Attachment_A_PIMC_Provider_Notification.pdf

APPENDIX. A Phoenix Indian Medical Center

PROVIDER NOTIFICATION OF: SPECIMEN AND PATIENT NON-COMPLIANCE, AND CHANGES TO

VERIFIED LAB DAT A

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

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

PATIENT ________________ PIMC# ________________ _

PROVIDER LOCATION ______________ _

TEST(S) ORDER DATE _____________ _

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

Specimen Identification and or Requisition is Non-Compliant:

D Specimen not labeled D Specimen incorrectly labeled D Illegible requisition D Incomplete Information

Specimen Collection is Non-Compliant:

D Incorrect Tube D Damaged blots (PKU) D None received D Leaked in Transit D Unsuccessful venipuncture D Clotted

Specimen Integrity Questionable:

D Hemolyzed O Icteric Laboratory Accident:

D PIMC Laboratory

D Lipemic D Room Temp

D Reference Laboratory

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

D Slide NOT labeled with Name or ID# D Name or ID# DO NOT match requisition

DQNS

D NOT frozen 0 Thawed

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

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

D Test request(s) accessioned in error D Data entry error D Incorrect Provider accessioned in error 0 Incorrect location accessioned in error D Other Explain _______________________ _

Laboratory personnel rejecting specimen: ______________ ---'Dateffime: ________ _ Reference Laboratory rejecting specimen: Dateffime: ____ _ Non-Laboratory personnel rejecting specimen: Location: Dateffime: ___ _

Laboratory Action: ____________________________________ _

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-----------

Attachment A PIMC Provider Notification

RFQ-19-PHX-13