12-07-2013, 04:07 PM
PATHOLOGY - DOCUMENTATION
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1. General Information
The accuracy and completeness of documentation surrounding pathology service requests will ensure that the most appropriate tests are performed, reported and followed up.
2. Definitions
Electronic Health Record (EHR): a systematic collection of electronic health information about individual clients. The EHR is the primary health record into which client personal and health information must be entered. Two EHR systems are used within Remote Health Branch, namely:
- Primary Care Information System (PCIS)
- East Arnhem Communicare System (EACS). This is a version of Communicare which is specifically adapted to meet the needs of DoH East Arnhem North clients and health centres.
Pathology Service Providers1: the private and public Approved Pathology Providers who provide diagnostic pathology services to remote health centres. At present there are only three providers: Western Diagnostic Pathology, QML and LABTRAK (ASH & RDH).
Assigning Officer (PCIS): the person at the health centre nominated to access the appropriate inbox (usually the Work unit inbox) and assign all unassigned messages to the correct clients.
PCEN (PCIS): the unique PCIS Central system ID code allocated to an individual PCIS pathology request form. This number is used to match the electronic pathology result to the correct episode and client record.
Unassigned Messages (PCIS): any messages not linked to the client through PCIS but delivered to a PCIS work unit or other inbox. These include among others, discharge summaries, OPD appointments, specialist letters and pathology or other results (where the request was not generated on PCIS).
Acknowledging (PCIS): providing the final comment after taking appropriate action on inbox messages (results or correspondence). Items will remain in an inbox until they have been acknowledged. This applies to all clinical staff.
Labelling Pathology Specimen Containers
All requested details on pathology specimen labels must be completed, ensuring that the client is correctly identified and that the Medicare number is current. Where printed labels are generated by the EHR ensure that the label only covers the existing label on the tube, and leaves a window open between the edges of the labels. Where a bar code is present, this should also be left visible.
Printed labels may not be used if collecting specimens for immuno-haematology such as blood grouping for antenatal clients. It is an Australian and New Zealand Society of Blood Transfusion (ANZSBT) requirement that these labels be hand written. See ANZSBT Guidelines Section 1.1 Request Forms and Sample Collection.
Always label specimens immediately after they have been taken and before moving on to the next client or commencing the centrifuge process. Do not leave unlabelled specimens unattended.
Accidental Duplication of Pathology Requests for One Episode
If more than one practitioner is involved in a consultation, communicate clearly who is responsible for generating the pathology request. If, through misunderstanding, duplicate EHR requests are generated for a single episode, the duplicate request must be deleted from the client record to avoid tracking difficulties. The Data Correction Service Item should be used in consultation with the PHCM or other appropriate clinical supervisor to delete the second copy. See Making Corrections to a Health Record (PCIS / EACS) for details of the process.
Pathology Tests – Cancelling Recalls
Not all test and investigation results need clinical review or follow-up and there may be instances where it may not be possible to recall a client. Routine recalls may be cancelled by clinical staff after consultation with the health centre team. See Diary Recall (PCIS) / Manual Recalls (EACS) for instructions on how to do this. This process includes recording the reason for the cancellation.
High priority recalls may only be cancelled after all reasonable steps have been taken to recall the client and if appropriate authority is received from the Medical Practitioner / RMP. In extreme cases contact Legal Services as described in Client Recall Systems. This course of action must be fully documented in the client record .