Patient Assessment & Documentation Flashcards
7 cards from real MLS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
A patient's requisition form lists the collection time as 0800, but the specimen arrives at the lab at 1400. What is the most appropriate action?
Answer: Document the discrepancy and contact the ordering provider
Discrepancies between collection time and receipt time must be documented and the provider notified, as delays may affect result validity.
Which of the following is the MOST reliable method for identifying a patient prior to specimen collection in an inpatient setting?
Answer: Compare wristband information with the requisition using two identifiers
Two-identifier verification using the patient wristband compared to the requisition is the standard for positive patient identification.
An MLS receives a requisition with illegible handwriting for the test ordered. What should be done?
Answer: Contact the ordering clinician for clarification before processing
Illegible orders must be clarified with the ordering clinician to prevent errors and ensure the correct test is performed.
Which documentation is MOST critical to include when reporting a critical (panic) value?
Answer: The name of the person notified, time of notification, and value reported
Critical value documentation must include who was notified, the time of notification, and the value reported to ensure a complete audit trail.
A specimen labeled with only the patient's last name and room number is received in the lab. Per CAP standards, this specimen should be:
Answer: Rejected and a recollection requested with proper labeling
CAP standards require a minimum of two patient identifiers on every specimen label; a specimen with only one identifier must be rejected.
When reviewing a patient's medical record prior to phlebotomy, the MLS notes the patient is on warfarin. What is the primary concern for specimen collection?
Answer: Prolonged bleeding after venipuncture requires extended pressure time
Patients on warfarin have prolonged clotting times, so extended pressure must be applied after venipuncture to achieve hemostasis.
What information is required on a chain of custody form for a forensic or medico-legal specimen?
Answer: Each individual who handled the specimen, with date and time of transfer
Chain of custody requires documentation of every person who handled the specimen, along with dates and times, to ensure specimen integrity for legal purposes.