1of 2
WAIVED TESTING PROTOCOL
Policy Number: CLIN. 43
Goal:
Waived tests are performed to assist the provider in determining
diagnoses, in screening for disease, and following prescribed therapy to
determine effectiveness. Waived tests are performed according to
established standards or instructions by competent staff.
Scope:
This protocol applies to all HDI medical sites.
Responsibility:
Laboratory, nursing, provider, WIC staff
Protocol:
1. Waived testing is performed only by staff with demonstrated competency in the
specific waived test, which is being utilized. Competency is demonstrated as
defined in the orientation and annual performance appraisal documents.
2. The following waived tests are performed at HDI medical sites:
Waived Test
Site
Urinalysis using Clinitek 50 Analyzer
All Primary Care sites
Urinalysis using Multistix or Uristix
Janes St. OB Dept., HDI OB/GYN and Midwifery
Services, Migrant, Wolverine
All Primary Care sites, Wolverine
Blood glucose using McKesson
TrueTrack
Hemoglobin using Hemocue
All Primary Care sites
McKesson Medi-Lab Performance hCG
Urine Cassette
MeKesson Medi-Lab Performance Strep
A Test Cassette
Poly Stat Mono Test and McKesson
Medi-Lab Performance Infectious
Mononucleosis Test
PT/INR using HemoSense
All sites (excluding Wolverine)
Provider performed microscopy
All sites (excluding Wolverine)
Fecal Occult Blood test cards
All sites (excluding Wolverine)
All Primary Care sites
All Primary Care sites
Janes St., Bayside
U:\comonwp\A-HDI Policies\/Clinical\Waived Testing Protocol.doc
2 of 2
DCA 2000 Analyzer for HbA1c
Janes St., Ruffin, Bayside, DRG, Imlay City, Bridgeport
pH paper, Nitrozene paper
Stat Crit - Hematocrit testing
Janes St. OB/GYN Dept., HDI OB/GYN and Midwifery
Services
HDI OB/GYN and Midwifery Services
Accuchek InstantPlus - Cholesterol test
Bayside, Migrant
3. Each test is performed by following the manufacturers’ instructions.
4. Universal precautions are followed at all time.
5. Waived testing instruments are tested per quality control guidelines and
according to the preventive maintenance schedule.
6. Waived test results are documented in the patient chart on the progress note
and/or in-house laboratory test result form.
7. Each waived test result is assessed by the provider. (Exception - Urine
Pregnancy tests done at Bridgeport, and Bayside and in the OB-GYN
Department at Janes Street. The nursing staff perform these tests and
results are given to the patient with no provider assessment.) Waived test
results are used in the diagnostic assessment of patients as follows:

Hemoglobin/Hematocrit- screening and following therapy

Urinalysis - screening, diagnosis, and following therapy

Glucose - screening and following therapy

Strep A - diagnosis

Pregnancy test - diagnosis and following therapy

Mono - diagnosis

Microscopy - diagnosis

PT/INR - following therapy

Cholesterol - screening

HbA1c - following therapy

Fecal Occult Blood - screening

pH/Nitrozene paper - diagnosis
8. CLIA (Clinical Laboratory Improvement Act) certification is maintained and
posted at each site in the “laboratory” area.
Reviewed By:
Quality Improvement Committee
Effective Date:
November 21, 2000
Revision Date:
May 13, 2003; March 17, 2006
Review Date:
March 17, 2008
Approval:
________________________________________
Medical Director
U:\comonwp\A-HDI Policies\Clinical\Waived Testing Protocol.doc