Chapter 11: Testing and Laboratory Procedures

abnormal or critical lab values

- CLIA requires rapid communication of critical laboratory values - technology allows alerts to be send to the provider for rapid review - if MA receives a critical value, ensure accuracy of the information by repeating the test results back to the lab personnel - notify the provider immediately and accurately document the communication and actions taken in the EMR

matching specimen to patient and completed requisition

- MA can complete lab requisitions based on providers' orders - requisitions that aren't accurately completed can result in a rejected specimen, which causes patient dissatisfaction and possible delays in treatments - responsibility of the MA to properly label all collected specimens and ensure the specimens are matched with the correct lab requisition or order - incorrect specimen labeling contributes to laboratory error more than any other factor - specimen containers should be labeled with patient information at the time of collection - labels should be verified against the patient chart and the lab order before sending the specimen to the lab for processing

Quality control logs

- MA is responsible for monitoring the functionality of various pieces of equipment within the health care facility - ensures that equipment is working properly and the accuracy of test results is examined - example = temperature of the refrigerator - maintain logbooks to validate the test was conducted under optimal conditions and control samples were accurate prior to testing patient samples

RAST testing

- Radioallergosorbent (RAST) - blood test used to detect antibodies associated with allergens - more invasive because it requires a blood draw, but safer regarding avoiding a potential allergic reaction

provider-performed microscopy procedure

- a CLIA term for microscopic examinations that require the expertise of a physician or mid-level provider qualified in microscopic examinations, falls under CLIA's moderate-complexity category - allows provider to develop a preliminary diagnosis and begin treatment as warranted

Random urine

- a urine specimen collected in a clean container for screening purposes; no preparation is required - the patient urinates in a clean, non-sterile container. This specimen is used for screening purposes.

Clean-catch midstream

- a urine specimen that is collected in the middle of the urinary stream in a sterile container after perineal cleaning - The patient performs perineal cleaning using moist wipes, begins to urinate, and then collects the specimen midstream in a sterile urine container. This specimen is used for cultures or when a non-contaminated specimen is desired.

Demographic information

- accuracy is important for billing purposes and patient identification - this section typically includes... patient name, address, date of birth, sex, telephone number, insurance information, provider information, diagnosis or indications for testing, and order date

Specimens for cultures

- always collected in sterile containers - take precaution to avoid touching the insides of lids, swabs, or container which could contaminate the specimen - if specimen is not properly collected, the identification of the causative agent will not occur and proper treatment cannot be started

handling non-blood specimens

- always follow proper office procedure and reference the lab manual for proper handling of non-blood specimens - kit is usually provided for chain of custody tests, and a signature of everyone who has contact with the specimen is required - dark container is typically required for specimens such as urine that require testing for bilirubin to protect the specimen from light

Commission on Office Laboratory Accreditation (COLA)

- an independent firm that provides accreditation for laboratories and has a goal of meeting CLIA standards - focuses on meeting CLIA regulations with a goal of providing the best care to the patient

spirometry testing

- automated test that produces graphic results - patient should wear loose clothing, sit in an upright or standing position, and breathe through the mouth, pursing the lips around the mouthpiece - MA will likely apply a clip to the patient's nose to avoid nose-breathing during the procedure - patient should lift the chin slightly and extend the neck a little during the test to reduce breathing resistance - no large meals 2 hours before the test, no smoking 1 hour before the test, and discontinuing the use of bronchodilators or other breathing therapies (inhalers, nebulizers) for at least 6 hours before the test are required

Nonblood specimens

- be familiar with the types and requirements of tests ordered and ensure that the patient receives complete instructions on how to collect the specimen to maximize accuracy of results - patient should receive the appropriate specimen containers with directions for their use

Ova and parasites (O&P) testing

- can be collected for parasites or to evaluate for bacterial infections - specific containers are used for each test - provide containers to the patient along with instructions on collection - test detects the presence of parasites and their eggs, either of which require treatment

reminders for specimen collections

- collect the specimen at the appropriate time - collect the specimen from the site of suspected infection - minimize transport time to a reference lab - collect the appropriate quantity - use the appropriate containers and label them accordingly

Sputum specimens

- collected in sterile containers - important for the patient to produce a deep, productive cough - produces specimen from deep within the lungs rather than saliva from the mouth - best collected in the early morning before eating or drinking - patients should avoid mouthwashes prior to sputum collection

billing information

- compare the insurance card to the requisition for accuracy - the guarantor, insurance plan, and ID numbers are necessary to file the insurance claim - accurate contact information for the patient will facilitate billing when the patient is a self-pay or if the insurance company does not cover the cost of testing

skin testing

- delivers rapid results and is minimally invasive - typically performed on the forearm or the back - conducted with provider supervision because allergic reactions and anaphylaxis are possible

scratch testing

- diluted allergen is applied to a scratch or prick on the surface of the skin - if a wheal occurs in the first 15 minutes, the allergist can identify the substance as a possible allergen and consider intradermal testing - the larger the wheal, the more significant the allergy

intradermal testing

- diluted allergen is injected intradermally and the patient is observed - an initial wheal is expected - if the wheal becomes inflamed with induration (raised, hard area), the substance can be identified as an allergen

Testing Information

- each test is individually checked unless a panel is ordered - validate that the tests on the requisition match the provider's orders in the medical record - ensure any additional information is completed

CLIA regulations

- established in 1988 to ensure quality of diagnostic testing through laboratory regulations - three designations: CLIA-waived, moderate complexity and high complexity

fecal occult blood

- evaluation of a stool specimen for hidden blood - can indicate a disease process or gastrointestinal bleeding - correct patient instructions need to be delivered to avoid false positives - instruct patients on medications and foods to avoid for three days - patient will collect three separate specimens on filter paper

transporting non-blood specimens

- if the container has the potential to break or crack, padding and protection from leakage must occur - wrapping containers in absorbent material and placing the item in a biohazard bag are added safety measures to ensure that the outside of the package does not get contaminated - when transported via mail, biohazard identification on the outside of the package alerts handlers of potentially infectious agents within the package

Labeling specimens

- information on label depends on the laboratory/facility policy - should always contain patient's name and the date and time of collection - other required information might be... DOB, provider's name, and initials of the person collecting the specimen - label container, not the lid

color vision testing

- males are more commonly affected by colorblindness - most common is red-green deficiency - tested on 11 plates within an Ishihara book - if the patient misses four or more, there might a color deficiency and further testing is warranted

quality control

- measures incorporated to maximize reliability and accuracy of results while recognizing and eliminating errors in testing - included in quality assurance but is more specific; it is related to test reliability and accuracy while attempting to uncover errors and eliminate them - examples = reviewing the the expiration of urine multi-sticks and checking the temperature of the laboratory refrigerator and documenting it on a log

spirometry/pulmonary function tests (electronic, manual)

- noninvasive lung functioning tests can be used in the ambulatory care setting - MA is responsible for preparing the patient for the procedure, performing and documenting the procedure, and providing results to the provider for interpretation - two most common tests = spirometry and peak flow meter testing

vision tests performed in ambulatory care

- noninvasive screenings to detect visual abnormalities of the eye (hyperopia, myopia, presbyopia) - use charts and have the patient identify shapes or letters

computerized physician order entry

- only licensed or legally authorized individuals are allowed to enter laboratory orders in the electronic record - under the direction of a provider, only credentialed MAs are authorized to enter orders (enforced through MACRA) - In April 2015, Meaningful Use was replaced with the Medicare Access and CHIP Reinforcement Act of 2015 (MACRA), which deals with payment for health care under the direction of the CMS

Parts of a laboratory requisition form

- patient demographic information - provider's signature or authentication that the provider ordered the lab work - specific tests need to be marked and are often organized on a laboratory requisition based on the department that will test it - source of the specimen, as well as date and time of specimen collection

visual field testing

- perimetry testing - detects eye diseases such as glaucoma - patient will look straight ahead and respond to instructions - automated test where patients respond to seeing lights flash - manual test where patients identify when they can see hands or fingers in their peripheral vision

quality assurance

- policies and procedures to maximize patient safety and ensure reliability related to laboratory testing - comprehensive and relates to policies and procedures that must be implemented for reliability of test results - examples = rotating stock to put newest containers in the back of storage areas and checking the temperature and maintaining it between 39 degrees and 41 degrees F

Common point-of-care tests

- pregnancy testing - rapid streptococcus testing - dipstick, tablet, or multi-stick urinalysis - hemoglobin - spun hematocrit - blood glucose - hemoglobin A1c - cholesterol testing - helicobacter pylori - mononucleosis screening - nasal smear for influenza types A and B - drug testing - fecal occult blood

Quality control procedures

- quality control samples are tested to ensure patient samples are accurate - referred to as controls and use a quantitative result range or qualitative descriptor - example = calibrating machine for hemoglobin to 12.6 + or - 0.3 meaning that if the result falls between 12.3 and 12.9 that the patient result is accurate - example = for the fecal occult slide, if a control strip turns blue, it means the developer is effective. If it does not turn blue, the developer is not working or the slide is not valid

proper disposal of non-blood specimens

- red biohazard waste bags are sufficient for specimen containers that are not breakable - sharps containers for anything that could break or splinter - designated sink is often adequate for disposal of urine specimens - follow the policies and procedures outline by the facility and adhere to OSHA standards

near vision testing

- screens for presbyopia or hyperopia using a near vision acuity chart - patient reads printed material of various sizes 14 to 16 inches away from the yes without corrective lenses - test each eye separately and then both together - level at which the patient can read the smallest printing clearly is the result

ICD-10 coding information

- some requisitions are already populated with the appropriate ICD-10 codes - lab testing is strictly coded from the provider's reason for ordering the test - ensure the complete diagnosis information is included on the from to appropriately assign codes

Processing non-blood specimens

- some specimens might need to be processed prior to transport to maintain the integrity of the specimen - make sure swabbed specimen are moist by breaking the fluid chamber within the specimen container - urine specimens for microscopic analysis can require centrifuging prior to transport with the supernatant fluid removed - proper storage

storing non-blood specimens

- some specimens require refrigeration (i.e., urine) if testing is not immediately performed - refrigeration is done to avoid chemical changes or biological breakdown of the specimen - other specimens might need to be maintained at body temperature, such as swabs for STDs - MA needs to be familiar with the characteristics of the specimen being collected and refer to the lab manual for proper handling and storage

distance vision testing

- tested by using a distance vision acuity chart to evaluate for myopia - patient stands 20 feet from a chart at eye level and identify letters, shapes or the direction an "E" is pointing - eyes are tested separately and then together and corrective lenses can be worn during the test - the line at which the patient can clearly see the letters or pictures is the result - the patient can miss one item and still pass the line - vision is a fraction with 20/20 representing normal vision

CLIA-waived testing

- the Food and Drug Administration (FDA) requires that all testing meet federal guidelines and determines the complexity of the tests performed in the laboratory - ambulatory care centers typically perform Clinical Laboratories Improvement Amendments (CLIA) Waived testing, which is the simplest of laboratory procedures - MAs are trained in CLIA-waived testing and may perform these tests per provider request

tympanometry

- the process of recording the movement of the tympanic membrane through pressure variances in the external ear canal - using a small ear bud, eardrum movement can be measured by changing the amount of air pressure applied - valuable for determining presence of fluid and potential infections in the middle ear - normal tympanogram produces a peak on the graph - abnormal tympanogram produces a flat line

speech, tone and word recognition information

- used on patients (especially children) who can respond to directions of pushing a button or raising a hand to acknowledge when various tones are heard through headphones - level of hearing is documented in decibels and the frequency in hertz - adult with normal hearing should be able to hear tones at 25 decibels and a child should be able to hear at 15 decibels - tuning forks are used to determine the patient's ability to hear tones transmitted through air and bone conduction - vibrating tuning fork is placed on top of the head or on the mastoid process to test hearing

Processing, handling, and transporting specimens

- used to avoid contamination of specimens that are being prepared for transport and testing - used to protect healthcare staff from exposure to potentially infectious agents - hand washing is the most effective means of preventing the spread of infection - PPE should be used based on the specimen being handled - most common specimens are blood, urine and swab samples

Tape test

- used to detect pinworms - usually affects small children - provide parents with a slide with a piece of tape on it - tape is placed over child's anus before getting up in the morning and then back on the slide, which is brought to the provider for analysis

Challenge testing

- used to detect specific allergies, such as food allergies - not a first choice of testing but can be prescribed if scratch or intradermal tests are positive and the patient (usually a child) has suspected life-threatening food allergies - patient receives increasing amounts of food suspected of causing an allergy - conducted in a controlled environment where medication and treatment are available for acute allergic reactions

peak flow testing

- used to monitor lung function in the home, especially for patients who have chronic respiratory disease, such as asthma - measures the forced expiratory volume which indicates the effectiveness of airflow out of the lungs patient instructions: - wear nonrestrictive clothing - begin with the marker at the bottom of the scale on the meter - in an upright sitting or standing position, take a deep breath and forcefully blow out of the mouth, which is secure around the mouthpiece of the machine - record the number where the marker is located at the end of the test - repeat the test two to three times and record the results assist patient by providing instructions, demonstrating the technique, and allowing the patient to practice several times before completing the procedure

procedures for normal values

- with EMRs, communication of lab tests is expedited through the provider portal - some offices don't have EMRs, so the results need to be scanned or uploaded into the provider portal - note date of review and the action being taken - results should be made accessible to patients (if possible) - MA may need to call or mail results to patient - verify correct address and identify when communicating information over the phone to maintain HIPAA compliance - do not relay lab results to patients without a review and sign off from the provider

urine urobilinogen values

0.1 to 1

international normalized ratio (INR) values

0.8 to 1.2

urine specific gravity values

1.005 to 1.030

prothrombin time (PT) values

10.4 to 15.7 seconds

urine pH value

4.5 to 8

fasting blood glucose (FBS) values

60 to 110 mg/dL

other CLLIA accreditation organizations

CLIA develops their standards and regulations with support from the Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS)

CLIA-waived regulations

The most common designation for ambulatory care and is the lowest level of complexity. These tests could be performed in the home environment or easily conducted in the medical office.

first morning specimen

The patient collects the first specimen of the morning in a clean container. This specimen is more concentrated and used for pregnancy testing, or when other analytes (protein, nitrites) need to be evaluated.

Moderate- and high-complexity regulations

These tests are considered non-waived. Labs performing these tests must have a CLIA certificate and undergo inspections to ensure standards are being met. These tests are typically performed in a reference or hospital laboratory

Catheterized collection urine specimen

This method is used when a sterile urine sample is needed or if patients are unable to provide a specimen on their own. It involves insertion of a sterile tube (catheter) through the urethra into the bladder. This procedure is performed by the provider or nurse, with the medical assistant prepping the patient and assisting.

24-hour urine specimen

This method uses a container with preservatives. The patient discards the first morning specimen and collects all specimens for the next 24 hours, including the first void of the second day. This type of collection is important in quantitative analysis of components such as protein when analyzing kidney function.

helicobacter pylori

a blood sample screens for H.pylori, which is the main cause of gastric ulcers

presbyopia

a gradual, age-related loss of the eyes' ability to focus actively on nearby objects

panel

a group of tests that are connected to one particular body system; profile

critical value

a laboratory result that is outside of the established reference range and presents potential health risks to the patient

hemoglobin

a machine is used to screen for the oxygen-carrying protein in whole blood, performed using capillary blood from a finger stick (capillary puncture)

chain of custody

a series of processes and procedures used to ensure security and accuracy

Ishihara test

a set of templates with patterns or numbers embedded within them to test for color blindness

qualitative

analysis that identifies quality or characteristics of components such as size, shape, and maturity of cells; typically reported as positive or negative

quantitative

analysis that identifies quantity or actual number counts

myopia

difficulty seeing things far away; nearsightedness

hyperopia

difficulty seeing things up close; farsightedness

Clinical Laboratory Improvement Amendments (CLIA)

federal standards that regulate laboratory testing, handling and processing

spun hematocrit

finger stick collection of blood in micro-capillary tubes is centrifuged and evaluated for the percentage of red blood cells

high-density lipoprotein (HDL) values

greater than 40 mg/dL

low-density lipoprotein (LDL) values

less than 130 mg/dL

triglycerides value

less than 150 mg/dL

total cholesterol values

less than 200 mg/dL

cholesterol testing

lipids are evaluated using capillary blood

erythrocyte sedimentation rate (ESR) values

males = 0 to 20 mm/hr females = 0 to 30 mm/hr

hemoglobin (Hgb) values

males = 13 to 18 g/dL females = 12 to 16 g/dL

hematocrit (Hct) values

males = 42% to 52% females = 36% to 48%

Matching specimens to the lab requisition form

many requisitions also include numbered identification stickers that should be adhered to all specimen containers; this is an added verification tool to ensure the specimen and requisition match

all other urine values

negative

controls

specific tools used in the laboratory with a known result, used to compare with results of a patient sample to confirm validity of the test and specimen

drug testing

substances can be detected in urine and blood samples

forced expiratory volume

the amount of air that can be forcibly exhaled

dipstick, tablet, or multistick urinalysis

the urinalysis is a screening tool for analytes that are excreted in the urine

hemoglobin A1c

this capillary blood test shows diabetes control over an approximate 3-month period

Nasal smear for influenza types A and B

this screening is a qualitative test for influenza antigens using a swab that is inserted into the nostril

mononucleosis screening

this screening tool tests for the presence of the Epstein-Barr virus in capillary blood

rapid streptococcus testing

throat swabs are obtained to screen for Group A streptococcus

pregnancy testing

urine is screened for the presence of human chorionic gonadotropin (hCG) antibodies

Point-of-care testing

various tests related to chemistry, immunology, microbiology, and hematology are identified as CLIA-waived and easily performed in physician office laboratories

blood glucose

whole blood is analyzed in a glucometer for a quantitative glucose level and is a screening test for diabetes, performed using capillary blood from a finger stick (capillary puncture)