Wiki Documentation for POC testing

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I am questioning what needs to be documented when nurses perform in house POC testing, such as a venipuncture or fingerstick for a PT/INR, hg A1c, etc. We use a system where the test is ordered and marked acquired once completed, the nurses are questioning our process of requiring them to document "venipuncture was performed" or fingerstick was performed and pt tolerated well. They feel they are documenting twice, since the system marks the tests acquired when they perform them and it's a given that they have to do a venipuncture for a blood draw, so why do they need to document that they are doing a venipuncture. Any ideas where I can find something in writing that states they must do this documentation? Thanks!
 
If a specimen is tested and lab results obtained, I can't see that any auditor would challenge that the nurses actually did the work of collecting the specimen - it seems self-evident that if they hadn't collected it, the lab wouldn't have been able to perform the tests.

As long as they are making a entry into the system under their sign-in that shows that they have completed the order, I don't know of any reason or regulatory requirements that they would also need to document something separately just to state they did the venipuncture. I'd agree with the nurses that this is duplicate work.
 
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I would think, though, that the nurses should be documenting how the patient tolerated the procedure, the site of the injection, the time, how many tubes were drawn.
A simple templated nursing note would work for this if the system isn't already set up to accommodate documenting this type of information.
 
I would think, though, that the nurses should be documenting how the patient tolerated the procedure, the site of the injection, the time, how many tubes were drawn.
Ideally yes, but a venipuncture is such a simple and routine procedure and of such minimal financial impact that I can't see it becoming a problem. Not sure what purpose would be served by documenting how many tubes were drawn. Certainly if there was any adverse outcome such as a significant hematoma, that should be documented. As mentioned in the last post, this could all be easily handled with a template.

I'd consider these good recommendations for documentation quality purposes, but I wouldn't make them requirements. Be mindful of the fact that unnecessary administrative requirements just end up adding to the cost of care. In my years working in healthcare, I've never encountered any payer or regulatory entity that audited venipuncture documentation.
 
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