RFHHA FACEBOOK FREE CME OF JANUARY 2015 THEME: Laboratory Science SESSION THREE: INFORMATION FLOW IN THE CLINICAL LABORATORY In addition to understanding the organization of the clinical laboratory setting and identifying the reason laboratory testing might be performed, it is important to know how information is exchanged within the laboratory. To ensure that laboratory test results are as meaningful as possible to the health-care provider, all those involved with specimen collection, processing, and testing must use the required paperwork and database correctly. This information exchange will involve a laboratory requisition, a laboratory directory, a computer database, and a laboratory report. Laboratory Requisitions A laboratory requisition is the form used by a physician (or other qualified health-care professional) to document the tests that are to be performed for a patient. The form is filled out by the health-care provider who orders the test or by the provider’s office staff. This requisition must be complete with various data linking the patient to the tests ordered, and must provide billing information for that patient. The laboratory staff will use this requisition to enter the orders into their database for the patient, and the form is often used for reimbursement procedures as well. Although all laboratories may use unique formats, standardized information should be present on all requisitions for testing and reimbursement purposes: • Patient demographic information, including name, address, phone number, and birth date. • Patient gender. • Complete patient insurance and billing information. • Date and time of collection, and identification of the person who performed the collection. • Documentation of how the results are to be relayed to the health-care provider who ordered the tests, and documentation of any other practitioner who is to receive a copy of the results. • Appropriate diagnostic information in the form of an ICD-9 code to allow for reimbursement for the test ordered. An ICD-9 code is the numeric indicator for the diagnosis or symptom associated with the laboratory test ordered. •Test selection, clearly marked with a check, circle, or X in the appropriate area on the requisition. Tests may also be written in if they are not preprinted on the requisition used. • Any additional comments that may assist with the ordering or interpretation of the test. Laboratory tests may be ordered as panels or profiles, which consist of a group of tests that are designed to indicate a problem with a specific organ system or disease process. Tests may also be ordered individually, or the requisition may contain orders for a combination of both. Often the requisitions are organized according to the general types of tests, such as hematology, serology, or chemistry. On the requisition, each test will have a five-digit procedure code (known as a CPT code), which is necessary for reimbursement purposes. There may also be a code or symbol included on the requisition, indicating the type of tube or specimen container that is necessary for that specific test. This information is valuable as a quick reference for the phlebotomist when collecting the specimen. Most requisitions also include some sort of label that can be peeled off and applied to the specimen container. This label may have numbers, bar-code symbols, or both. These labels link the patient information provided on the requisition with that specific sample once it has been entered into the database for the laboratory. Laboratory Directory As discussed, laboratory requisitions often provide information about what type of tube to use for a blood draw for a specific test by using a code or symbol, but the information provided on the requisition is limited at best. The requisition does not include information about how to process and store the specimen, or what the minimum volume may be for the test ordered. It also does not include information about how often the laboratory performs that specific analysis if the physician needs to know this information. This additional information about specimen collection and handling may be found in a laboratory directory Commonly, a laboratory directory is a computer database of specific information about tests that are performed by that laboratory. The directory may also be provided in a book format, which can be consulted by facilities that do not have Internet access. The laboratory directory (also known as a directory of services) provides the following types of information: • The internal test number used to enter the test order into the database • CPT five-digit code used for reimbursement for that test • Related information if there is more than one place within the directory where the test is addressed • Acronyms or abbreviations that may be listed on the requisition for that test, or perhaps used to order the test in the computer system for that laboratory • The type of specimen required, and in some cases the type or color of tubes to use for the blood draw or identification of the additives that must be present in the tubes • The requested specimen volume and the minimum acceptable specimen volume • Collection notes and/or specific requirements necessary for some tests • Storage instructions for the specimen after collection and during transportation (room temperature, frozen, refrigerated, etc.) • Reference ranges (also known as normal ranges) for the test ordered • Clinical significance and interpretation of the test results • Testing intervals/frequency and testing locations Once the specimen requirements have been established, the collection process can continue. The employee who is performing the collection must document two unique identifiers for the patient, the employee ID (or initials), the date of collection, and the time of collection on the requisition and on the tube or alternative collection container. This same employee may also be responsible for entering the patient information into the computer database, whereas in other laboratories the specimen and paperwork may be prepared for transport to another location where the information will be added to the database upon arrival. Laboratory Reports Once the specimen has been processed, delivered to the correct department, and tested within the laboratory, a laboratory report is generated to transmit the test results back to the health-care provider. The laboratory report document will list the results for the tests performed, as well as the reference ranges (also known as normal ranges) that have been established by the laboratory for that test. Reference ranges are the results that are expected in the general healthy population 95% of the time for a particular laboratory test. A range is necessary (instead of a specific value) because of differences in the population due to age, race, and gender. Geographical locations may also affect the reference range, as will the testing methods used by that laboratory. A notation will be present on the laboratory report for all results that are outside the expected reference range for that patient, based on demographics, the testing method, and the test ordered. The gender and age of the patient may affect the reference ranges used for interpretation of the results, so it is critical that this information is provided whenever a sample is collected. The laboratory report will also include the date and time of the specimen collection, the name and identification number for the patient, and the name and address of the laboratory where the test was performed. The specimen source is identified, as well as the date and time the report was generated. Laboratory reports may be hand-delivered to the ordering health-care provider by a medical assistant within an office or via a courier service from a reference laboratory. They may also be faxed, mailed, or in some cases transmitted via e-mail. In some situations, the laboratory reports may also be available online through a dedicated laboratory link so that the provider can view the results on site. These results must be reviewed as soon as possible so that appropriate action can be taken for those outside of the normal reference range. Laboratory reports are a legal document that becomes part of the patient’s health record. Dr Madhav Madhusudan Singh
Posted on: Thu, 01 Jan 2015 12:29:34 +0000
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