Documenting Physician Review of Abnormal Results

International accreditation standards require physician review of certain abnormal results such as transfusion reaction and antibody workups.  This post describes how such review is documented in Medinfo Hematos IIG dedicated blood bank software.

In general there are three main ways to do this:

  1. User ID associated with each transaction
  2. Comments against results, analysis, or globally
  3. Physician direct entry of results (e.g. transfusion reactions)

This applies to all modules of Medinfo, including donor and patient.

User ID:

The system records the User ID of the staff member who performed an action—this includes the authorized transfusion physicians  This covers everything in the system, donor or patient.  However, it may require a specific query by user ID to list all of that person’s transactions.  This is not easy to show an external assessor/inspector unless the query is performed in advance.

Comments:

For those cases requiring review, comments can be placed with the results, which will be visible to anyone viewing that record.  Additionally, internal comments can be added to the analysis and globally within the record.

Direct Physician Entry of Results and Interpretations:

For transfusion reaction workups, physicians may directly enter their interpretations and results in the system.

Subsequent posts will show how comments and direct physician entry of results are performed in the system.