LEARNING OBJECTIVE: Recall clinical laboratory administrative procedures and ethics policy.
The medical technologist is not expected to make diagnoses from test findings or to institute definitive treatment based upon them. However, with the availability of modern communications facilities, having the results of these tests available will greatly assist the technologist in giving a clearer clinical picture to the supporting physician.
Needless to say, accuracy, neatness, and attention to detail are essential to obtain optimum test results. Remember also that these tests are only aids to diagnosis. Many other clinical factors must be taken into consideration before treatment may be started.
ADMINISTRATIVE PROCEDURES AND RESPONSIBILITIES
The ability to perform clinical laboratory tests is a commendable attribute of the medical technologist. However, the entire testing effort could be wasted if proper recording and filing practices are ignored and the test results go astray. As a member of the medical team, it is your responsibility to make sure that established administrative procedures are followed with regard to accurate patient and specimen identification. It is your further responsibility to ensure laboratory reports in your department are handled and filed properly.
Since the test results are a part of the patientís clinical picture, their precision and accuracy are vital. Test results have a vital bearing upon the patientís immediate and future medical history. They are, therefore, made part of the patientís health record (inpatient or outpatient). Laboratory reports of inpatients are placed in the inpatient health record, while laboratory reports of outpatients are placed in the outpatient health record.
ETHICS AND GOOD PRACTICES IN THE LABORATORY
The nature of laboratory tests and their results must be treated as a confidential matter between the patient, the healthcare provider, and the performing technician. Chapter 16 of the MANMED outlines the Navyís ethics policy with regard to disclosure of the contents of a patientís medical record, including lab reports. It is good practice to prevent unauthorized access to these reports, to leave interpretation of the test results to the attending provider, and to refrain from discussing the results with the patient.