#06-5558 Accrd Manual V7 - COLA

CRITERIA FOR QUALITY LABORATORY PERFORMANCEPre-AnalyticTest requisitions, testing records, and test reports are required documents. These can be combined into oneform or kept as separate forms.PRE 1 EAre all specimens accompanied by a requisition?Test requisitions, testing records, and test reports are all required documents for a complete Patient TestManagement System. These documents may be paper based or electronic. A single document may servemultiple purposes.Often the charge sheet, super-bill or routing slip is used as a requisition. Some facilities elect to combine allthe requirements into the design of a single form. The patient’s chart may also be used as both the requisitionand report form, as long as the chart remains available for laboratory personnel during testing and canbe made available at the time of survey.PRE 2 RIf an oral request for a test has been made, is it followed with a written requisition within 30 days?This includes in-house ordering, but the requisition may be the written request on the chart, if that is yournormal method of requisitioning. Otherwise, a requisition to be kept in the laboratory must be obtained fromthe ordering physician.PRE 3 RIf the laboratory accepts referred specimens from another facility: Do you maintain documentation of attemptsto obtain a written test request when the initial request was verbal?Reference laboratories must have written requests for the tests they perform. If that is not possible, you documentthat you tried to obtain one.Does the requisition that accompanies the patient specimen contain the following: (PRE 4-9)PRE 4 RThe patient’s name and a secondary identifier?To contribute to reducing the number of medical errors related to mis-identification of the patient, laboratoriesneed to establish a unique identification system. The system should encompass a means for uniquepatient identification that links the request, to the specimen, and the report. This can be easily accomplishedby using two identifiers, such as patient name and a secondary identifier, such as birth date, medical recordnumber, social security number, barcode, or accession number.PRE 5 RThe name or unique identification of the legally authorized requestor, the individual responsible for using thetests results, and the address(es) where the report should be sent?When space is an issue or in some information systems the requesting party’s name & address may beassigned a unique code number. In such cases, it is necessary to have a master list that defines the name &address assigned to each code number.PRE 6 RThe test (examination) requested?The term examination is used globally in place of test.14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org