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documenting site for lab draws

  • 1.  documenting site for lab draws

    Posted 2 hours ago
    In a coding review of charts, an outside examiner identified that we are not identifying the site for lab draws in our outpatient lab or any of our sites with lab services. We do identify the site if it is a difficult draw, or this requires a RN for lab draw as part of the documentation -free text in the patient's record. Our EHR does not support this documentation. Our lab techs are only approved to draw from antecubital sites. I have not seen or heard about any outpatient lab sites that do document sites for routine blood draws. I am curious about other sites . 

    Joan Brewer, MSN, RN

    Senior Director of Clinical Operations

    Community Health Centers

    RiverStone Health
    123 South 27th St. Billings, MT 59101
    Office: 406.247.3295

    Cell: 406.861.2678

     Joan.bre@RiverStoneHealth.org

    RiverStoneHealth.org

     

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