Documentation Standards Flashcards

In forensic or legal blood alcohol testing, what document tracks every person who handles the specimen?

Answer: Chain-of-custody form

A chain-of-custody form records every transfer of the specimen so it holds up in court.

Which item is typically NOT required on a specimen tube label?

Answer: Patient's insurance policy number

Insurance details belong in billing records, not on the specimen label.

Timed specimens like a 2-hour postprandial glucose require what documentation?

Answer: The exact time of collection relative to the meal or dose

Timed tests are only valid if the exact collection time is recorded against the reference event.

A patient faints during venipuncture but recovers quickly. What documentation is required?

Answer: An incident report per facility policy

Adverse events such as syncope must go on an incident report for safety and liability.

Under HIPAA, which action protects patient information on requisitions?

Answer: Keeping requisitions face down and out of public view

HIPAA requires reasonable safeguards to keep protected health information from unauthorized viewers.

Blood bank specimens usually require which extra documentation step?

Answer: A special armband or ID number linking the patient to the specimen

Blood bank ID systems link the patient, specimen, and blood products to prevent fatal transfusion errors.

When documenting in an electronic health record, why must phlebotomists never share login credentials?

Answer: Every entry must be traceable to the person who made it

Unique logins create an audit trail that ties each entry to one accountable user.