Principle: | Procedure | Order Retrieval | Limitations | References:
There are two databases involved in the electronic communication of patient information. The CLICS database has ADT (Admit, Discharge, Transfer) and most of the order information, while SafeTrace Tx has a repository of patients that have had past blood bank work. ADT and order information from CLICS is automatically received into a SafeTrace Tx holding table. This procedure addresses the process used to register the Blood Bank Specimen, electronically retrieve patient information and save the electronic order. This Automatic ordering procedure reduces the number of steps required to build an order compared to the manual method.
1. With the specimen and the requisition in hand, click on the PW and the red question mark to bring up the current Pending Worklog. View the names listed on the PW to make sure your patient has not populated the screen. If that patient name is on the list then be assured that your patient has an active specimen recorded in the system and the orders have attached to that specimen (it may be necessary to cancel orders and reject the newest specimen). If it is determined that the tests should be completed on the newer specimen, then the blood banker will re-assign the orders to the new specimen. After the new specimen has been recorded, see IV. 2.
A. In the Patient/Order module, on the tool bar, use the Patient pull down menu and choose Record Specimen.
B. The Open Patient screen will appear:
C. Place the cursor in the Last Name field. Type the patient last name. Tab to the first name field, and type in the first letter of the first name. Enter or click Query.
a. If more than one patient or patient information appears, choose the appropriate one by comparing the information on the requisition with the information on the screen in order to positively match at least two identifiers. It may be necessary to use the lower scroll bar to see all the information in order to make an informed decision. If two records appear identical, choose the one identified as C (meaning current vs. previous). The patient information will be sent to the record specimen form. (Proceed to II. M. Record Specimen; Identify/Accession)
b. If SafeTrace cannot find any patient information in its database that is similar to the information entered, you will see an information message:
c. Click OK.
d. Type the MR into the MR No: field. Click Query.
e. If the correct patient appears, click OK.
1. Open Patient Visit form will open. If the correct visit is not listed, click Query.
2. If the correct visit is still not listed, click OK.
3. The Record Specimen form will open. Click Select Visit.
4. Find the correct visit associated with the order in hand.
5. Click OK.
6. The correct date will be on the Record Specimen form. (Proceed to II. M. Record Specimen; Identify/Accession)
D. If the correct patient information does not appear, click NEW.
E. The Open Patient from ADT Holding form will open with your patient information on the lower grid. Make sure to verify patient match with at least two identifiers.
F. Click OK.
G. The New Patient – Using ADT Holding Defaults will appear with your patient information.
H. Click OK. (Proceed to II. M. Record Specimen; Identify/Accession)
I. If a similar, not identical record appears, carefully review the data to determine positive patient match.
a. If it is determined this is a match, click OK to update the ADT information from holding.
b. The new ADT information will appear for comparison. If the information matches, click YES.
c. Click OK. The new patient information will be sent to the record specimen form. (Proceed to II. M. Record Specimen; Identify/Accession)
Warning: Be aware that SafeTrace may try to insert older ADT information into this spot if there is old information in holding. Be very careful that the information to be updated is a match to the information on the current patient requisition. If it does not match, click NO.
J. If none of the patients listed is a correct match:
a. Clear out the name fields,
b. Enter the MR # and click Query.
c. If the correct patient information does not appear, click New.
d. Proceed to II. M. Record Specimen; Identify/Accession
K. If one of the options is a match:
a. Highlight the correct patient record and click OK. The New Patient – Using ADT Holding Defaults form will appear with the patient information.
b. Click OK. The new patient information will be sent to the record specimen form. (Proceed to II. M. Record Specimen; Identify/Accession)
L. Find Current Visit: The Open Patient Visit may open. Choose the visit which matches the requisition in hand. (Match the date and the External Visit number to the Acct. No: on the requisition.)
a. When you choose the visit and click OK, the Record Specimen will open with the current admission date in the Admission Date field.
b. Observe very closely the Admission Date listed on the Record Specimen field. If the date listed in the Admission Date field is obviously not for the current admission:
1. Click New Visit
2. Click on the ADT Visit button if active. Then the ADT Visit Holding form will appear.
3. Click on the correct visit information line.
4. Click OK. The New Patient Visit form will reappear with the information filled into the fields.
5. Click OK. The new patient information will be sent to the record specimen form. Return the cursor to the Accession No: field. (Proceed to II. M. Record Specimen; Identify/Accession)
c. If ADT VISIT is not active, click OK, and choose SELECT VISIT. Check the listed visits for the one with the correct information and choose it.
d. It will be necessary to redirect the cursor to the Accession No. field after choosing one of the VISIT options.
a. Bar code (or manually type) the specimen accession number (from the tube).
b. Record the phlebotomist initials, date and time of collection in the appropriate fields.
c. Click OK. This form will disappear from the screen. The specimen is now recorded to the current visit and the order is on the PW.
III. Order Retrieval
1. The order will appear on the Pending Worklog.
2. Add-on orders placed on patients with a current specimen recorded in SafeTrace will automatically appear on the PW.
3. A new feature located to the far right on the tool bar is OP. When an item is highlighted on the Pending Worklog (PW), the order profile may be accessed, by clicking on OP. Common uses of this feature include:
A. Division of rbc/crossmatch orders in situations when not enough units are available to fill the order at a given time.
a. Highlight RBC line.
b. Edit; Insert row.
c. Fill in product, quantity, etc.(The crossmatch order will occur automatically)
d. Repeat steps 3 and 4 for the total amount of the original order.
e. Save these changes.
f. Cancel the original RBC order line using Order, Cancel, Item.
B. Add on testing due to reflex situations (i.e. Antibody Identification or Antigen Typing.)
C. GTS needed for surgical crossmatch order on patients who have had recent PAT testing.
D. Cancellation of duplicate orders
1.All specimens tested in the blood bank that do not include the complete GTS testing algorithm, and have the appropriate identification verification, required for crossmatching, must be inactivated at the end of testing. This will ensure that no add-on crossmatches will be associated with specimens that are not completely tested. Open the Specimen Detail screen and change the status from AV (available) to IN (inactive). Click OK.
2. In the event that an add-on order is associated with the current in-lab specimen, but a different specimen is required for that particular order, these steps must be taken:
A, Record the second specimen in SafeTrace using the current accession number associated with the new specimen.
B. On PW, click on the line of the correct patient test.
C. Click on the OP on the Menu Bar to open the order profile.
D. Place the cursor in the Specimen field and click on the binoculars (find).
E. Click on Query.
F. The Patient Specimen form will open with all active specimens available.
G. Choose the specimen required for the current test.
H. These steps will be required for all orders; crossmatch orders are separate from GTS orders.
3. Check to make sure the new Automatic order on the PW is associated with the correct specimen.
4. Proceed with Results Entry.
1. SafeTrace Txâ Upgrade Release Documentation, Version 3.2.0, 3.3.0, 3.4.0, 3.4.1, 3.5.0, 3.5.1.
i. June 2011 M. Burger, N. Combs