Documentation & Record Keeping Flashcards
7 cards from real CLT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
Which element is NOT typically required on a laboratory specimen label?
Answer: Technologist's home address
A technologist's home address is never required; labels must include patient identifiers, collection date/time, and specimen ID.
In the context of laboratory documentation, what does 'traceability' mean?
Answer: The ability to follow the history, application, or location of a result or process through recorded information
Traceability means the documented ability to track a result, sample, or process back through its entire history using recorded information.
When a critical value is called to a nurse, what information must be documented?
Answer: The result, date/time, name of the person notified, and who reported it
Critical value documentation must include the result, date and time of notification, the name of the person notified, and the reporting technologist's identity.
What is a 'delta check' in laboratory documentation?
Answer: A comparison of a current result with a previous result for the same patient to flag unexpected changes
A delta check compares a patient's current result with their prior result to detect clinically unlikely changes that may indicate an error.
A laboratory receives a sample with a broken chain of custody form. In which testing scenario is this most critical?
Answer: Forensic or legal drug testing
Chain of custody documentation is legally mandatory for forensic and drug testing specimens to ensure specimen integrity is defensible in court.
Which of the following best describes a nonconformance report (NCR) in a laboratory quality system?
Answer: A document recording any deviation from established procedures or quality standards
A nonconformance report documents any deviation from established procedures or quality standards, triggering investigation and corrective action.
Which record must be maintained to demonstrate that a laboratory's reference intervals are appropriate for its patient population?
Answer: Reference interval validation records
Reference interval validation records document that normal ranges have been verified or established for the laboratory's specific patient population.