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  • 1.  documenting site for lab draws

    Posted 4 days 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

     

    Our Mission is to Improve Life, Health, and Safety




  • 2.  RE: documenting site for lab draws

    Posted 3 days ago

    Hello Joan,

    My organization developed an Epic smart phrase, which feeds into a flowsheet, for documentation of phlebotomy:

    Patient identification verified by {IDENTIFIERS:2100018409}. Labs were drawn 8:40 AM  via venipuncture. The venipuncture site was {left/right:311354} {AMB BLOOD DRAW SITES:2100018610}, {SUCCESSFUL_UNSUCESSFUL_N/A:304254941} x *** attempts. Drawn by Dedria R Sowder, RN. Tubes drawn include {Blood Tubes:2100026377}

    The smart phrase ensures consistent documentation and ease of locating the information during audits.

    Thanks,

    Dedria



    ------------------------------
    Dedria Sowder, MSN-Ed, RN, AMB-BC, NPD-BC, CPN
    Leadership SIG Past Chair
    Clinical Educator, Carilion Clinic
    Roanoke Virginia
    540-314-3028
    ------------------------------



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