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Laboratory, Radiology and Waived Testing

Sets out how the Agency arranges laboratory, radiology and pathology services: only on a physician's or practitioner's order that fits the plan of care, through licensed providers under written agreement (and, for its own inpatient facility, under a qualified physician's direction), and how any test staff perform themselves, such as a fingerstick blood glucose, is done only under a CLIA certificate of waiver or other CLIA certificate, following the manufacturer's instructions.

Preview: full text with a package
About this policy
Policy number
NC-HSP-LAB-01
Version
1.0
Main rule
10A NCAC 13K .1203
Library
North Carolina hospice · 60 policies
Category
Clinical tasks
Sections
19

In short

  • Order tests only when the result will help the patient's comfort or care, and only with a physician's or practitioner's order.
  • Do not do any test yourself, even a fingerstick glucose, unless the Agency holds a CLIA certificate and you have shown competency on that device.
  • Follow the manufacturer's instructions, run quality control and clean shared meters between patients.
  • Label specimens at the bedside with two identifiers, the date and the time.
  • Report results outside the ordered range to the physician at once and document the response.

What's inside

19 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (10A NCAC 13K .1203)
  • 5. Ordering Tests
  • 6. Laboratory, Radiology and Pathology Providers
  • 7. Testing by Agency Staff: CLIA
  • 7.1 Tests by the patient or family
  • 8. Doing a Point-of-Care Test
  • 9. Collecting and Sending Specimens
  • 10. Results
  • 11. Responsibilities
  • 12. Records and Compliance Monitoring
  • 13. Staff Training
  • 14. References
  • 15. Related Policies and Forms
  • 16. Approval
  • 17. Revision History

An inspector may ask

  • Do your nurses check blood glucose with a meter? Show me your CLIA certificate.
  • Which laboratory do you use, and where is the agreement?

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