WT.05.01.01 TJC Maintaining an Audit Trail

What test(s) are being performed?  All of our Point of Care test results go directly into an EMR system:  Hospital - Meditech (as a nurses note) & Physician offices - Greenway.  No more paper. In both EMR systems there is the provider order, the test, the results (any associated QC), time/ date stamped along with the operators initials.

We are a 100 bed community hospital with 15 physician office practices.

We have IT anlaysts who focus on report writing, some of what I have compiled are spreadsheets with requested data driven off of POC order entry within our EMR.   

We use practice partner in the clinic setting. We have function that allows us to place an “In house” order. Every month I run a report of all in house orders to audit charting of results. We still use paper logs for daily quality control.

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Ruth, so how do you associate QC results on the log to a record in the EMR?

Yes they do.  Urine pregnancy, Strep, mono tests have a line to check the internal QC associated with the test.  Urine pregnancy is done in both Greenway and Meditech.  The other 2 tests just in Greenway.

All of this was built before my time.........but if you need more information, just reach out! acasavant@southcountyhealth.org

Zach are you referring to internal quality control? Internal QC is documented in the chart with the result. All external QC is documented daily on a log.

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I had the test built with the result fields of Lot number and expiration date of kit used along with a box to check that the quality check as passwd to be included with the result.