A phlebotomist reports a stat result to a provider by verbal report. What should the phlebotomist include in the follow-up documentation?
Patient's insurance information
Room number of the patient
Name of the provider contacted
Provider's phone number
The Correct Answer is C
Choice A Reason:
Patient's insurance information is not typically included in the follow-up documentation of a stat result. Insurance information is relevant for billing purposes and does not pertain to the immediate clinical care or the communication of test results.
Choice B Reason:
The room number of the patient might be included in the internal documentation for logistical purposes but is not the primary piece of information required following a verbal report of a stat result. The focus should be on the communication details rather than the location.
Choice C Reason:
The name of the provider contacted is essential information in the follow-up documentation after a verbal report. This ensures that there is a record of who received the information, which is crucial for accountability and continuity of care.
Choice D Reason:
The provider's phone number is not necessary in the follow-up documentation if the name of the provider is already included. The phone number would have been used to make the initial contact, and the key information is the confirmation that the provider was reached and informed of the stat result.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A Reason:
Notifying the provider about the error is an important step, but it does not correct the error in the patient's chart. Communication with the provider ensures that they are aware of the mistake and can make informed decisions regarding patient care. However, the physical correction of the documentation is also necessary to maintain accurate medical records.
Choice B Reason:
Asking an administrator to erase the error is not a recommended practice. Erasing or using correction fluid can make the chart appear tampered with, which can have legal implications. It is essential that the original entry remains visible to preserve the integrity of the medical record.
Choice C Reason:
Striking a line through the error and initialing is the correct method for correcting a written error in a patient's chart¹². This approach allows the original entry to remain legible, which is crucial for legal and clinical reasons. It also shows that the correction was made by an authorized individual, as the initials indicate who made the change.
Choice D Reason:
Erasing the error and entering the correct information is not an acceptable practice for the same reasons as choice B. It is important not to remove or conceal the original entry, as this could be considered falsifying medical records.
Correct Answer is C
Explanation
Choice A Reason:
Signing a release for laboratory results is a form of expressed consent, not implied consent. Expressed consent is given explicitly, either orally or in writing, and is clearly and unmistakably communicated.
Choice B Reason:
Similarly, signing a document of agreement for a research study is another example of expressed consent. The patient is actively agreeing to participate in the study, which is a direct and informed action.
Choice C Reason:
Implied consent occurs when a patient's actions suggest consent without verbal or written confirmation. Offering an arm to a phlebotomist is a non-verbal communication that implies the patient is willing to have their blood drawn. This is a common practice in medical settings where the action of presenting an arm indicates readiness for the procedure.
Choice D Reason:
A family member nodding for a phlebotomist to proceed does not constitute the patient's implied consent. Consent must come directly from the patient unless they are unable to provide it, in which case a legal surrogate may give consent on their behalf.
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