Documentation Standards Flashcards

A physician orders a test verbally. Under CLIA, the lab must request written or electronic authorization within what time frame?

Answer: 30 days

42 CFR 493.1241 requires the lab to request written authorization within 30 days of an oral test request.

What is the main purpose of chain-of-custody documentation for a forensic drug test specimen?

Answer: To document every person who handled the specimen, plus when and why

Chain of custody proves the specimen's integrity by documenting every transfer, so the result holds up legally.

An electronic laboratory information system must keep an audit trail. What does the audit trail capture?

Answer: Who created or changed a record, when, and the original value

Audit trails record user identity, timestamps, and previous values so every change to a record can be traced.

A specimen is rejected because it is hemolyzed. What should be documented?

Answer: Patient identifiers, the reason for rejection, the person notified, and the date and time

Rejection records must show why the specimen was rejected and who was told, so recollection can be followed up.

Where may a technologist write a refrigerator temperature that is out of range?

Answer: On the temperature log, with the corrective action and initials

Out-of-range temperatures must be recorded on the official log along with the corrective action taken.

Which item is a CLIA-required element of a patient test report?

Answer: Name and address of the laboratory that performed the test

42 CFR 493.1291 requires the report to name and give the address of the testing laboratory, along with results, units, and reference intervals.

When should a specimen be labeled during collection?

Answer: At the bedside, in the patient's presence, right after the draw

Labeling in the patient's presence right after collection prevents mislabeled and wrong-blood-in-tube errors.