Electronic Health Records and LIS Basics for Phlebotomists

Why Phlebotomists Use Electronic Health Records and the LIS

Modern clinical laboratories run on two connected digital systems: the Electronic Health Record (EHR) and the Laboratory Information System (LIS). As a phlebotomy technician, you will interact with both every shift. Understanding how they work—and how errors in them cause patient harm—is a core professional skill, not just a computer task.

The EHR is the patient's complete digital chart, shared across departments. Physicians, nurses, and other providers enter orders, document assessments, and view results here. When a provider orders a lab test, that order travels electronically to the LIS.

The LIS is the laboratory's dedicated software. It receives orders, assigns accession numbers, tracks specimens from collection through result reporting, and stores reference data such as tube types and handling instructions. Think of the LIS as the laboratory's command center.

How an Order Flows from Provider to Phlebotomist

1. A provider enters a test order in the EHR (or on a paper requisition that a clerk then enters).

2. The order transmits to the LIS, which assigns a unique accession number to that order.

3. The phlebotomist or a clerk confirms the order and prints a collection label directly from the LIS.

4. The phlebotomist collects the specimen, applies the correct label to the correct tube at the bedside or draw station, and sends the specimen to the lab.

5. Laboratory staff use the LIS to track processing, instrument results, and final reporting to the EHR.

Each handoff is a potential error point. Your role is to catch discrepancies before the needle touches the patient.

Key Tasks You Will Perform in the LIS

Entering and Confirming Orders

When working from a paper requisition, you may need to enter or verify the order in the LIS yourself. Always confirm:

• Patient full name and date of birth (two unique identifiers)
• Ordering provider name
• Test name or test code
• Ordering date and time
• Any special instructions (fasting, timed draw, chain of custody)

Never guess at a test code. If the test name in the LIS does not exactly match the requisition, stop and clarify with the ordering provider or your supervisor before collecting.

Printing Collection Labels

A correctly printed label contains the patient's name, date of birth, medical record number or patient ID, accession number, test name(s), collection date and time, and the collecting phlebotomist's identifier. After printing, compare every field on the label to the original requisition before applying it to a tube. A label attached to the wrong tube or the wrong patient is a critical patient safety error and is one of the leading causes of specimen identification failures in the laboratory.

Never pre-label tubes before you are at the patient's side and have confirmed identity.

Looking Up Specimen Requirements

The LIS contains a built-in reference, sometimes called a test catalog or compendium, listing for every orderable test:

• Required tube type (by color code and additive)
• Minimum volume needed
• Number of tubes required
• Temperature and light-sensitivity handling notes
• Special collection timing or patient preparation requirements
• Rejection criteria (e.g., hemolyzed, grossly lipemic, or insufficient volume)

Look up requirements before every collection if you are unfamiliar with the test. Using the wrong tube invalidates the result and requires a redraw—an avoidable harm to the patient.

Patient Safety Rules That Apply Here

Two-identifier verification is mandatory. Before printing any label or beginning a draw, confirm the patient's identity using at least two identifiers (e.g., full name plus date of birth, or name plus medical record number). The LIS does not do this for you; you do it in person at the patient's side.

Label at the bedside, not at the desk. Print labels in advance only if your facility's policy permits it, and even then, apply them only after confirming identity.

Resolve mismatches before you collect. If the LIS order does not match the requisition or the patient's stated information, do not collect. Document the discrepancy and notify the appropriate staff.

Protect patient privacy. LIS screens display protected health information (PHI). Log out of the system whenever you step away. Do not share login credentials.

Working in a Training Environment

Your program uses a training-environment LIS that mirrors real software without touching actual patient data. Treat it exactly as you would a live system—same steps, same habits. The workflows you practice now become the reflexes that protect patients on the job. If a step feels unfamiliar or uncertain during training, ask. It is far better to ask a question in the classroom than to hesitate at a patient's bedside.

Connecting LIS Skills to Your Certification Exam

The CPT credential exams from NHA, AMT, and ASCP all test knowledge of specimen labeling requirements, order of draw, and pre-analytical error prevention. Understanding the LIS is the practical foundation beneath those content areas. Errors caught in the LIS—wrong test ordered, wrong tube selected, wrong patient identified—prevent the pre-analytical errors that account for the majority of laboratory mistakes. Mastering these basics now directly supports your success on the exam and in your career.