information management Flashcards
A system that incorporates all the
processes needed for effectively managing data– both incoming and outgoing patient information.
information management
○ Incoming:
includes demographic data, services, attending physician, primary diagnosis of patient
○ Outgoing:
test results, final diagnosis, findings, treatment and medication
○ Can get data in a short amount of
time
Need to ensure that the laboratory has an efective management information system in place in order to achieve accessibility, accuracy, timeliness, security, confidentiality and privacy of patient information
Laboratory Directors
- final checking of the results
what are the important elements of information management
★ Unique identifiers for patients and samples
★ Standardized test request forms (requisitions)
★ Logs and worksheets
★ Checking processes to ensure accuracy of data recording and transmission
★ Protection against loss of data
★ Protection of patient confidentiality and privacy
★ effective report systems
★ effective and timely communication
[★ effective communication is the most important skill needed in clinical laboratory
★ Laboratory services can be delivered effectively]
Process by which information is
exchanged and understood by two or more people, usually with the intent to motivate or influence behavior
communication
- exchange of thoughts, messages, or information using speech, signals, writing, or behavior
- a system, such as mail, telephone, or computer, for sending and receiving messages
The art and technique of using words effectively to impart information or ideas
communication
The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups
communication
(sender > message body > receiver)
model of communication process
(image)
★ Encode
○ To select symbols with which to compose a message.
★ Message
○ The tangible formulation of an idea to be sent to a receiver.
★ Channel
○ The carrier of a communication.
★ Decode
○ To translate the symbols used in a message for the purpose of interpreting the meaning.
★ Feedback
○ A response by the receiver to the
sender’s communication.
communication and information flow
ppt
A plan used by the laboratory for the dissemination of information
management communication strategy
[t ensures that the right people get the right information at the right time, helping the lab run smoothly and avoid mistakes.]
elements of a communication plan
○ Define objectives and purpose of the plan
○ Use a concise message
○ Gear communication to education level of recipient
○ Identify the structure and format of written communication
■ Design a format and use it as a template for all written communications
○ List recipients of laboratory communication
■ Identify all stakeholders who should receive communication
○ Identify the method(s) of communication
■ Written (memo, newsletter, email, specimen collection manual)
■ Verbal (phone call, intercom)
■ Visual (banner, poster, video)
cycle of communication in process laboratory determination
ppt
request form should contain at least these 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
○ Results and date of reporting
test report contents
ppt
general qualities of a lab report
★ Compactness
★ Consistency of terminology, format, and usage of understandability
★ Clear and easy to understand
★ Statement of date and time of collection
★ Gross description of source of specimen when pertinent
★ Sharp diferentiation of reference or normal and abnormal values
★ Sequential order of multiple results on single specimen
★ Identification of patient, patient location and physician
★ Assurance of accuracy of transcription of request
who is responsible for all laboratory results
Laboratory head
important documents inn clinical laboratory
Quality manual > SOPs > reference materials
[1️⃣ Quality Manual 📖 – The big rulebook that explains how the lab ensures quality and follows standards.
2️⃣ Standard Operating Procedures (SOPs) 📝 – Step-by-step guides on how to perform lab tests and processes correctly.
3️⃣ Reference Materials 📚 – Trusted sources like textbooks, guidelines, or control samples that help ensure accurate test results.
👉 Think of it like this: The Quality Manual sets the rules, the SOPs show how to follow them, and Reference Materials help confirm accuracy!]
One of the 12 essential elements of the quality system
documents and records
★ The management system addresses both use and maintenance of 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. (WHO)
documents
characteristics:
■ Communicate information to all persons who need it
■ Need to be updated or maintained
■ Must be changed when a policy, process or procedure changes;
■ Establish formats for recording and reporting information by the use of standardized forms-once the forms are used to record information, they become records
■ Examples: quality manuals
■ SOP, job aids
Collected information produced by the laboratory in the process of performing and reporting a laboratory test. (WHO)
records
■ Sample log book or register
■ Workbooks, worksheets
■ Instrument printouts
■ Maintenance records
■ Quality control data
■ EQA/PT records
■ Patienttest reports
○ Characteristics:
■ Need to be easily retrieved or accessed
■ Contain information that is permanent, and does not require updating
Major product of the laboratory, so manage it carefully with a good system for the laboratory’s documents and records (WHO)
information
A document that describes the quality management system of an organization
quality manual
(ISO 15189)
purpose:
○ Clearly communicate information
○ Serve as a framework for meeting quality system requirements
○ Convey managerial commitment to the quality system.
The key points to remember about the
quality manual
○ There is only one ofcial version
○ The quality manual is never finished —it is always being improved
○ It should be read, understood and accepted by everyone
○ It should be written in clear, easily understood language
○ The quality manual should be dated and signed by the management.
what does the manual contain
○ The quality policy of the laboratory
○ Reference to all processes and procedures
○ Table of contents:
■ Description of the lab
■ Staff education and training
