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IDEAS THAT WORK
LAB AUTHENTICATION
Proof That Your Docs Reviewed Pre-Op Tests
T
o make it easy to comply with the relatively new standard that
requires documentation on the patient's chart that a physician
has reviewed labs, make a small (1½" x ¾") red stamp that
includes a place for the date and the surgeon or anesthesiologist's signature.
The pre-op phone call nurse stamps the lab report when she
receives the labs, and the physician signs and dates (authenticates)
the lab when he sees the patient in the pre-op area on the day of
surgery.
For labs that are done in pre-op (urine pregnancy and blood glucose
tests, for example), where the results are handwritten, the nurse will
document results on the pre-op form. In addition, these 2 labs are preprinted in the anesthesia plan portion of the pre-anesthesia assessment. The anesthesiologist will fill in the results when he addresses
the anesthesia plan, and his signature at the bottom of this
form will confirm authentication.
Linda W. Frix, RN, BSN, CAPA
Northern Virginia Surgery Center
Fairfax, Va.
lfrix@fairoakssc.com
M A R C H 2013 | O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E
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