Sig Elite Interim Result Reporting
As I get my sea legs under me again in POC, I find myself with a question regarding "interim" result reporting. I couldn't locate the subject using search.
We use EPIC (HIS) , Sunquest (LIS), and Telcor.
My understanding has been that if the results were not available in the EMR at the time of treatment, they had to be recorded somewhere/somehow, at the time they were being used to assess/treat the patient. Especially as the instrument being used does not transmit results until it is manually directed to. CAP standard POC.04400 is the only item I could locate regarding this. Our OR records their results in EPIC using Quicknotes.
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POC.04400 |
Results in Medical Record |
Phase II |
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There is a written procedure for entering POC test results into the permanent patient record. NOTE: To ensure patient safety and prevent medical error, health care workers should not make management decisions based on POC test results unless those results are entered into patient records. POC test results may be uploaded into the electronic medical record after decision making. |
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Setting the scene: several Elites had not been downloaded, one in nearly a month (added that check to my weekly checklist!). A test was performed using an encounter discharged three days previously. Apparently, this department does not record their ACT results during the procedure so they couldn't definitively tell me who the result was for other than so-and-so was the patient having a procedure at that time in that room. They have two procedure rooms, each with an Elite but they don't always stay in the assigned room so I don't feel comfortable assigning this result to the patient without documentation.
What are other facilities doing? Am I interpreting the standard correctly that these should be recorded at the time of testing?
Thank you for any insight!
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