Tarangnan Community Hospital — Clinical Laboratory
Records Done Right
Create it at the time. Correct it so the original can still be read. Make it traceable to you.
INFOGRAPHIC IG-15 Source: LAB-QM-007 Version V0 — DRAFT
1 · Create it right — §5.3
Create the record at the time the activity is performed, or as soon as practicable after.
Never complete a record in advance, and never reconstruct one unless authorized and documented.
Entries must be complete, accurate, legible and readily understandable. Leave no blank field where information is required.
Every record identifies: title, date, time, process, equipment ID, specimen ID, personnel ID, location, and its unique record number.
2 · Make it traceable — §5.5
The system must show who performed a critical step — and when, where and why.
Specimen labels carry the collector's initials + staff/badge ID.
Worksheets record who performed the procedure and the times received and completed.
LIS entries are attributable to the staff member who made them — the name/ID of whoever entered a result must be identifiable.
Five record families (§5.2): Quality · Technical · Operational · Personnel · Administrative — all controlled under this policy.
3 · Correct it right — §5.4 (paper records)
1
With a dark ink pen, draw a single line through the wrong entry — it must stay fully legible.
2
Write the correct entry next to, above, or below the wrong one.
3
Put your initials near the correction.
4
Put the date near your initials. (State the reason when appropriate.)
5
Return the corrected record to its proper location. Correct errors as soon as they are discovered.
The policy's own example:NegativePositive RC 15-06-2026
Never
Obliterate, write over, tape over, or hide an entry with correction fluid/tape. Never discard the original record. Anything that makes the original unreadable is prohibited.
Released reports are different: §5.4 covers paper records only. Correcting a released patient report follows LAB-QM-POST-001.
Store & dispose (§5.8, §5.10–§5.12): protect records from fire, water, humidity, pests and unauthorized removal; access for authorized personnel only. Retention periods are owned by LAB-QM-POST-004 (see IG-13). Dispose only after the period ends and with the CMT/LQM's written authorization on F-QM-002-A-V0 — by secure shredding, incineration, or permanent electronic deletion.
