Documentation Standards Flashcards

Which practice violates electronic signature standards in a laboratory information system?

Answer: Sharing login credentials so a coworker can verify results

Electronic signatures must be unique to one person, so shared credentials make every attribution meaningless.

Under HIPAA's minimum necessary standard, what patient information should a technologist access?

Answer: Only the information needed to do the assigned job

The minimum necessary standard limits access to protected health information to what the job function requires.

A specimen arrives with a label name that does not match the requisition. What is the correct action?

Answer: Reject the specimen, document the discrepancy, and request recollection

Mismatched identification is grounds for rejection, because relabeling risks a wrong-patient result.

What does a lot-to-lot comparison record for a new reagent lot document?

Answer: That results from the new lot match the current lot before it is used for patients

Lot-to-lot verification records show that a new reagent lot gives results comparable to the lot in use before it goes into service.

Where should the lab document a QC result that falls outside the acceptable limits?

Answer: On the QC record, with the rule violated, the corrective action, and the repeat QC results

QC failures and their corrective actions must be recorded so the lab can show patient results were not affected.

When a retired procedure is removed from the active manual, what must the lab do with it?

Answer: Keep it for at least 2 years with the dates it was in use

CLIA requires discontinued procedures to be kept for 2 years with their dates of initial use and discontinuance.

Which entry on a maintenance log is acceptable?

Answer: "10/11/2026 – Probe cleaned per SOP; verified OK – JD"

Log entries must be dated, specific, permanent, and attributable, and must never be back-dated.