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chapter 6 patient identification and specimen requirements
Terms in this set (26)
what are the orders for laboratory tests?
- electronic heath record (EHR)
what are laboratory requisitions?
entered in HIS or LIS
documentation of tests ordered
computer provides accession number
what are the required content for charts?
patient's date of birth
ordering physician's name
type of test
date and time is to be performed
how to greet the patient?
- reduce anxiety
- knock and wait for response
how to talk to the patient when you need blood work?
- talk directly to child
- never lie
- keep distracted
- repeat questions or instructions as necessary
- be compassionate
how to talk to sleeping patient?
try not to startle them
inform patient before turning on lights
NEVER ATTEMPT TO COLLECT A SPECIMEN FROM A SLEEPING PATIENT!
what is the code of ethics?
- set of written rules, procedures, or guidelines
- helps determine right from wrong
- varies by individual, religion ,social status, and heritage
- rule of conduct or action enforced by controlling authority
what are the legal terms?
- direct cause
how to prevent malpractice?
burden pf proof is plaintiff
follow guidelines to prevent malpractice
what are patient's rights?
patients have the right to:
- refuse care
- be treated with respect
- have all records and information classifies as confidential
- be informed about the purpose and expected results of treatments
- have access to their medical records
what is informed consent?
explain the procedure
interpret if necessary
gain the attention of distracted patients
get parent's consent for minor children
inform the nurse or healthcare provider if patient refuses
what patient identification?
what inpatient identification?
check ID band
compara with requisition
ask nurse for verification if patient is sedated
what outpatient identification mean?
ask the patient's name
ask for formal ID
ask the patient to verify information on the requisition form
use at least two or three verification items
what is labeling the specimen?
label specimens immediately
- after collection
- before leaving the patient
- apply label properly
never label specimens that you did not collect
what are the required for information for patient?
patient's date of birth
unique patient identifier
collection time time and date
what are the factors that can affect the lab tests?
altitude and geographical location
temperature and hydration
posture and exercise and stress
what are other stuff that can affect the lab tests?
timing of specimen collection
- specific timing required for some tests
patient basal state
- fasting for at least 12 hours
- little or no exercise
- variation in analytes throughout the day
what factors can affect the tests?
can medications inter fer with the lab tests?
interfering substances (medications)
- cause abnormal color in blood or urine
- alter the level of chemicals
additives in collection tubes
how to transport specimens?
- STAT tests
- specimens that must be processed quickly
- medical courier service
- may require special handling procedures
how to track the lab specimen?
update lab records
- questions about specimen quality
- status of test collections
- completion times
what is confidentiality?
health insurance portability and accountability Act (HIPAA)
- national standard for electronic healthcare transactions
- protects patient privacy and confidentiality
what are HIPAA guidelines?
close patients' room doors
do not talk about patients in public places
turn computer screens away from public viewing
log off computers when finished
close medical records when leaving
what are electronic health records?
health information technology for economic and clinical health act (HITECH)
- encpurages EHRs (EHRs)
- establishes standards for use
chapter 6 summary
laboratory tests may be ordered only by a licensed healthcare practitioner. laboratory requisitions must include doctor's name; patient's name, age, DOB, and ID number; tests to be performed; and date and time for specimen collection. communicating with patients in a professional manner helps instill patient confidence. following a code of ethics during patient interactions helps prevent accusations of malpractice. patients must consent and have the right to refuse any procedures. patients must be using at least two unique patient identifiers. specimen labels must include patient's name, DOB, and unique patient identifier; actual specimen collection time and date; and collector's ID. phlebotomist must document patient situations that can compromise specimen quality. patient factors that may affect results include altitude, geographic location, temperature, hydration, posture, exercise, stress, and deviation form basal state. specimens must be handled properly and delivered to the lab promptly and delivered to the lab promptly. proper documentation allows for test and specimen tracking. patient information is stored in hospital and laboratory computers as part of the patient's EHR.
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