Documentation Standards Flashcards

How long should a phlebotomist wait to document a collection after performing it?

Answer: Promptly, at the time of collection

Documenting at the time of the procedure keeps records accurate and complete.

A specimen requires protection from light, such as bilirubin. What should the label or documentation reflect?

Answer: That it was protected from light, per lab requirements

Light-sensitive analytes like bilirubin break down in light, so handling should be noted.

Which document records a needlestick injury to the phlebotomist?

Answer: An exposure incident report

OSHA's Bloodborne Pathogens Standard requires exposure incidents to be documented and followed up.

An unconscious emergency patient has no ID. How is the specimen typically documented?

Answer: With a temporary ID or trauma number assigned by the facility

Facilities assign temporary identifiers so specimens stay linked to the patient until identity is confirmed.

What is the purpose of noting the collection site, such as 'left antecubital', on some records?

Answer: To support follow-up if complications such as a hematoma occur

Recording the site helps with follow-up if bruising, nerve injury, or other complications occur.

Which statement about late entries in a medical record is correct?

Answer: Late entries should be clearly marked as late with the current date and time

Late entries must be labeled as such with the actual date and time they were written, never backdated.

A physician gives a verbal order for an additional test. What should happen per documentation standards?

Answer: The order is documented, read back for verification, and authenticated per policy

Verbal orders must be written down, read back, and authenticated so there is an accurate record.