Documentation Standards Flashcards

A technologist notices a transcription error in a handwritten QC log. What is the correct way to fix it?

Answer: Draw a single line through the error, write the correct entry, and initial and date it

A single-line strike-through keeps the original entry readable while documenting who made the correction and when.

Under CLIA, how long must a laboratory keep routine patient test records, including requisitions and QC records?

Answer: At least 2 years

42 CFR 493.1105 requires most test records, including QC and test requisitions, to be kept for at least 2 years.

When a critical value is phoned to a nurse, which documentation is required?

Answer: Name of the person notified, date and time, the result, and confirmation of read-back

Critical value documentation must show who received the result, when, what was reported, and that it was read back.

Which pair is an acceptable set of patient identifiers on a specimen label?

Answer: Full name and date of birth

The Joint Commission requires two person-specific identifiers, and a room or bed number is not one.

A test result is found to be wrong after the report has gone out. What must the corrected report do?

Answer: Clearly show it is corrected and keep the original result on record

Corrected reports must be clearly labeled as corrected, and the original data must be kept for traceability.

What must be recorded on a newly opened reagent bottle?

Answer: Date opened, new expiration date if it changed, and initials

Opened reagents need the date opened and any changed expiration date so their stability can be tracked.

Under CLIA, when must a new procedure in the procedure manual be approved, signed, and dated by the laboratory director?

Answer: Before it is used for patient testing

CLIA requires the director or a designee to approve, sign, and date procedures before they are used.