CLT Documentation & Record Keeping 3 — Questions and Answers
Question 1: Which element is NOT typically required on a laboratory specimen label?
- Patient name and date of birth
- Collection date and time
- Technologist's home address (Correct answer)
- Accession or specimen ID number
Correct answer: Technologist's home address
A technologist's home address is never required; labels must include patient identifiers, collection date/time, and specimen ID.
Question 2: In the context of laboratory documentation, what does 'traceability' mean?
- The ability to locate misplaced samples
- The ability to follow the history, application, or location of a result or process through recorded information (Correct answer)
- The process of transferring results to another lab
- Comparing results between laboratories
Correct 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.
Question 3: When a critical value is called to a nurse, what information must be documented?
- Only the result value
- The result, date/time, name of the person notified, and who reported it (Correct answer)
- The patient's insurance information
- The laboratory accession number only
Correct 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.
Question 4: What is a 'delta check' in laboratory documentation?
- A financial audit of laboratory costs
- A comparison of a current result with a previous result for the same patient to flag unexpected changes (Correct answer)
- A check of instrument calibration records
- A review of reagent lot numbers
Correct 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.
Question 5: A laboratory receives a sample with a broken chain of custody form. In which testing scenario is this most critical?
- Routine CBC
- Forensic or legal drug testing (Correct answer)
- Lipid panel
- Thyroid function tests
Correct 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.
Question 6: Which of the following best describes a nonconformance report (NCR) in a laboratory quality system?
- A record of employee attendance
- A document recording any deviation from established procedures or quality standards (Correct answer)
- A patient billing record
- A log of reagent purchases
Correct 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.
Question 7: Which record must be maintained to demonstrate that a laboratory's reference intervals are appropriate for its patient population?
- Instrument maintenance log
- Reference interval validation records (Correct answer)
- Proficiency testing shipment log
- Staff scheduling records
Correct 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.
CLT Documentation & Record Keeping 3
Which element is NOT typically required on a laboratory specimen label?