Notes for Manual Procedure Labs

Sample Identification

• Minimum ID in labs is the patient’s full name (record last name, a comma and then first name), the accession number and the MRN.
  • Two unique identifiers must be included on all sample pour off cups such as accession number, medical record number and/or health care number.
  • If the accession number has a letter associated with it then it must be included with the number.
  • The name is not considered a unique identifier.
• Print legibly
• Proper sample identification must be recorded in the “Sample ID” box in the patient results portion of the worksheet
• Correct sample ID (full name and accession number) must also be recorded on all other worksheets, report forms, slides, sample test tubes or pour off (aliquot) tubes
• Any errors on sample identification result in a “0” on the analysis portion of lab assessments

Worksheet vs. Report Form

• The worksheet is the lab’s record of the analytical process.
  • QC results and patient results are recorded here as well as calculations and notes about testing.
  • The worksheet stays in the lab for a pre-determined time period, e.g. 1 year
• The report form is what the physician will see.
  • It includes patient information, the results, units, reference ranges and any applicable comments.
  • Only sign the report if your results are accurate.
  • Make sure that all of the information is clearly legible

Worksheets

• Clerical
  • Ensure that all records are recorded in pen, legible to colleagues and supervisors
  • Make changes to clerical errors by drawing a single line through the original word or number and then recording the correct value/word next to it.  Initial next to the change. Do not erase!
• QC results
  • Must be recorded in the QC section on the worksheet.
  • Do confirm that it is acceptable before recording/reporting patient test results.
  • Record QC lot # and expiry date directly from the QC vials
  • If your QC is outside of acceptable range please let your instructor know. Do NOT report patient results if you QC is out.
• Linearity Range (Dynamic range)
  • Ensure that all recorded results are within the dynamic (linear) range for that testing method.
  • If patient result is outside the acceptable range, use an arrow (↑ or ↓) to the right of the result when you record it on the worksheet.
  • If a result is below the bottom of the dynamic range, record as “< (bottom end of range)”.  If the result is higher than the top end of the range, perform the appropriate dilution procedure and then report the corrected result.
• Remember you can “think on paper” – perform calculations and record your thoughts about QC or result correlation on the worksheet. This document stays within the lab and is not seen by the doctor.

Assessing Results

• Before filling out a report form, ensure that all results are accurate and complete.  This includes checking QC and dynamic ranges.

Report Forms

• Record all pertinent patient information including the patient’s full name (last name first, comma, then first name) accession number, DOB, physician name, date and time collected, HCN, MRN, as well as the date the results are being reported and the person verifying the results.
• Record results and their corresponding units and reference ranges in the appropriate boxes.
  • If result is outside the acceptable range, use an arrow (↑ or ↓) to the right of the result.
• At times you might need to add a comment or qualifier to specific results regarding possible sources of error that may have an impact such as “specimen slightly lipemic”.
  • Attach the comment to the specific test(s) affected by using an asterisk immediately next to the result and then printing an asterisk and the comment on the “comment” line at the end of the report.
• Make sure that all information is clearly legible, if an error is made put one line through it, record the correct result and your initials.
• Reporting invalid results will result in mark deductions during lab assessments.
  • This is because the results may be inaccurate, and the patient may be harmed if the doctor acts on the basis of the results.

QC vs Calibrators

• Be very careful when reading labels.
• Calibrators are standards and are only used for determining new calibration curves.
• QC samples are not calibrators.
• They are materials that are used to confirm if a calibration is acceptable with a known expected value.

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