Physician Requisition Orders for Point of Care testing

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We almost got a deficiency for this.

All lab testing including point of care testing requires a requisition.
For example, when there is point of care glucose testing, the nursing staff can only perform the test when it is ordered by the physician.

When a physician/anesthesiologist runs an epoc or GEM blood gas test, they are required to have a requisition as well.
Even though the epoc test run under point of care is an unsolicited order, they still need a requisition. 
The inspector informed us that they are required to have a requisition before the test or, they can run it without a requisition if it is a routine test that is in their policy.

The anesthesiolgists are forgetting to submit a requisition for the point of care test for the epoc.

I'm aware of the 1st part but the bold part, but I'm unsure of the CAP regulations or Joint Commission regulations.
How does everyone handle this situation? I want to create the path of least resistance and speak to the head anesthesiologist to have a section about running the point of care test in their policy.

Thank you for any assistance.

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Hi Jo,
  I think this comes up in every facility from time to time.  The best description I have heard from an anesthesiologist to explain their testing "routine" is that 'the anesthesia record is prescriptive in nature and records any and all emergent needs deemed necessary during the patient procedure, including any required point-of-care testing."

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Jo Win
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