Information Management Flashcards by SHEKINAH MOLO

Q

Defined as a system that incorporates all the processes needed for effectively managing data—both incoming and outgoing patient information.

A

Information Management

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Q

_____ need to ensure that the laboratory has an effective information management system in place in order to achieve accessibility, accuracy, timeliness, security, confidentiality, and privacy of patient information.

A

Laboratory Directors

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Q

Important Elements of Information Management:

A

Unique identifiers for patients and samples
Standardized test request forms
Logs and worksheets
Checking processes to ensure the accuracy of data recording and transmission
Protection against loss of data
Protection of patient confidentiality and privacy
Effective reporting systems
Effective and timely communication

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Q

Elements under Logs and Worksheets:

A

Control logbooks
Calibration worksheets
Temperature monitoring worksheet
Result logbooks

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Q

The process by which information is exchanged and understood by two or more people, usually with the intent to motivate or influence behavior.

A

Communication

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Q

The exchange of thoughts, messages, or information using speech, signals, writing, or behavior.

A

Communication

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Q

The art and technique of using words effectively to impart information or ideas.

A

Communication

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Q

A system, such as mail, telephone, television, or computer, for sending and receiving messages.

A

Communication

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Q

The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups.

A

Communication

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Q

Identify the Model of Communication:

To select symbols with which to compose a message.

A

Encode

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Q

Identify the Model of Communication:

The tangible formulation of an idea to be sent to a receiver.

A

Message

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Q

Identify the Model of Communication:

The carrier of communication.

A

Channel

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Q

Identify the Model of Communication:

To translate the symbols used in a message for the purpose of interpreting its meaning.

A

Decode

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Q

Identify the Model of Communication:

A response by the receiver to the sender’s communication.

A

Feedback

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Q

Identify the Person who Stated the Importance of Communication in Management Theories:

“The first executive functions is to develop and maintain a system of communication.”

A

Chester Barnard

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Q

Identify the Person who Stated the Importance of Communication in Management Theories:

“Organizational interaction depends on communications.”

A

Hicks

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Q

Identify the Person who Stated the Importance of Communication in Management Theories:

“The nature and used of communications in excellent companies are remarkable.”

A

Peters and Waterman

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Q

A plan used by the laboratory for the dissemination
of information.

A

Management Communication Strategy

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Q

Discuss the Cycle of Communication in Processing Laboratory Determination.

A

Circular Diagram: Physician, Patient/Laboratory Request, Specimen Collection, Laboratory Processing, and Releasing of Results

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Q

Request Form should contain at least the following information:

A

⚬ Laboratory procedure
⚬ Identification of the patient
⚬ Name of the physician
⚬ Date and time the specimen was collected
⚬ Date and time the specimen was received
⚬ Date, time and by whom the specimen was examined
⚬ Condition of any unsatisfactory specimen
⚬ Type of test or procedure performed
⚬ Results and date of reporting

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Q

General Qualities of a Laboratory Report:

A

⚬ Compactness
⚬ Consistency of terminology, format and usage of understandability
⚬ Clear and easy to understand
⚬ Statement of date and time of collection
⚬ Gross description and source of the specimen when pertinent
⚬ Sharp differentiation of reference or normal and abnormal values
⚬ The sequential order of multiple results on a single specimen
⚬ Identification of patient, patient location and physician
⚬ Assurance of accuracy of transcription of request

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Q

Who is responsible for all Laboratory Report?

A

Laboratory Head

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Q

1 of the 12 essential elements of the quality system.

A

Documents and Records

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Q

A major goal of keeping documents and records is _____.

A

To find information whenever it is needed.

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Provide written information about policies, processes and procedures.

Documents

The collected information produced by the laboratory in the process of performing and reporting a laboratory test.

Records

Examples of Documents:

Quality Manuals SOP Job Aids

Important Documents in Clinical Laboratory:

Quality Manual Reference Material Standard Operating Procedure (SOP)

A document that describes the quality management system of an organization (ISO 15189).

Quality Manual

Purpose of having a Quality Manual:

⚬ Clearly communicate information ⚬ Serve as a framework for meeting quality system requirements ⚬ Convey a managerial commitment to the quality system.

What are the things indicated in a Laboratory Quality Manual?

1. Meeting management 2. Safe manipulation 3. Equipment installation process 4. Equipment repair process 5. Decontamination of laboratory equipment 6. Equipment decommission 7. General sampling conditions 8. Sample labelling 9. Sample rejection or acceptance 10. Sample transport 11. Results validation 12. Critical results reporting 13. Internal audit 14. Orientation checklist form 15. Internal training 16. Competency assessment 17. Customer survey 18. Customer complaint 19. Nonconforming event management 20. Internal documents management 21. SOP management 22. Document management 23. Short term archiving 24. Document control

True or False: There is two official version of a Quality Manual

False There is only one official version of a Quality Manual

True or False: The quality manual is never finished - it is always being improved.

True The quality manual is never finished - it is always being improved.

General Information that are contained in the Manual:

Quality policy of the laboratory Reference to all processes and procedures Table of contents: Description of the laboratory and staff education and training

State the laboratory and institutional policy for the guidance of those working in the laboratory.

Policy Manual

Information included in the Policy Manual:

⚬ Dress Codes ⚬ Food and smoking rules ⚬ Telephone use ⚬ Laboratory organizations and reporting relationship ⚬ Writing, review and authorization of procedures ⚬ Vacation and holiday request ⚬ Supply requisition ⚬ Absences and late arrival notification ⚬ Reporting and releasing of test results ⚬ Specific statements about enforcement of safety rules

Contain written step-by-step instructions that laboratory staff should meticulously follow when performing a procedure.

Standard Operating Procedures

Written SOPs ensure the following:

Consistency Accuracy Quality

SOP should have the following:

* Title * Purpose * Instructions * Name of person preparing the SOP * Signatures of approving officials and dates of approval

A good SOP should be:

* Detailed, clear and concise * Easily understood by new personnel or students in training * Reviewed and approved by the laboratory * Updated on a regular basis

Good Reference Materials are needed in order to find scientific and clinical information about:

Diseases Laboratory Methods Procedures

Importance of Paper System when Storing Documents and Records:

Permanence Accessibility Security Traceability

Importance of Electronic System when Storing Documents and Records:

Permanence Security Traceability

Factors on Record Retention:

* The length of time the laboratory will need to have access to its records * Government requirements or standards that dictate record retention times * Whether the laboratory is engaged in ongoing research requiring many years of data * The time interval between the laboratory’s assessments or audits

These are Laboratory Information, either written by hand or computer-printed; they are permanent, and are not revised or modified.

Records

Record Retention for: Requisition and Accession Logs

2 Years

Record Retention for: Maintenance and Instruments Logs

2 Years

Record Retention for: Quality Control Records

2 Years

Record Retention for: Blood Bank Donor/Receipt Records

10 Years

Record Retention for: Blood Bank Patient Records

10 Years

Record Retention for: Blood Bank Employees Signature

10 Years

Record Retention for: Blood Bank QC Records

5 Years

Record Retention for: Clinical Pathology Test Records

2 Years

Record Retention for: Reports (Cytology, Surgical, Non-Forensic)

10 Years

Record Retention for: Cytogenetic Reports and Images

20 Years

Record Retention for: Flow Cytometry Plots and Histograms

10 Years

Computer network of hardware and software for receiving, processing, and storing laboratory data and information.

Laboratory Information System

Laboratory Information System can interface with _____ to transfer data into patient records, evaluate quality control data, and store preventive maintenance records.

Laboratory Instruments

Components of an LIS:

1. The LIS Software User Interface 2. Request Entry 3. Data (Results) Entry 4. Data Storage 5. System Security 6. Barcoding 7. Interface 8. Manual Procedures 9. System Maintenance 10. Disaster Recovery

Information provided by an LIS:

- Patient Demographics - Work Lists - Data Retrieval (Inquiry) - Quality Control - Quality Assurance - Management Reports - Encoding Systems

Advantages of Computerized Systems:

* Error reduction * Quality control management * Provision of option for data searching * Access to patient information * Generate reports * Ability to tracks reports * Improved capacity for maintaining patient confidentiality * Financial management * Integration with site outside the lab

Disadvantages of Computerized Systems:

* Training * Time to adapt to a new system * Cost * Physical restrictions * Need for backup system