Information Management Flashcards
Defined as a system that incorporates all the processes needed for effectively managing data—both incoming and outgoing patient information.
Information Management
_____ need to ensure that the laboratory has an effective information management system in place in order to achieve accessibility, accuracy, timeliness, security, confidentiality, and privacy of patient information.
Laboratory Directors
Important Elements of Information Management:
- Unique identifiers for patients and samples
- Standardized test request forms
- Logs and worksheets
- Checking processes to ensure the accuracy of data recording and transmission
- Protection against loss of data
- Protection of patient confidentiality and privacy
- Effective reporting systems
- Effective and timely communication
Elements under Logs and Worksheets:
Control logbooks
Calibration worksheets
Temperature monitoring worksheet
Result logbooks
The process by which information is exchanged and understood by two or more people, usually with the intent to motivate or influence behavior.
Communication
The exchange of thoughts, messages, or information using speech, signals, writing, or behavior.
Communication
The art and technique of using words effectively to impart information or ideas.
Communication
A system, such as mail, telephone, television, or computer, for sending and receiving messages.
Communication
The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups.
Communication
Identify the Model of Communication:
To select symbols with which to compose a message.
Encode
Identify the Model of Communication:
The tangible formulation of an idea to be sent to a receiver.
Message
Identify the Model of Communication:
The carrier of communication.
Channel
Identify the Model of Communication:
To translate the symbols used in a message for the purpose of interpreting its meaning.
Decode
Identify the Model of Communication:
A response by the receiver to the sender’s communication.
Feedback
Identify the Person who Stated the Importance of Communication in Management Theories:
“The first executive functions is to develop and maintain a system of communication.”
Chester Barnard
Identify the Person who Stated the Importance of Communication in Management Theories:
“Organizational interaction depends on communications.”
Hicks
Identify the Person who Stated the Importance of Communication in Management Theories:
“The nature and used of communications in excellent companies are remarkable.”
Peters and Waterman
A plan used by the laboratory for the dissemination
of information.
Management Communication Strategy
Discuss the Cycle of Communication in Processing Laboratory Determination.
Circular Diagram: Physician, Patient/Laboratory Request, Specimen Collection, Laboratory Processing, and Releasing of Results
Request Form should contain at least the following information:
⚬ Laboratory procedure
⚬ Identification of the patient
⚬ Name of the physician
⚬ Date and time the specimen was collected
⚬ Date and time the specimen was received
⚬ Date, time and by whom the specimen was examined
⚬ Condition of any unsatisfactory specimen
⚬ Type of test or procedure performed
⚬ Results and date of reporting
General Qualities of a Laboratory Report:
⚬ Compactness
⚬ Consistency of terminology, format and usage of understandability
⚬ Clear and easy to understand
⚬ Statement of date and time of collection
⚬ Gross description and source of the specimen when pertinent
⚬ Sharp differentiation of reference or normal and abnormal values
⚬ The sequential order of multiple results on a single specimen
⚬ Identification of patient, patient location and physician
⚬ Assurance of accuracy of transcription of request
Who is responsible for all Laboratory Report?
Laboratory Head
1 of the 12 essential elements of the quality system.
Documents and Records
A major goal of keeping documents and records is _____.
To find information whenever it is needed.
Provide written information about policies, processes and procedures.
Documents
The collected information produced by the laboratory in the process of performing and reporting a laboratory test.
Records
Examples of Documents:
Quality Manuals
SOP
Job Aids
Important Documents in Clinical Laboratory:
Quality Manual
Reference Material
Standard Operating Procedure (SOP)
A document that describes the quality management system of an organization (ISO 15189).
Quality Manual
Purpose of having a Quality Manual:
⚬ Clearly communicate information
⚬ Serve as a framework for meeting quality system requirements
⚬ Convey a managerial commitment to the quality system.
What are the things indicated in a Laboratory Quality Manual?
- Meeting management
- Safe manipulation
- Equipment installation process
- Equipment repair process
- Decontamination of laboratory
equipment - Equipment decommission
- General sampling conditions
- Sample labelling
- Sample rejection or acceptance
- Sample transport
- Results validation
- Critical results reporting
- Internal audit
- Orientation checklist form
- Internal training
- Competency assessment
- Customer survey
- Customer complaint
- Nonconforming event
management - Internal documents management
- SOP management
- Document management
- Short term archiving
- Document control
True or False:
There is two official version of a Quality Manual
False
There is only one official version of a Quality Manual
True or False:
The quality manual is never finished - it is always being improved.
True
The quality manual is never finished - it is always being improved.
General Information that are contained in the Manual:
Quality policy of the laboratory
Reference to all processes and procedures
Table of contents: Description of the laboratory and staff education and training
State the laboratory and institutional policy for the guidance of those working in the laboratory.
Policy Manual
Information included in the Policy Manual:
⚬ Dress Codes
⚬ Food and smoking rules
⚬ Telephone use
⚬ Laboratory organizations and reporting relationship
⚬ Writing, review and authorization of procedures
⚬ Vacation and holiday request
⚬ Supply requisition
⚬ Absences and late arrival notification
⚬ Reporting and releasing of test results
⚬ Specific statements about enforcement of safety rules
Contain written step-by-step instructions that laboratory staff should meticulously follow when performing a procedure.
Standard Operating Procedures
Written SOPs ensure the following:
Consistency
Accuracy
Quality
SOP should have the following:
- Title
- Purpose
- Instructions
- Name of person preparing the SOP
- Signatures of approving officials and dates of approval
A good SOP should be:
- Detailed, clear and concise
- Easily understood by new personnel or students in training
- Reviewed and approved by the laboratory
- Updated on a regular basis
Good Reference Materials are needed in order to find scientific and clinical information about:
Diseases
Laboratory Methods
Procedures
Importance of Paper System when Storing Documents and Records:
Permanence
Accessibility
Security
Traceability
Importance of Electronic System when Storing Documents and Records:
Permanence
Security
Traceability
Factors on Record Retention:
- The length of time the laboratory will need to have access to its records
- Government requirements or standards that dictate record retention times
- Whether the laboratory is engaged in ongoing research requiring many years of data
- The time interval between the laboratory’s assessments or audits
These are Laboratory Information, either written by hand or computer-printed; they are permanent, and are not revised or modified.
Records
Record Retention for:
Requisition and Accession Logs
2 Years
Record Retention for:
Maintenance and Instruments Logs
2 Years
Record Retention for:
Quality Control Records
2 Years
Record Retention for:
Blood Bank Donor/Receipt Records
10 Years
Record Retention for:
Blood Bank Patient Records
10 Years
Record Retention for:
Blood Bank Employees Signature
10 Years
Record Retention for:
Blood Bank QC Records
5 Years
Record Retention for:
Clinical Pathology Test Records
2 Years
Record Retention for:
Reports (Cytology, Surgical, Non-Forensic)
10 Years
Record Retention for:
Cytogenetic Reports and Images
20 Years
Record Retention for:
Flow Cytometry Plots and Histograms
10 Years
Computer network of hardware and software for receiving, processing, and storing laboratory data and information.
Laboratory Information System
Laboratory Information System can interface with _____ to transfer data into patient records, evaluate quality control data, and store preventive maintenance records.
Laboratory Instruments
Components of an LIS:
- The LIS Software User Interface
- Request Entry
- Data (Results) Entry
- Data Storage
- System Security
- Barcoding
- Interface
- Manual Procedures
- System Maintenance
- Disaster Recovery
Information provided by an LIS:
- Patient Demographics
- Work Lists
- Data Retrieval (Inquiry)
- Quality Control
- Quality Assurance
- Management Reports
- Encoding Systems
Advantages of Computerized Systems:
- Error reduction
- Quality control management
- Provision of option for data searching
- Access to patient information
- Generate reports
- Ability to tracks reports
- Improved capacity for maintaining patient confidentiality
- Financial management
- Integration with site outside the lab
Disadvantages of Computerized Systems:
- Training
- Time to adapt to a new system
- Cost
- Physical restrictions
- Need for backup system
