LSUHSC Point-of-Care Testing Services Forms
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RN Performing Urine Pregnancy Test
  
Documentation is extremely important to quality patient care. Authorization to perform testing in an area and by an individual is necessary to achieve accreditation requirements and insure the highest level of care for our patients. Though electronic documentation is available for some test procedures, others require that manual quality control and patient accession logs be maintained. The following are common forms to Point-of-Care Testing. Should you not find or need assistance in locating the appropriate form to utilize, please contact our POC Labortory Staff for assistance at 318-675-7951 or 318-675-5572.
         
Authorization Forms Occult Forms Urine Automated Forms
pH Forms Urine Dipstick Forms
Clinitest Forms
UPT Forms
Employee Forms Strep Forms
Glucose Forms
 

Authorization Form

    
  Request Approval For Area To Perform Point-of-Care Testing
   
Used to request authorization to perform point-of-care testing in an area by POC certified personnel. This form must be complete and forwarded to the POC supervisor who will present the request to the POC committee. The POC committee has final authority to accept or reject the request for testing in an area based on need, financial constraints, and outcomes.
 
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Employee Forms        
Point-of-Care Competency Form Example
 
Competency assessment is performed on new personnel initially, at six months, and annually thereafter by supervisor or trainer for the area. Use area specific competency form. For additional information, please contact the POC area of the Clinical Laboratory at 675-7951 or 675-5572.
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Clinitest Forms
  Fecal / Urine Accession Log
   
This form is utilized when performing test on either fecal or urine specimens to record patient information utilizing patient labels. A separate log should exist for each specimen type (fecal vs. urine).

Fecal / Urine Quality Control Log
This form is utilized when performing test on either fecal or urine specimens to record two levels of quality control. A separate log should exist for each specimen type (fecal vs. urine).
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Glucose Forms
  Glucose Notification of Errors Form
   
The glucose notification form is utilized by testing personnel to document errors that require correction during the testing process. The information should be completed and then faxed to the POC area of the Clinical Laboratory at 675-8544.
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Occult Forms
Fecal - Hemoccult Accession and Quality Control Log
 
This form is utilized to document test performed on a patient as well as quality control. Patient labels are utilized initially to create a patient log. Additionally, policy states that placing the label on the log indicates that the positive and negative control monitor embedded in the card performed as expected. This label, therefore, serves also as documentation that quality control was successfully performed on each test card.
Gastric - Gastroccult Accession and Quality Control Log
 
This form is utilized to document test performed on a patient as well as quality control. Patient labels are utilized initially to create a patient log. Additionally, policy states that placing the label on the log indicates that the positive and negative control monitor embedded in the card performed as expected. This label, therefore, serves also as documentation that quality control was successfully performed on each test card.
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pH - Gastric Forms
Gastric pH Accession Log
 
This form is utilized when performing test on gastric specimens to record patient information utilizing patient labels.
Gastric pH Quality Control Log
 
This form is utilized when performing test on gastric specimens to record two levels of quality control.
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Strep A Screen Forms  
Strep A Screen Accession and Quality Control Form
 
This form is utilized to document test performed on a patient as well as the quality control. Patient labels are utilized to create a patient log. The top and bottom of the form are for recording lot numbers of kits as well as controls.
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Urine Automated Forms
Automated Urine Accession Log
 
This form is utilized when performing test on automated urine specimens to record patient information utilizing patient labels.
Automated Urine Calibration Log
 
This form is utilized when calibration is performed on the automated urine analyzer.
Automated Urine Quality Control Log
 
This form is utilized when performing tests on urine specimens to record two levels of quality control.
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Urine Dipstick Forms
Ketodiastix Accession Log
 
This form is utilized when performing dipstick test on urine to record patient information utilizing patient labels.
Ketodiastix Quality Control Log
 
This form is utilized when performing dipstick tests on urine specimens to record two levels of quality control.
Multistix Accession Log
This form is utilized when performing dipstick test on urine to record patient information utilizing patient labels.
Multistix Quality Control Log
This form is utilized when performing dipstick tests on urine specimens to record two levels of quality control.
Uristix Accession Log
 
This form is utilized when performing dipstick test on urine to record patient information utilizing patient labels.
Uristix Quality Control Log
 
This form is utilized when performing dipstick tests on urine specimens to record two levels of quality control.
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Urine Pregnancy Test Forms
UPT Accession and Quality Control Log Combined
 
This form is utilized when performing pregnancy test on urine to record patient information utilizing patient labels and to record at least two levels of quality control.
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