F-QM-POST-003-A-V0 — STAT / TAT Exception and Verbal/Telephone Order 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-003 — Turnaround Time and STAT Testing Policy (parent is encoded in the form number)
Rendered in-browser from the project's Word file F-QM-POST-003-A-V0-stat-and-tat-exception-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-003-A-V0 | Parent Document | LAB-QM-POST-003 — Turnaround Time and STAT Testing Policy |
|---|
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Part 1 — STAT Test Receiving & Turnaround Time Monitoring Register
Benchmark Targets per LAB-QM-POST-003: STAT Blood Typing / Rapid Tests <= 30 min; STAT CBC / Urinalysis <= 45 min; STAT Clinical Chemistry <= 60 min.
| Date | Accession No. | Patient Full Name | Ward / ER | Test(s) Ordered | Time Received | Time Released | Actual TAT (min) | Target TAT (min) | Status: [M] Met / [D] Delay | Testing MT Initials | Delay Incident Ref # |
|---|---|---|---|---|---|---|---|---|---|---|---|
| HH:MM | HH:MM | [ ] M [ ] D | |||||||||
| HH:MM | HH:MM | [ ] M [ ] D | |||||||||
| HH:MM | HH:MM | [ ] M [ ] D | |||||||||
| HH:MM | HH:MM | [ ] M [ ] D | |||||||||
| HH:MM | HH:MM | [ ] M [ ] D | |||||||||
| HH:MM | HH:MM | [ ] M [ ] D |
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Part 2 — Turnaround Time Delay & Technical Exception Incident Record
Start this record when a STAT examination exceeds the established target TAT by > 15 minutes or a routine batch is delayed by > 2 hours.
| Delay Ref No. | Date & Time Identified | Patient Full Name & HRN | Affected Section | Primary Analyte |
|---|---|---|---|---|
| DEL-YYYY-____ | YYYY-MM-DD HH:MM |
2.1 Root Cause of Analytical Delay
- [ ] Analyzer Malfunction / Hardware Fault: Instrument failure during run; switch to backup method or engineer dispatched.
- [ ] Analytical QC Failure / Calibration Shift: Westgard rule violation; recalibration and repeat required prior to release.
- [ ] Pre-Analytical Specimen Quality Issue: Hemolyzed, clotted, or insufficient specimen requiring recollection.
- [ ] Computer / LIS / Printer Downtime: Manual result calculation and handwritten backup slip issued per downtime policy.
- [ ] Complex Morphological / Pathologist Consultation: Marked atypical cells or severe delta failure requiring review.
2.2 Immediate Action & Clinician Notification
- Requesting physician / ward informed of delay: [ ] Yes Time Notified: HH:MM
- Contact Person: ____________________________________ Revised Estimated Release Time: HH:MM
- Corrective Action Implemented: ________________________________________________________________________
- Investigated by: ________________________________, RMT Noted by (Pathologist): ____________________
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Part 3 — Verbal and Telephone Orders / Add-On Test Record
Policy Mandate: Document all verbal/telephonic orders and add-on requests. The receiving technologist must read back two patient identifiers (Full Name, HRN) and requested tests. A signed written requisition must follow within 48 hours.
| Order Date & Time | Patient Full Name | Hospital No. (MRN) | Ward / ER | Requesting Physician & Caller Name | Test(s) Requested | Order Type: [N] New / [A] Add-On | Read-Back Verified? | Residual Volume & Stability OK? | Written Order Received within 48h? | Receiving MT Signature |
|---|---|---|---|---|---|---|---|---|---|---|
| YYYY-MM-DD HH:MM | Dr. ________ / ________ | [ ] N [ ] A | [ ] Yes [ ] No | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | |||||
| YYYY-MM-DD HH:MM | Dr. ________ / ________ | [ ] N [ ] A | [ ] Yes [ ] No | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | |||||
| YYYY-MM-DD HH:MM | Dr. ________ / ________ | [ ] N [ ] A | [ ] Yes [ ] No | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | |||||
| YYYY-MM-DD HH:MM | Dr. ________ / ________ | [ ] N [ ] A | [ ] Yes [ ] No | [ ] Yes [ ] NA | [ ] Yes [ ] Pending |
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Part 4 — Monthly Review and Pathologist Endorsement
4.1 Medical Technologists
We confirm that STAT examinations were prioritized upon receipt and all verbal orders were confirmed with immediate read-back.
| Technologist Name | PRC License Number | Date | Signature |
|---|---|---|---|
4.2 Chief Medical Technologist / Laboratory Quality Manager
- STAT TAT Compliance Rate: (Met Targets / Total STAT Runs) × 100 = ______ % (Target: >= 90%)
- Verbal Orders Written Authentication Status: [ ] 100% reconciled within 48 hours [ ] Non-receipt escalated
- Signature: ________________________________________ Date: ____________________
4.3 Pathologist / Head of Laboratory
- Signature: ________________________________________ Date: ____________________