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Processing Laboratory Orders - 150 > 1 > Flashcards

1 Flashcards

1
Q

what is the purpose of the physician’s order sheet?

A

to communicate medical care for each patient

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2
Q

all physician’s orders should contain what?

A
  1. date and time order was written
  2. orders
  3. doctors signature
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3
Q

what are the classifications of a physician’s order?

A
  1. activity
  2. diagnostic
  3. dietary
  4. medication
  5. treatment
  6. miscellaneous
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4
Q

what are activity orders referred too?

A

refer to the type of activity the patient is allowed

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5
Q

what are examples of a diagnostic order?

A
  1. ECG
  2. lab work
  3. ultrasounds
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6
Q

what are dietary orders referred too?

A

nourishment that will be given to the patinet

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7
Q

what are medication orders, ordered for?

A
  1. ease pain
  2. treat disease
  3. prepare patients for diagnostic or surgical procedures
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8
Q

what are examples of treatment orders?

A
  1. IV therapy
  2. dressing changes
  3. respiratory therapy
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9
Q

what are miscellaneous orders?

A

orders that do not fall into the five classifications

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10
Q

what are the 4 types of physicians orders?

A
  1. standing or counting orders
  2. standing or counting orders PRN
  3. one time orders or short orders series
  4. STAT orders
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11
Q

what is a standing or continuing order?

A

orders stay in effect until they are discontinued or changed by a written doctor’s order

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12
Q

what is a standing or continuing order PRN?

A

orders in effect until changed or discontinued by the physician. they are only in effect when the patient is in need

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13
Q

what are one time or short order series orders?

A

orders a doctor may only want carried out once

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14
Q

what are stat orders?

A

first order transcribed in a set of orders

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15
Q

what does the symbol “k” mean?

A

the order has been transcribed onto the kardex

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16
Q

what does the symbol “RMO or Req” mean?

A

requisition has been completed

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17
Q

what does the symbol “LMO” mean?

A

label made out

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18
Q

what does the symbol “EC” mean

A

entered in computer

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19
Q

what does the symbol “aware” mean?

A

the correct department or medical staff have been notified of the order

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20
Q

what does the symbol “DONE” mean?

A

the order has already been completed

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21
Q

what is the laboratory department responsible for?

A

performing tests on body fluids to aid in the diagnosis and treatment of the patient

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22
Q

what are the different laboratory departments?

A
  1. pathologist
  2. hematologist
  3. microbiologist or bacteriologist
  4. lab technologist
  5. phlebotomist or lab assistant
  6. lab clerk
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23
Q

what are the hours of the lab?

A

24/7

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24
Q

how can the lab department be contacted?

A
  1. phone

2. computer

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25
Q

BCCDC

A

British Columbia Centre for Disease Control

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26
Q

what is the pathologist?

A

department head

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27
Q

what is the hematologist?

A

specialist who deals with blood disorders

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28
Q

what is the microbiologist or bacteriologist?

A

specialist who deals with infectious diseases

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29
Q

what does the laboratory technologist do?

A
  1. draws blood
  2. tests blood
  3. urine test
  4. stool test
  5. CSF
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30
Q

what does the phlebotomist or lab assistant do?

A
  1. draws blood

2. routine lab procedures

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31
Q

what does the lab clerk do?

A

maintains records and reports

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32
Q

basic procedures for entering lab orders in the computer

A
  1. open patient chart on meditech
  2. select new order and tick the tests to be ordered
  3. all tests ordered will be collected on the next routine draw.
  4. indicate if test is STAT, urgent, or routine
  5. record the diagnosis if the lab test requires one
  6. double check physician’s order, and orders you have selected in meditech
  7. only call lab to draw blood if
    a) STAT order
    b) scheduled lab draws have ended for the day
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33
Q

steps for processing physicians orders?

A
  1. check previous order for completion
  2. read over all orders
  3. scan to pharmacy
  4. collect all necessary requisitions and forms that will be needed
  5. read order before completing any requisitions or entering into the computer
  6. transcribe lab orders onto kardex
  7. MAR any necessary items
  8. look over orders one last time
  9. add blank physician’s order to the patient chart prn
  10. flag order for nurse to check
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34
Q

what are the steps to insure transcription accuracy?

A
  1. complete concentration
  2. all labels are on correct patient
  3. re-read orders
  4. double check patients name
  5. always ask if unsure
  6. you must transcribe from the doctor’s order sheet
  7. symbolize after each completed order
  8. re-read the forms
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35
Q

VBG - Venous Blood Gas is taken by?

A

Lab Tech

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36
Q

Gastric washing’s, sputum, stool, swabs are taken by?

A

Nurse (sputum is sometimes taken by the respiratory technologist)

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37
Q

ABG - Arterial Blood Gas is taken by?

A

Physician
RT
RN

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38
Q

Biopsies, bone marrow, cerebral spine fluid(CSF), cervical swab, thoracic fluid, peritoneal fluid are taken by?

A

the doctor

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39
Q

steps for communicating with the lab

A
  1. doctor will write order for lab test
  2. NUA will process the order
  3. lab or nurse will come to collect
  4. test are preformed in the hospital lab or necessary tests are sent out to provincial lab prn
  5. lab results are sent to the nursing station via printer
  6. results are filed into patients chart when we have time
  7. doctor sees results and may order more test prn
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40
Q

what does a CBC (complete blood count) test include?

A
  1. white blood count (WBC)
  2. red blood cell count (RBC)
  3. hemoglobin (Hgb)
  4. hematocrit (Hct.)
  5. peripheral smear
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41
Q

if the doctor orders a CBC+diff what do NUA’s order?

A

CBC and in the comments to lab we say “CBC+Diff”

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42
Q

what is a ESR (erythrocyte sedimentation) test for?

A

to look for inflammatory activity in a patient

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43
Q

what is a Plt. Count (platelet count) test for?

A

to test a patients platelet levels

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44
Q

what is a RBC morph (red blood cell morphology) test used for?

A

to look for the size and shape of RBC’s

45
Q

what is Retic. Count (reticulocyte count) test for?

A

used for diagnostic purposes only

46
Q

what are the hematology basic tests?

A
  1. CBC
  2. Diff
  3. ESR
  4. Plt. Count
  5. RBC Morph
  6. Rectic. Count
47
Q

what are hematology special tests?

A
  1. Activated partial thromboplastin time - (PTT)
  2. Prothrombin Time/INR - (PT, INR)
  3. Fibrin Degradation Products - (FDP)
  4. Fibrinogen
48
Q

what does the NUA do when ordering a anticoagulant test?

A

note to the lab if patient is on anti-coagulants

49
Q

what is an Activated partial thromboplastin time test?

A

anti-coagulant test

50
Q

what is an Prothrombin Time/INR test?

A

anti-coagulant test

51
Q

do you need to notify the lab if an Prothrombin test is ordered?

A

no

52
Q

what test is a Fibrin Degradation Products?

A

blood clotting test

53
Q

what test is a fibrinogen test?

A

blood clotting test

54
Q

NUA’s responsibilities for processing routine hematology blood work

A
  1. Enter blood work into med-tech
  2. Kardex - record into blood work section
  3. symbolize on the doctors order sheet “K” & “EC”
55
Q

what do you do if medi-tech crashes?

A

downtime requisitions

56
Q

what are the steps of downtime requisitions ?

A
  1. label requisition with correct patient
  2. record date, doctor that’s ordering, patient diagnosis
  3. check off correct ordered test
  4. scan to lab
57
Q

steps to enter coagulation test: PTT

A
  1. enter into med-tech - if patient is on a anti-coagulant
  2. kardex under lab work
  3. symbolize on order sheet
58
Q

what does the hematology department do?

A

test on blood
tests on bone marrow
cerebrospinal fluid

59
Q

what can the hematology department determine

A
  1. number, size, shape and appearance of blood cells
  2. clotting and bleeding disorders
  3. coagulation studies
60
Q

what is the most common method of obtaining bone marrow?

A

inserting a large bore needle, under local or general anesthesia into the bone

61
Q

once bone marrow is aspirated where is it sent?

A

sent to the lab for anaylsis

62
Q

what are bone marrow aspirations used for?

A

to diagnosis blood disorders and malignant diseases

63
Q

does a legal consent need to be filled out when getting a bone marrow aspiration?

A

yes

64
Q

when tests require patients to be fasting how long of fasting do they need?

A

8-12 hours

65
Q

if fasting blood work is ordered on a patient when will it be done?

A

following day - unless patient is already NPO that day

66
Q

where do you record the lab test on the kardex?

A

under lab work

67
Q

what does “fasting” mean?

A

without food

68
Q

what is fasting blood sugar?

A

the level of glucose in the blood without eating for a certain period of time

69
Q

why is a FBS test performed?

A

to determine how much glucose that is ingested daily is used by the body

70
Q

what are some problem solving techniques for illegible/unfamiliar lab orders?

A
  1. check with RN/PCC
  2. check with doctor if still around
  3. check lab manual
  4. call the lab or ask another clerk
71
Q

what do you do if a lab test is not done at your hospital?

A
  1. inform the doctor

2. write in red pen beside the lab order the lab order is not available at your hospital

72
Q

what does the chemistry department do?

A

analyze specimens of body fluids for chemical components

73
Q

what are common specimens that may be analyzed for chemical components?

A
  1. Blood
  2. urine
  3. sweat
  4. stool
  5. CSF
  6. amniotic fluid
  7. synovial fluid ( from the joint)
74
Q

who draws a blood chemistry test (venous blood)

A

lab tech

75
Q

how is a venous blood test obtained?

A

direct puncture into the vein

76
Q

who draws arterial blood gas (ABG)

A
  1. doctor
  2. RT
  3. RN
77
Q

T/F - you may be asked to indicate wether a patient is on 02?

A

Ture

78
Q

who draws therapeutic drug level tests? (venous blood)

A

lab tech

79
Q

who draws miscellaneous lab tests?

A

lab tech

80
Q

who draws urine/misc - urine/stool tests?

A

nursing staff

81
Q

LFT’s

A

liver function tests

82
Q

what test are included in a liver function test? (LFT)

A
  1. ALT
  2. ALK PHOS
  3. Total Bili
  4. AST
  5. GGT
  6. Total protein
  7. ALB
83
Q

what are the unit clerk responsibilities for processing chemistry orders?

A
  1. enter test into the computer
  2. kardex test under lab work section
  3. symbolize the order with “EC”, “K” + initials
84
Q

what are the unit check responsibilities for miscellaneous orders?

A
  1. enter test into the computer
  2. kardex under lab work section
  3. symbolize orders with “EC” and “K”
85
Q

what is the definition of therapeutic drug levels?

A

drug levels can assist the doctor in determining the appropriate dosage to make sure the required therapeutic response with minimal risk of toxicity to the patient

86
Q

therapeutic tests can also be referred to as?

A

trough test

87
Q

what type of test would go under therapeutic tests?

A
  1. digoxin level
  2. dilantin/phenytoin level
  3. theophylline level
  4. antibiotic levels
88
Q

T/F - (therapeutic drug) the NUA may be asked to enter the last time the patient took the drug

A

Ture

89
Q

unit clerk responsibilities for therapeutic drug levels?

A
  1. enter into computer
  2. MAR the order
  3. kardex under lab work
  4. symbolize “EC” and “K” on order sheet
90
Q

how long after you enter a STAT order will you receive the results?

A

within 1 hour

91
Q

when you place an “urgent” order when will you receive the results?

A

within 3 hours

92
Q

what lab order will you receive results the same day ASAP?

A

routine order

93
Q

what does the pathology department analyze ?

A

tissues and cells for evidence of disease

94
Q

what does the blood bank do?

A
  1. orders and receives blood from red cross

2. gives blood to patients in the hospital

95
Q

who collects venous blood gas?

A

lab tech

96
Q

name 4 specimens that nurses collect?

A
  1. gastric washings
  2. sputum
  3. stool
  4. swabs
97
Q

who collects arterial blood gases?

A

respiratory technologist

98
Q

name 4 specimens that the doctor will collect?

A
  1. biopsy
  2. bone marrow
  3. cerebrospinal fluid (CSF)
  4. cervical swab
  5. thoracic fluid
  6. peritoneal fluid
99
Q

a urinalysis is performed by?

A

chemistry department

100
Q

what does a routine urinalysis include?

A
  1. PH
  2. protein
  3. glucose
  4. ketones
  5. specific gravity
101
Q

what does a microscopic urine include?

A
  1. RBC
  2. WBC
  3. pus cells
  4. epithelial cells
  5. hyaline casts abd crystals
102
Q

unit clerk responsibilities for urinalysis

A
  1. enter test into computer
  2. kardex under lab work section
  3. print label for correct patient
  4. symbolize on order sheet “LMO, EC, K” in red ink
  5. go back into med-tech and change “uncollected” to “collected” once nurse brings you specimen
103
Q

name 6 chemistry tests for urine and miscellaneous body fluids:

A
  1. amylase
  2. barbiturate
  3. calcium
  4. chloride
  5. creatinine
  6. creatinine clearance
104
Q

steps to print a label in med-tech?

A
  1. open medi-tech (first screen)
  2. go to reports
  3. click forms/labels
  4. put in correct patient name
  5. choose correct printer & number of labels
  6. print
105
Q

unit clerk responsibilities for processing random urine chemistry tests:

A
  1. enter order into med-tech
  2. print label
  3. kardex under lab work
  4. symbolize with “LMO, EC, K”
  5. once specimen has been collected go back into med-tech and change it to “collected”
106
Q

unit clerk responsibilities for occult blood tests / stool OB

A
  1. print 3 labels and write “stool OBx1, OBx2, OBx3” and out onto kardex
  2. enter these into med-tech one at a time
  3. in the comments you indicate which stool OB it is
107
Q

when do you draw a blood specimen before a trough test ?

A

half hour before

108
Q

what lab tests are included in a lytes panel ?

A
  1. sodium
  2. potassium
  3. chloride
  4. anion gap
  5. C02
109
Q

what lab tests are included in a lipid panel?

A
  1. cholesterol
  2. triglycerides
  3. high density lipoprotein
  4. low density lipoprotein

Processing Laboratory Orders - 150 (9 decks)

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