Patient Identification Chapter 6 Quiz

Laboratory Test Orders

• Orders for laboratory tests include inpatient and outpatient methods.
• Inpatients utilize charts or electronic health records; outpatients may require prescriptions, phone calls, or faxes.

Laboratory Requisitions

• Requisitions are entered in Health Information System (HIS) or Laboratory Information System (LIS).
• They document tests ordered and provide an accession number through the computer.

Required Chart Content

• Essential information includes patient's name, date of birth, medical record number (MRN), ordering physician's name, test type, status, and scheduled date and time.

Patient Interaction

• Greet patients with a smile, professional demeanor, and self-introduction.
• In outpatient settings, reducing anxiety is key; in inpatient settings, respect privacy by knocking before entering.

Communication with Patients

• Pediatric patients require direct communication and distractions; maintain honesty.
• For geriatric patients, repeating instructions and showing compassion is important.

Interacting with Sleeping Patients

• Gently awaken sleeping patients without startling; speak softly and inform them before turning on lights.
• Specimens should never be collected from sleeping patients.

Ethics and Legal Terms

• Ethics consist of rules and guidelines determining right from wrong, influenced by various factors.
• Legal terms include respondent superior, assault, battery, negligence, and malpractice criteria.

Malpractice Prevention

• Malpractice can be mitigated by the plaintiff's burden of proof and adhering to guidelines of caring, communication, and competence.

Patient Rights

• Patients possess rights to refuse care, respectful treatment, confidentiality, understand procedures, and access their medical records.

Informed Consent

• Patients must be clearly informed about procedures and implications; consent is especially crucial for minors.

Patient Identification

• Confirmation methods require asking, comparing data, and validating patient identity through means like checking ID bands for inpatients.

Specimen Labeling

• Specimens must be labeled immediately after collection to avoid errors; always label your own collected specimens.

Required Information for Specimens

• Each specimen label should include patient's name, date of birth, a unique identifier, collection date and time, and collector's ID.

Factors Affecting Lab Tests

• Environmental factors like altitude, temperature, and hydration can impact results.
• Patient conditions such as posture, exercise, stress, and fasting state also significantly influence test outcomes.

Specimen Transport and Tracking

• Specimens require prompt transport, using medical courier services if necessary, especially for critical tests.
• Document identification and update lab records to monitor specimen quality and test statuses.

Confidentiality and HIPAA

• HIPAA establishes national standards for the protection of patient privacy in electronic healthcare transactions.
• Compliance includes measures such as closing patients' room doors, restricting conversations in public areas, and ensuring computer screens are not visible to the public.

Electronic Health Records (EHR)

• The Health Information Technology for Economic and Clinical Health (HITECH) Act promotes the use of EHRs and sets standards for their implementation.

Chapter Summary

• Laboratory tests must be ordered by licensed practitioners, with requisitions detailing patient and test information. Patient engagement and ethical conduct are vital for maintaining trust and preventing liability issues. Two unique identifiers are necessary for patient identification, and proper labeling is critical for specimen management. Factors affecting specimen quality include a multitude of environmental and patient-related conditions. Compliance with EHR regulations is also essential for effective patient record management.