What is considered best practice?
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I recently have started as the POCT Coordinator at my job. I have a few questions on what is best practice and what is needed for document retention.
1. For Urinalysis QC and results, should you keep the printouts off the analyzer if QC is logged on a log sheet and Patient results are entered into the LIS? Is it a requirement to keep the printouts or just good practice? Or neither? We are a small facility and don't have the capability of entering QC into the LIS, yet. QC can be stored in the Clinitek but I'm wondering if it's okay to do that or keep the printouts?
2. How long do you have to keep POCT documentation, such as QC, competencies, etc.
Sorry, very new to this!
Thanks,
Kim
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Hi Kim! For question number 2, keep QC docs and comps for 2 years.
Sent via Groupsite Mobile.
Our POCT lab is part of a University student health service and one year our CLIA surveyor advised us as follows:
If you're your analyzer is not interfaced data entry of results should be verified by a second person. His rationale: catches data entry errors before the final report is transmitted.
As for record retention: All results (paper) should be retained for at least 2 years.
Competency documents, I have 4 years worth. However, I believe it is also 2 years.
Hi Ramona,
Yes, we were actually just cited about the non-interfaced data entry. Any result that is manually entered needs to be verified by a second person. This needs to occur daily. Depending on the volume of non-interfaced tests you may be able to take a sampling of results and check those. (This is what our main lab does.) At the POC, our volumes are such that we are now requiring all non-interfaced results to be double checked by a secondary operator. We have incorporated a 'double check' line in our charting templates with a hard stop to make sure it's entered.
As for record retention, you are correct, 2 years for everything.
Good Morning Kelyn,
This is not something that we routinely do with our POC testing. Could you share the standard that speaks to handling non-interfaced data? Any information would be greatly appreciated.
Thank You,
Kelly
Kelly VanWagner MLS(ASCP)CM SHCM
Point of Care Administrator
Covenant HealthCare Laboratory
Saginaw, MI
Hi Kelly,
We are surveyed by TJC...the standard they were referring to was QSA.02.11.01 "The Laboratory conducts surveillance of patient results and related records as part of it's quality control program'. EP5 within this standard states 'The Laboratory performs daily screening for errors in patient test results due to handwritten or manual data entry (for example, clerical errors). The daily screening is documented.
The actual standard states that a sampling of data is acceptable, but we were told by our surveyor that if our sample size per day was less than a certain number (I believe it was 100...) we needed to review them all.
Prior to this we were screening a selection of results on a monthly basis.
As a completely unrelated aside...I grew up in Bay City...nice to see someone here from my old 'stomping grounds'!! :)
Kelyn
Thank You, Kelyn. I was unaware of that standard but we are CAP, so I can breathe again.
I am Bay City born and raised. Such a small world!!
Kelly VanWagner MLS(ASCP)CM SHCM
Point of Care Administrator
Covenant HealthCare Laboratory
Saginaw, MI
Here is an excerpt from the CAM Lab Joint Commission regs regarding review of manual entry results.
Does anyone have the regulations from COLA on this subject? I'm a little anxious now, too!