The CMS guidelines require either a physician/CNP/PA documentation of the patient's refusal or a consent for blood draw form marked as refused by the patient and witnessed by a staff member. We have no "Consent for blood draw" form as this is included in the Condition of Admission so no means of meeting this option. Our policy is for the phlebotomist to document the patient's refusal in the lab results form and this is trackable electronically as to who entered the data. We have a couple of failures due to this patient refusal, usually at 3 of 4 a.m. when they are awakened for yet another blood draw just short of the 5 a.m. blood draw which is outside the 6 hour window. I have submitted this situation to QualityNet and they do not seem inclined to accept this as a witnessed refusal. We do not have a process in place to have the physician document this patient refusal. Any suggestions?
Bruce Bainbridge, RN, BA | Clinical Data Analyst | Tri-City Medical Center | Quality & Performance Improvement | 4002 Vista Way | Oceanside, CA 92056 760-940-3789 I [email protected]<mailto:[email protected]> |www.tricitymed.org<http://www.tricitymed.org/> CONFIDENTIALITY NOTICE This message and any included attachments are from the Tri-City Healthcare District and are intended only for the addressee. The information contained in this message is confidential and may constitute non-public information under international, federal, or state securities laws and is intended only for the use of the addressee. Unauthorized forwarding, printing, copying, distributing, or using such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
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