Patient Assessment & Documentation Flashcards

Which scenario represents an example of a post-analytical documentation error?

Answer: Reporting results to the wrong patient's chart

Reporting results to the wrong patient's chart is a post-analytical error that occurs after testing is complete and can have serious clinical consequences.

A patient's electronic order requires a 'timed specimen' for cortisol at 0800. The MLS collects the specimen at 0830. What is the correct action?

Answer: Document the actual collection time as 0830 and notify the provider of the delay

The actual collection time must always be documented accurately; the provider should be notified of the 30-minute delay so they can determine if the result is still clinically useful.

Which of the following patient conditions identified during assessment would most directly affect the integrity of a coagulation specimen?

Answer: Receiving IV heparin infusion

IV heparin directly anticoagulates the patient's blood and will produce falsely prolonged PT and aPTT results if not accounted for in specimen collection and interpretation.

Under HIPAA, laboratory documentation containing patient results may be shared without explicit authorization with:

Answer: The patient's treating physician involved in direct care

HIPAA's Treatment, Payment, and Operations (TPO) exception permits sharing PHI with treating providers without explicit patient authorization.

An MLS suspects that a specimen was collected from a patient with an active IV line in the same arm without note on the requisition. Which result pattern would MOST support this concern?

Answer: Markedly decreased potassium and glucose with diluted electrolytes

IV fluid contamination typically causes diluted electrolytes (low potassium, low sodium) and decreased glucose, reflecting the composition of the infusing fluid.

Which component of patient documentation is most important when an MLS performs a corrected report after releasing erroneous results?

Answer: Issuing a corrected report that references the original incorrect report with the reason for correction

A corrected report must reference the original incorrect report, state the reason for correction, and be clearly labeled as corrected to maintain a complete and transparent audit trail.

A pregnant patient at 28 weeks gestation is scheduled for a 1-hour glucose challenge test (GCT). She states she ate breakfast 30 minutes ago. The MLS should:

Answer: Proceed with the test, as the GCT does not require fasting

The 1-hour glucose challenge test (GCT) is a non-fasting screening test; the patient does not need to fast before the 50-gram glucose load.