Asking physicians to meet another documentation requirement is challenging. We are working on a trigger in Cerner to send an alert to the ordering MD when the phlebotomist documents the refusal that they will only need to acknowledge to provide their required documentation. Just another hoop that we and the physicians have to jump through for something that is already documented.
From: PAMELA J. ANDERSON [mailto:[email protected]] Sent: Monday, June 06, 2016 10:48 AM To: Bruce S. Bainbridge; '[email protected]' Subject: RE: Patient Refusal of Blood Draw What about encouraging your physicians to mention the refusal in their progress notes? Pamela Anderson, BSN, RN Clinical Data Abstractor Loyola University Health System Center for Clinical Excellence Maguire Center | Bldg 105-3909 | Maywood, IL 60153 (O) 708-216-5544 | (F) 708-216-7867 | (E) [email protected]<mailto:[email protected]> NOTE: The information contained in this message may be privileged and confidential and protected from disclosure. If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you believe you have received this communication in error, please notify us immediately by replying to the message and deleting it from your computer. Thank you. Loyola University Health System From: Sepsisgroups [mailto:[email protected]] On Behalf Of Bruce S. Bainbridge Sent: Friday, June 03, 2016 12:25 PM To: '[email protected]' Subject: [Sepsis Groups] Patient Refusal of Blood Draw 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. This message has been scanned for malware by Websense. www.websense.com<http://www.websense.com/> Confidentiality Notice: This e-mail, including any attachments is the property of Trinity Health and is intended for the sole use of the intended recipient(s). It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please delete this message, and reply to the sender regarding the error in a separate email. Click here<https://www.mailcontrol.com/sr/BwWnv4Q0oQbGX2PQPOmvUlhe+RbjMF0Hg6MPUjt2oRvNFvCSNPwKFIho1aizdVACW1o6Wq5IHf+DL!bKPtQR4w==> to report this email as spam.
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