I currently work in a blood bank where all the techs complain about double documentation, excessive amount of writing, and loss of time due to documenting every move that is made.   So, my question is, how much documentation of patient results is actually required to meet the joint commission standards?  At this time, we document everything we do on paper including antigen typing (along with qc) then enter all these same results into the computer system (Cerner).  Is this necessary or can we just go straight to the computer with our results?

We do the same except few tests where we read and record results directly in computer. It depends on your computer system. I believe cerner is not easy when it comes to document antigen typing results. You have no choice but to document results on paper and then enter in computer as cerner doesn't allow to enter partial results. eg. once you enter IS results for rh typing and the result is negative you incubate it for 5-10 minutes then you will read again and enter result in computer. Cerner doesn't allow that all typing results must be entered same time that is why we need paper.

Some of the computer system allows enteries at different time so you can enter IS and after 10 minutes go back and enter RT result.

 

& also your STATE and CAP regulations must be checked before getting rid of any paper documentation.

Thanks for the response Eagle Eye!

 

I can't think of anything we do that isn't documentable in Cerner (every stage of testing and interpretation.)  Even the special antigen typing has a customized worksheet built in cerner. 

Most techs here would agree that the problem is that we have a generation of techs (and recently retired supervisor) who are from a time before computers and have a fear of them.  We are on the brink of a new supervisor taking over and changes taking place.  Hopefully our new supervisor is going to make our blood bank policies and procedures more current.  If anyone knows of any standards or restrictions that require paper documentation of patient testing, please let me know.  Thanks!   

Our lab is also staffed by techs who have been around since before computers. It was difficult for many of them to "give up" writing down everything.

 

I do not know of any standard that requires paper documentation of patient testing.

Virtually all results are recorded directly into the LIS.  I would view double recording as an extra opportunity to make a clerical error.  We do have downtime worksheets so that results can be recorded on paper during computer downtime.  Some tech who are less comfortable with antigen typing will use the worksheet to record antigen results on paper and enter into the computer.  That's about the only time we see double recording of results.  Most will record antigen results directly into the LIS. We do also have an Antibody ID worksheet and a few things are recorded there, additional investigational studies, ABO typing discrepancy workup.  Another exception is that antibody panel results are recorded on paper on the panel manufacturer's antigram.  These are not double recorded (paper only) as we only enter the interp in the computer.

If you have a BBIS you should just document in that.  There is no need for paper documentation (if you validated your system and if you use it you better have validated it).  Resulting on paper and then transcribing into your BBIS is just another step where a transcription error can occur.  I inspected a hospital years ago that did all the work on paper and then back-entered into the computer.  When we went to the pt area to watch a transfusion we had to bring the blood back because the patient needed irradiated products (documented in the computer not the pt record card).  You have validated your BBIS - dump the paper.  I know I have lost jobs because I told the interviewing staff that the first thing I would do is scrap the paper recording . . . the BBIS truth tables alone make this a wise decision.

We record our antigen typing results on paper and put only the interps into Cerner.  However, most of our test results are recorded directly into the computer system.  At one time we were cited by the State for too much double documententation (we were still on paper at the time, using history cards and a log book) because this was percieved as an increased risk for transcription errors.

I totally agree with the posters who said record directly in the computer system.. The chance of transcription errors is too great. Get rid of as much paper as you can. Do you save the original pieces of paper on which the result is written for the required amount of time?

We use Mediware which is actually pretty good for entering all reactions and comments, other than full AB panel results - which I would not want to type into a computer anyway.

 

Still, we use cards while testing and transcribe to the computer system.  The cards are saved for 7 years or whatever, and yes,indeed, the inspectors consider those our primary record.  We are hoping to move to a papaerless test recording protocol some day.

 

We know of other hospitals who have "dropped" paper result recording altogether -- but in reality, it appears that some techs routinely record results while testing on scrap paper so they can enter all results together into thier system.  This is a big no-no of course.

 

Scott

We save antibody workups on antigram papers in the patient's BB chart, as well as antigen typing,since paper is where we document our QC results for the antisera, just documenting the interpretation in the computer. All other QC and patient results are entered directly in the computer.

Drop the paper records and welcome to the 21st century!  Think of the time savings, less chance of a clerical error, less paper to store and discard confidentially.

 

And at inspection time it is great to have things in the computer.  I had a CLIA inspection and was able to pull everything I needed related to pt testing directly from the computer system.  Makes for a quicker inspection and really is a more accurate way to document almost anything done in the BB.

I am also not a fan of writing things on paper just to have to transcribe them into a computer system. Introduces another chance of error. Get rid of as much paper as possible.

• We result directly into Cerner. Our Rh typing sera (Bio_rad) do not call for an IS, only for the 5 min reading so that is not an issue. We are still using Cerner Classic. Had the first meeting (of many) this morning with the consultant do the build for Cerner Milennium. Any advice for those of using Milennium on things  to watch out for?