Patient Reports (Hospital Setting)

Autosend Reports

Nursing units that require immediate access to hard copy data are provided with Autosend Reports. Stat and Urgent testing, or all test results can be broadcast to a directed printer depending on the needs of the unit. Chemistry, Hematology, Microbiology and Blood Bank data are transmitted as soon as test results are verified. Each report contains the newest test result activity, and only redisplays previous information when a test is part of a profile that was partially resulted on the first report.

Autosend reports contain the following information for Chemistry and Hematology testing:

· Ordered test(s)

· Collection Date & Time // Received Date & Time

· Test name and corresponding results

· Reference ranges and corresponding units of measure (when applicable)

· Abnormal results demarcated with * symbol

· Critical values highlighted with ** symbols

· Priority codes such as STAT

Microbiology procedures display:

· Ordered test(s)

· Collection Date & Time // Received Date & Time

· Procedure Name

· Specimen Source

· Special requests or comments

· Results including susceptibility testing

· Report Status: Pending or Final

Blood Bank testing includes:

· Ordered test(s)

· Collection Date & Time // Received Date & Time

· Information about each allocated unit for Type & Crossmatches

· Patient ABO/Rh

· Antibody information

Canceled tests are indicated by the comment “Request credited”, which is followed by a reason for the cancellation.

Cumulative Summaries

Cumulative Summaries are printed daily, and contain in chart form, all of an inpatient’s laboratory results starting with the date of admission. A patient qualifies for a Cumulative Summary whenever new activity takes place. Three types of Summaries are generated on a daily basis:

1) Cumulative Summaries by Location - [Burgundy border]

These reports contain all test data starting with the admission date, until the patient qualifies for a ‘Split’ report. Previous ‘burgundy’ reports should be discarded from the chart when a new one is available.

2) Split Cumulative Summaries - [Buff border]

‘Splits’ are generated to conserve paper, and reduce the number of pages on the current ‘burgundy’ cumulative report. The term ‘Split’ means that the ‘burgundy’ report has reached 10 pages, and the system should ‘Split’ off certain information to a separate report that will be part of the patient record during the inpatient stay.

The next ‘burgundy’ report that is printed after the ‘Split’ will contain only the new information that had not been included on the ‘Split’, PLUS any data that had NOT previously printed on a chart copy cumulative. Accession numbers collected within the last two days do not qualify for the split cum, nor will any accession numbers with pending tests. This data will be contained in the ‘burgundy’ cumulative report.

ALL ‘Split’ reports are permanent records during the inpatient stay. As each new ‘Split’ report is generated, it should be added to the chart, leaving any previous ‘Split’ reports as part of the medical record.

3) Final Cumulative Report - [Teal border]

Inpatients qualify for a Final Cumulative Report after discharge, and all testing has been completed. These reports contain all test data starting with the admission date of the inpatient stay. They are sent to Medical Records to be retained as the permanent chart copy. Any previously printed ‘burgundy’ and ‘buff’ reports should be replaced by the Final Report.

On occasion, there is a need to update a patient record after the Final Cumulative Report has printed. This activity will generate a new Final Cumulative Report that includes the most recent updates plus any other test results for the inpatient stay. Previous Final Cumulative Report Summaries should be discarded when a new report is generated.

Cumulative Summary Report Description

All types of Cumulative reports display data in the same format. The order of procedures printed on the report starts with Chemistry, followed by Urinalysis, Hematology, Immunology, Reference Laboratory Testing, Microbiology, and Blood Bank.

For Chemistry and Hematology, data is displayed as follows:

Format:

         ·        Horizontal Date:
                  >>> Collection dates print left to right in reverse chronology.
                  >>> Tests print vertically from top to bottom on the left side of the page.

             OR

          ·        Vertical Date:
                   >>> Reference testing, and those with lengthy text results display in this format.
                   >>> Collection dates print vertically from top to bottom on the left side of the page in reverse
                           chronology; tests print next to each date.

Collection Time:

           +          Indicates results associated with this collection time are new since the last cumulative printing.

           “R”     indicates the Received Time; and only prints when the collection time is unknown.

Test Information:

           ·        Test name
           ·        Reference range
           ·        Units
           ·        Results - Abnormal tests demarcated with *
                                       Critical values demarcated with **
           ·        Footnotes sort at the bottom of the page first by ‘predefined text codes’ in alphabetical order; and are
                    followed by ‘free text’ comments that are labeled A, B, C, etc.

Result Date/Time: (Final Discharge Reports ONLY)

           ·        The date and time individual results are available are printed on the right hand side of the report.

Addendum Reports

These reports are printed daily for inpatients that have pending tests at discharge. As the testing is completed, the physician is forwarded a copy of the updated information.