1.1 Sept 2018 Policy transferred to new Trust Template; reviewed with minor amendments to 4.0, 5.0, 6.0, 6.2 and Appendix1; updated tables 7.0, 8.0, and 11.0.
1.0 July 2014 New Policy Alignment of Policies following TCS
Title of Policy Phlebotomy Policy
Unique Identifier for this policy BCPFT-PH-POL-08
State if policy is New or Revised Revised
Previous Policy Title where applicable n/a
Policy Category Clinical, HR, H&S, Infection Control etc.
Clinical
Executive Director whose portfolio this policy comes under
Heads of Nursing
Policy Lead/Author Job titles only
Physical Health Clinical Lead
Committee/Group responsible for the approval of this policy
Nursing Board
Month/year consultation process completed *
n/a
Month/year policy approved October 2018
Month/year policy ratified and issued November 2018
Next review date Sept 2021
Implementation Plan completed * Yes
Equality Impact Assessment completed * Yes
Previous version(s) archived * Yes
Disclosure status ‘B’ can be disclosed to patients and the public
Key Words for this policy Phlebotomy, Drawing of blood, Antecubital fossa, Tourniquet, Blood borne virus (BBV)
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