Patient and Specimen Requirements Flashcards
where is the lab order entered?
electronic medical record (EMR)/ electronic health record (EHR)
OR
hospital information system (HIS) or laboratory information system (LIS) (this is computerized physician order entry - CPOE)
if outpatient official requestion form to lab by physician on telepone or fax
some labs may provide physician offices with access to LIS for purpsoe of ordering tests and accessign results, making physician offices clients
@hat happens when a lab test is ordered
- put in HIS and is recieved on computer in LIS and provided an accession number (day of year (1-365 - Julian day - an test number)
- LIS prints requisition in label
what must a lab test requisition in form of computer label must contain ?
- pt name
- pt medical record number
- pt location
- bar code
- lab accession mumber
- requesting physician
- blood volume and tube type
- test status
- test performed
- pt age and gender
- DOB
- date and time of test
- lag section to which specimen should be delivered to
What does it mean if a specimen is STATE (ST), ASAP, or routine (RT)
- STATE (ST) = immediately
- ASAP = as soon as possible
- routine - ckkectuib tune as schedukles
requistion should contain :
● Patient’s name
● Patient’s date of birth
● Patient’s medical record number
● Patient’s location (if inpatient)
● Ordering physician’s name
● Type of test to be performed
● Test status (timed, fasting, STAT, ASAP)
● Date and time the test is to be performed
+ other requirements
what to do when greeting a pt
- smile, calm and pleasant
= identify by first name or from lab (depending on facility)
-greeting is super important cause pt may be nervous - knock and wait for a response before opening if door is closed or open
- open door slowly after a few sec and greet pt before proceeding in to room
venipuncture on children
- dont lie and say it wont heart
- distract children
- truth - you will feel a little quick sting
- comfort children
- approach child as adult
venipuncture on geriatric patients
- elderly pt may be sensory impaired but dont automatically raise voice, in long term care ask abt special assistance before entering
how to wake up pt
- gently wake up by nudging bed, talk in a soft manner, don’t turn on bright lights, give pt opportunity to shielf eyes from light, never draw from sleeping pt bc they could jerk
how to respond to pt questions
- state tests r routine by physicians and more info ask physician
- do not discuss test with pt, tjat os [hysician results
what are ethics?
- moral philophy varied by indv, religion, social status or heritage
whis code of thics
- set of written or unwritten ruiles, procedures, or guildeines that specify values, actions and choices
what is the law
- rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority
- if ,llaw is violated civil or ciminal case
- lawsuit have plaintiff (suing) and defendant (sued)
What is respondeat superior
- latin for let the master answer
- emplouer is responsible for act opf employees if acts r performed out of scope of employees duties
type of lawsuits against phlebotomist?
- assault (threat of harm)
- battery (act of bodily harm)
- neglience - malpractice - negligence to perform in matter expected by profession
What are the 4 Ds of malpractice?
Duty—the professional owes a duty of care to the accuser. (The healthcare
provider is expected to care for the patient. For example, a phlebotomist is
expected to perform venipunctures.)
● Derelict—the professional breaches the duty of care to the patient.
(The healthcare provider acts outside the standards expected
of his profession. For example, if the phlebotomist repeatedly
explores with the needle [probes] when drawing blood.)
● Direct cause—the breach of the duty of care to the patient is a
direct cause of the patient’s injury. (The care outside the standards of the profession causes the patient’s injury. For example,
repeated probing causes nerve damage to the patient.)
● Damages—there is a legally recognizable injury to the patient.
(The injury is deemed severe enough to warrant compensation.
For example, nerve damage caused by repeated probing is severe
enough to cause the patient not to be able to use her computer
and her job requires 8 hours a day of computer use.)
how to prevent malpractice cases as a phlebotomist?
- care abt pt
- communicate with pt
- be competent
What are patient rights?
- defned by American Hospital association in doc called Patient Care Partnership: Understanding Expectations, Rights and Responsibilities (formerly the
Patient’s Bill of Rights) - right to refuse care, be treated with respect, have all record and info classifed as confidential, be informed abt purpose and expectedresults of treatment, and access to medical records
What is informed consent for phlebotomy
- inform pt of procedure using simple language
- “im here to draw your blood”
- of no english use hand gesture , demostration or other means to get idea
- use translator, only family in extreme emergency situatiosn
- sign consent form
What forms does consent take ?
written agreements, spoken words, implicit or unspoken/implied actions, and
appointments for tests
what is expressed consent?
- the pt is informed of the procedure and process and sign consent form
- ex are drug and alchohgol screening and HIV testing
what is implied consent
if pt extend arm but does not acknowledge
- do not draw if not clear (ex: not speak english)
when is it okay not to draw someones blood
- when pt is recieving radiation treatment and phlebotomist is pregnamt or irate pt infected with hepatitis or AIDS might compromise the phlebotomists safety
When is written consent okay?
- if minor child or pt is mentally incompetent and is having blood drawn
