F-QM-POST-002-A-V0 — Critical Value & Notifiable Disease Notification Log
Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.
Parent document: LAB-QM-POST-002 — Reporting of Critical Values and Notifiable Diseases Policy (parent is encoded in the form number)
Rendered in-browser from the project's Word file F-QM-POST-002-A-V0-critical-and-urgent-results-notification-log.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.
| Document # | F-QM-POST-002-A-V0 | Parent Document | LAB-QM-POST-002 — Reporting Critical Values Policy |
|---|
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Part 1 — Life-Threatening Critical (Panic) & Urgent Results Verbal Communication Log
Policy Mandate: Call the attending physician, ER physician, or charge nurse by phone as soon as the result is verified (within 15 minutes). Require the recipient to read back the patient full name, hospital number, test name, and critical value word for word before ending the call.
| Log No. | Date & Time Verified | Patient Full Name | Hospital No. (MRN) | Ward / ER / OPD | Test Name & Result (with Units) | Category: [C] Critical / [U] Urgent | Recipient Name & Role | Read-Back Confirmed? | Notification Time & Elapsed Min | Reporting MT Signature | Remarks / Attending MD Orders |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) | ||||||||
| 2 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) | ||||||||
| 3 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) | ||||||||
| 4 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) | ||||||||
| 5 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) | ||||||||
| 6 | [ ] C [ ] U | [ ] Yes [ ] No | HH:MM (___ min) |
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Part 2 — Unusual Laboratory Findings & Extreme Delta-Check Technical Escalation Record
Use this record when a finding differs sharply from prior data, an extreme delta check fails, or microscopic morphology is unexpectedly abnormal.
| Escalation Ref No. | Date & Time | Patient Full Name | Hospital No. (MRN) | Analyte Involved | Current Value | Previous Value & Date |
|---|---|---|---|---|---|---|
| ESC-YYYY-____ | YYYY-MM-DD HH:MM |
2.1 Technical Investigation Checklist
- [ ] Primary tube inspected: No hemolysis, lipemia, micro-clots, or IV-infusion hemodilution.
- [ ] Duplicate re-run performed on analyzer: Replicate Value: ____________ (Reproducibility confirmed: [ ] Yes [ ] No).
- [ ] Daily IQC status on run verified: In Control (±2 SD).
- [ ] Attending clinician consulted regarding recent blood transfusion, IV fluid therapy, or acute clinical shift.
2.2 Pathologist Technical Evaluation & Authorization
- Pathologist Finding: _________________________________________________________________________________
- Disposition: [ ] Authorized for release with interpretive comment [ ] Immediate specimen recollection ordered
- Pathologist Signature: ____________________________________ Date: YYYY-MM-DD
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Part 3 — Notifiable Infectious Disease Case Report & Surveillance Log (RA 11332)
Mandatory Reporting Protocol: Under Republic Act No. 11332, reactive findings for Dengue Duo, Hepatitis B (HBsAg), and Syphilis (RPR) require duplicate confirmatory repeat from the primary tube, clinician notification, reporting to Tarangnan RHU / Samar PHO, and 6-month frozen (-20°C) retention of the reactive sample.
| Case Ref # | Detection Date | Patient Full Name | Age / Sex | Residential Address (Barangay / Municipality) | Notifiable Disease / Examination | Test Method & Kit Lot No. | Initial Result | Confirmatory Repeat Result | IPC & Clinician Notified | RHU / PHO Transmittal No. | Freezer Storage Location (-20°C) | MT Initials |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | YYYY-MM-DD | Dengue Duo (NS1/IgM/IgG) | RDT / Lot: ________ | Reactive | Reactive | [ ] Yes | Ref: ________ | Box: ___ Pos: ___ | ||||
| 2 | YYYY-MM-DD | Hepatitis B (HBsAg) | RDT / Lot: ________ | Reactive | Reactive | [ ] Yes | Ref: ________ | Box: ___ Pos: ___ | ||||
| 3 | YYYY-MM-DD | Syphilis (RPR Flocculation) | RPR / Lot: ________ | Titer: 1:____ | Titer: 1:____ | [ ] Yes | Ref: ________ | Box: ___ Pos: ___ | ||||
| 4 | YYYY-MM-DD | [ ] Yes | Ref: ________ | Box: ___ Pos: ___ |
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Part 4 — Monthly Supervisory Review & Sign-Off
4.1 Medical Technologists
We confirm that 100% of critical values were communicated with read-back verification and all reactive notifiable conditions were confirmed by duplicate repeat.
| Technologist Name | PRC License Number | Date | Signature |
|---|---|---|---|
4.2 Chief Medical Technologist / Laboratory Quality Manager
- Critical Values TAT & Public Health Compliance: [ ] 100% notification verified [ ] Zero missed read-backs
- Signature: ________________________________________ Date: ____________________
4.3 Pathologist / Head of Laboratory
- Signature: ________________________________________ Date: ____________________