Communication and Documentation Flashcards
7 cards from real CLS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Communication and Documentation flashcards as text
Under CLIA, how long must histopathology slides and pathology reports be kept?
Answer: 10 years
CLIA requires 10 years for histopathology slides and pathology reports, longer than for routine records.
A Spanish-speaking patient at the draw station does not understand the collection instructions. What is the most appropriate action?
Answer: Use a qualified medical interpreter service
Qualified interpreters give accurate communication and meet federal language-access requirements.
Which statement best describes autoverification documentation requirements?
Answer: The rules must be documented, validated, and approved by the lab director, and periodically rechecked
CAP requires the director to approve autoverification rules, which must be validated and periodically verified.
A trending QC shift is investigated, and corrective action is taken. Which record is most essential?
Answer: A written corrective action record describing the problem, the investigation, the action taken, and how patient results were assessed
CLIA requires documented corrective action, including whether patient results reported earlier were affected.
Which communication practice best reduces errors when reporting results with units that are easily confused, such as mg/dL vs mmol/L?
Answer: Always state the value with its units and confirm with a read-back
Saying the units out loud and confirming with a read-back prevents misinterpretation that could cause dosing errors.
A lab finds that its turnaround time for STAT troponin regularly goes over target. What is the best first step in communicating and documenting the problem?
Answer: Collect and document turnaround time data, report it through the quality program, and investigate root causes
Quality problems are handled by documenting data, reporting it through formal QA channels, and analyzing root causes.
A physician questions a result over the phone in an angry way. Which response best reflects professional communication?
Answer: Listen calmly, acknowledge the concern, review the result and QC, and follow up with documented findings
Professional handling means calm listening, objective investigation, and a documented follow-up.