3. PWS Appendix A.pdf

Phoenix Indian Medical Center, Phoenix, AZ Provider Notification Form

LIS.F.06-01 Effective Date: 09/18/13 Page 1

INFORMATION COMPLETED BY LABORATORY PERSONNEL FOR REQUESTING PROVIDER – DO NOT CHART

Phoenix Indian Medical Center

Laboratory Department

4212 North 16th Street

Phoenix, Arizona 86016

PROVIDER NOTIFICATION OF:

SPECIMEN AND PATIENT NON-COMPLIANCE, AND CHANGES TO VERIFIED LAB DATA

When specimen non-compliance, patient non-compliance, and/or changes to verified laboratory data occurs, laboratory personnel will complete the information below, route the ORIGINAL form to the provider, and place a copy of this form in the laboratory

“Specimen and Patient Non-Compliance” log book. If changes need to be made to verified lab data, refer to Computer Policy and Procedure No. 05-01 and choose Category A or B to make the necessary corrections.

PATIENT___________________________________________ PIMC #__________________________________

PROVIDER_________________________________________LOCATION______________________________

TEST(S)____________________________________________ORDER DATE____________________________

A. Select reason(s) for rejection of SPECIMEN:

Specimen Identification and or Requisition is Non-Compliant:

Specimen not labeled Specimen incorrectly labeled Slide NOT labeled with Name or ID#

Illegible requisition Incomplete Information Name or ID# DO NOT match requisition

Specimen Collection is Non-Compliant:

Incorrect Tube Damaged blots (PKU) None received QNS Clotted

Leaked in Transit Unsuccessful venipuncture

Specimen Integrity Questionable:

Hemolyzed Icteric Lipemic Room Temp NOT frozen Thawed

Laboratory Accident:

PIMC Laboratory Reference Laboratory

B. Select reason(s) for PATIENT Non-Compliance:

Refused Venipuncture NO SHOW for scheduled test Patient left lab and did not return

C. Select reason(s) for modifying VERIFIED LAB DATA:

Test request(s) accessioned in error Data entry error Incorrect Provider accessioned in error

Incorrect location accessioned in error Other Explain________________________________________________

Laboratory personnel rejecting specimen:________________________________________Date/Time:______________________

Reference Laboratory rejecting specimen:________________________________________Date/Time:______________________

Non-Laboratory personnel rejecting specimen:___________________Location:____________Date/Time:___________________

LaboratoryAction:____________________________________________________________________________________________

If collecting individual correctly identifies specimen(s) and would like specimen(s) to still be processed, fill out the following:

Collecting Individual’s Name:_______________________________Department or Location where the individual works:__________

Correct Patient’s Name:____________________________________PIMC #______________________________________________ Provider:________________________________________________Location:____________________________________________

Order Date:________________________ Test(s) New Accession #

Laboratory Review:______________________________________ Closure Date:________________________