This is a BBK documentation question related to CAP requirements - CAP checklist item TRM.33200 reads:
Can the laboratory identify the person performing each significant step in the collection, processing, testing, storage, and distribution of blood and blood components? COMMENTARY: Records must be complete in that all relevant data are available. This would include not only results, but also interpretation, dates, and identity of persons performing the work. A personnel audit trail must be maintained for each significant step in the collection, processing, testing, storage, and distribution of blood and blood components. Our issue is with the collection part of BBK specimen documentation. Currently, if Nursing collects blood samples, we use "CBN" as the identifier in Meditech. This includes BBK specimens. There is a question in our Lab about whether we need to be documenting the actual name/mnemonic of the blood collector in Meditech. We use the Hollister system, so the collector's signature is on the Hollister card, but the card is tossed out when the specimen expires, so there is no permanent documentation. If we replaced the "CBN" with the user's Meditech mnemonic, we would need to have a real-time list of Nursing staff signatures along with their Meditech mnemonic. Is anyone else dealing with this in Meditech? What are you doing to document the actual person who collected the specimen? Thanks! Britt Watters, MT(ASCP) Laboratory System Analyst Bartlett Regional Hospital Juneau,Alaska 907.796.8643
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