Name: ____________________________________________ Yr.

& Sec: __________________ Date: _________ Total Score :

_______ /105

Critical Dimensions 1 2 3 4 5
REFER BEGINNER COMPETENT PROFICIENT EXEMPLARY SCORE
(NO CONTENT) (LIMITED CONTENT) (ADEQUATE CONTENT) (REMARKABLE (PROFESSIONAL
CONTENT) CONTENT)
Pre-analytical Phase:

PPE (lab gown, mask, No PPE is worn. Only 1 PPEs are worn. Only 2 PPEs are worn. Only 3 PPEs are worn. Complete PPEs are worn.
gloves, hair cap)

Factor: 1
Materials and No materials 1-2 out of 6 are available 3 out of 6 are available 4-5 out of 6 are available Complete materials and
Instruments (special instruments
consideration to the
specimen if required)

Cleaning and Did not clean the Cleaned but did not Cleaned and disinfected
disinfection of working working area before disinfect the working area working area before starting
area starting or vice versa on the working
area before starting
Factor: 1
Analytical Phase:

Materials No materials Incomplete. (6 are Incomplete. (4 are lacking) Incomplete. (2 are lacking) Complete. (requisition form,
lacking) syringe, tourniquet, alcohol,
cotton, tape, indelible pen,
yellow bag, sharps
Factor: 2 container)
Patient identification Omitted patient Incorrect identification Proper courtesy, introduce Introduce yourself as Proper courtesy, introduce
identification and yourself as laboratory laboratory personnel, ask yourself as laboratory
rapport. personnel, ask Px’s full Px’s full name and compare personnel, ask Px’s full
name it with ID band. name and compare it with
ID band. Explains
procedure.

Site selection Didn’t apply tourniquet,
(vein) didn’t ask patient to
close fist, instruct the
patient to open and
close fist.
Factor: 2
Veins at the back of the (Antecubital fossa) last (Antecubital fossa) Second (Antecubital fossa) last
hand or wrist. Didn’t choice for the patient. choice for the patient. Didn’t choice for the patient.
apply tourniquet or did Didn’t apply tourniquet or apply tourniquet or did not Applied tourniquet and
not ask patient to close did not ask patient to close ask patient to close fist. asked the patient to close
fist. fist. fist.

Tourniquet application Omit tourniquet Too close to the puncture Applied 3-4 inches above Applied 3-4 inches above Applied 3-4 inches above
application site, more than 1min. the puncture site, less than 1 the puncture site, observe the puncture site, observe
minute. proper technique, less than 1 proper technique and
minute. tightness, less than 1 minute.
Factor: 1
Antiseptic application Omit antiseptic Clean site with 70% Clean site with 70% Clean site with 70% alcohol, Clean site with 70% alcohol,
alcohol improperly, alcohol, in concentric circle. in concentric circle, inward in concentric circle, inward
touched the skin after to outward. to outward, allowed drying.
Factor: 1 cleansing
Handling and insertion Improper handling and Insert 15-30 degrees Inspect needle and syringe, Inspect needle and syringe, Inspect needle and syringe,
of needle. needle insertion. angle, bevel up. insert 15-30 degrees angle, anchor the vein 1- 2 inches anchor the vein 1- 2 inches
bevel up. below the puncture site, below the puncture site, hold
insert 15-30 degrees angle, the syringe with thumb on
bevel up. top near the hub and fingers
underneath, insert 15-30
degrees angle, bevel up.

Factor: 1

Filling Omitted 3 steps Improperly done: all steps Improperly done: 2 out of 3 Improperly done: 1 out of 3 1. Proper and stable hold
without shaking.
2. Pull back syringe plunger
slowly.
3. without bubbles/ space
Factor: 3 inside the barrel.
Amount of Blood. Failed to collect blood Blood enters the hub Air bubbles in the syringe Insufficient blood collected. Desired amount of blood
Factor: 3 collected.
Withdrawing the needle. Did not release Released tourniquet, Did not release tourniquet, Released tourniquet, Released tourniquet,
tourniquet, withdraw withdraw needle while withdraw needle slowly. withdraw needle slowly. withdraw needle in one swift
needle while collecting. collecting. (Pulling of motion.
(Pulling of plunger) plunger)
Factor: 1
Application of pressure Did not use cotton and Used wet cotton Used dry cotton, did not Dry cotton balls on wound, Dry cotton balls on wound,
on the puncture site. did not apply pressure. apply pressure. applied pressure applied pressure
immediately immediately, asked patient
to apply pressure and check
Factor: 1 on wound before leaving the
bedside.
Post-analytical Phase:

Disposal of waste and Left the working area Disposed the waste in an Disposed the wastes in an Disposed all the waste in Properly cleaned and
cleaning of working dirty. inappropriate container, inappropriate container, proper container, did not disinfect the working area.
area did not disinfect disinfect the working area disinfect the working area.

Factor: 1
Returning of materials Left materials on the Left some materials on Left some materials on the Returned all materials, no Returned all materials, no
and glass wares working area, with the working area, with working area, no breakages, breakages, did not dry glass breakages, dried glass wares
breakages, did not dry breakages, did not dry did not dry glass wares wares
glass wares glass wares.
Factor: 1