Free Essay

Registered Nurse

In: Business and Management

Submitted By lauraannrn
Words 599
Pages 3
Procedure Number: SA 7.12.2013
Classification:
Substance Abuse
Subject: UA testing
Effective Date: 10.15.2013
Revision Date:

Purpose: To ensure proper process of a urine analysis for drug screening. This procedure will assist staff to maintain applicable compliance. 1. Client signs in: All clients must sign in. 2.1. UA Technician: will 2.2.1. Check client into and out of EPM 2.2.2. Order appropriate PMS standing order (CA-EHR 18 rev 7.30.2012) labs in the EHR through ORDERS 2. Obtaining Sample: Per protocol established with 11th District Drug Court. 3.2. UA Technician: will 3.3.3. Have client sign, initial and place date of birth on a label 3.3.4. Place signature label on the UA sheet 3.3.5. Place initial label on the specimen cup – date of birth is also written on the cup 3.3.6. Obtain specimen 3.3.7. Temperature in noted on the UA sheet. 3.3.8.1. If Client is unable to produce a sample the Technician will note the time on the UA sheet and a Non-Production Form is filled out and scanned into EHR.

3. Documentation Of Urine Analysis: All UA’s will have a PMS progress note documented in EHR. 4.3. UA Technician: will ensure that 4.4.8. Negative results are recorded on the UA sheet. 4.4.9. Positive results are recorded on the UA sheet and 4.4.10.2. The client must sign a positive UA form which will be scanned into the EHR. 4.4.10.3. The clients Probation officer (PO) and or Case Manger is contacted by phone and documented on the UA sheet and on the PMS Progress note. 4.4.10.4. PO/CM may request the specimen be sent to a lab for confirmation of results. 4.4.10.5.1. Specimen cup is packaged and mailed per guidelines. Documentation is noted on the Positive UA form, UA Sheet and PMS Specialty Progress Note 4.4.10.5.2. Results from the lab are received –scanned into EHR and the PO/CM are notified. 4.4. EHR Documentation. 4.5.10. All Clients will have an encounter through PMS BH home 4.5.11. Visit type-URINE DRUG SCREEN 4.5.12. Reason –UA COURT ORDERED 4.5.13.5. Select Order – from menu on left. 4.5.13.6. Select Office Services – then IN OFFICE LABS 4.5.13.7. Click – correct Assessment (should match reason for the drug screen) 4.5.13.8. Select which tests you will be performing, Drug Screen and/or creatinine 4.5.13.9. Click PLACE ORDER- then OK 4.5.13.10. Left click to highlight then Right click in the order box to open order 4.5.13.11. Manage office Lab order Select Obtained/Placed and interpretation complete 4.5.13.12. Enter Results—Click DTL, enter temp, and + or – for each of the substances you tested for. 4.5.13.13. Enter H0048 and click submit to Superbill – on each tab, you will see the red confirmation that CPT was submitted. 4.5.13.14. Click Save and Close 4.5.13. Enter into Specialty Progress Note (on the Left side Menu) 4.5.14.15. Enter time person begins urine collection – end when results are read. 4.5.14.16. Enter patient is present to have drug screen- in specialty progress note- 4.5.14.17. In the COMMENT box type Results and any other pertinent information 4.5.14.18. Final – Click PROGRESS NOTE DOCUMENT…...

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