Jump to content

patient signature on preop specimens


mammothbb

Recommended Posts

Hi,

My hosptial is converting to paperless requistions and I wondered how other paperless facilities handle the patient signature for preop specimens stating they have not been transfused or pregnant within the last 3 months. Do you have a separate form for the patient to sign or is there a way for them to sign "electronically".

Thanks!

Link to comment
Share on other sites

We have a form that is completed by the phlebotomist who will ask the questions. The form is kept in the chart and a copy is sent to the blood bank. The answers to the questions are entered into our LIS. We do not require the patient to sign a statement that they have not been pregnant or transfused in the last 3 months.

Link to comment
Share on other sites

I'm afraid there is no such thing as a "paperless" system, at least not for the foreseeable future. The best you can hope for is "paper reduced".

Having said that, I personally see not problem asking the question and then noting in the patient's record; "Patients states the have / have not been transfused or pregnant in the previous 3 months." A signature does not enhance memory I and can't tell you how many patients signed that they had not been transfused and during the search of previous records we discovered that they had been.

Saddly, it's an imperfect world.:raincloud

Link to comment
Share on other sites

We use a form stating 'no blood and not pregnant in 90 days' that is signed by the patient at the time of specimen collection. An ID card is sent home with them and they present it when admitted for surgery. The card is then signed, with that signature being compared to the original form as a way of confirming the identity of the patient (specimen drawn from the same person we are seeing the day of surgery). We hope to begin scanning both into the EMR, so that they become part of the patient's chart. That's what happens to other pieces of paper relating to our patients, such as reference sendout reports and blood product requisitions (Blood Bank is still on paper - the rest of the hospital is electronic records). Once the image has been checked to make sure it scanned properly, the paper can be discarded unless regs require it to be maintained for a specific time.

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
  • Recently Browsing   0 members

    • No registered users viewing this page.
  • Advertisement

×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.