Point of Care Testing - Activated Clotting Time (ACT)
Data Definition Tool
This audit is to be completed by the manager or designee on a monthly basis. POCT audits are due by the last day of the month.
Instructions: Indicate Yes, No, NA (Not Applicable) for each question below.
Updated 8-8-14
Submit 1 POCT audit per month using the Point of Care Testing -Activated Clotting Time (ACT) audit tool.
QUESTION
1
2
3
4
5
6
7
8
9
10
STANDARD
LOCATION
POCT testing book
YES
Yes means you are NOT doing
Has all testing performed in this patient care area been approved by the
any lab tests that you have not
Diagnostic Laboratories?
been approved for. Approval
NOTE: All POCT Testing must be approved prior to implementation. If
WT.01.01.01, EP 4
comes from the POCT
unsure of area approval, contact Point of Care personnel.
WT.02.01.01, EP 1 & 2
committee.
Manager/Educators Person trained by POCT in the
Is there a designated trained trainer with documented current
WT.03.01.01, EP 2, 3, 4, office training records last year to train other staff.
competency?
&6
Emails
Have sent POCT updates when
someone leaves work area or
Has the patient care area notified the Laboratory (POC) of changes in
new staff come to work area.
the list of testing personnel?
WT.02.01.01, EP 1
Manager/Educators Orientation records must be
office training records kept permanently, annual
Are current documentation records for training and competency
WT.02.01.01, EP's 1 & 2
recertifications must be kept for
records readily accessible?
WT.03.01.01, EP 3
2 years.
Can staff produce a copy of the current procedure (hard copy or
Computer/POCT
Can find procedure
online)?
WT.01.01.01, EP 5
manual
Has the manager performed a documented review of patient chart
POCT testing book
Manager has done quarterly
documentation to verify that patient results are properly documented
chart audits.
per procedure? (Review of Manager log)
WT.05.01.01, EP 4
Where supplies are
Unused supplies
kept
refrigerated,supplies in use at RT
Are all reagents, controls, and kits stored at proper temperature?
WT.01.01.01, EP 2 & 6
Where supplies are
When out of fridge must have
Are all reagents, controls, and kit boxes labeled with an appropriate
kept
altered expiration and initials
expiration date and initials
WT.01.01.01, EP 2
QC Log
QC must be run monthly and for
Have QC documentation logs been completed as required by
WT.04.01.01, EP 1 & 2 Book/downloaded
each new lot number and
procedure?
WT.05.01.01, EP 1
document
shipment of cuvettes
Problem
log
If had problem it is noted
Have corrective actions been documented?
WT.01.01.01, EP 2
11 Are all QC records kept for a minimum of 2 years?
WT.05.01.01, EP 5
WT.01.01.01, EP 2
Has the manager or designee performed a weekly review and sign off of WT.04.01.01, EP 1 & 2
WT.05.01.01, EP 1
12 quality control and other test specific required documentation?
Is all original documentation of patient results retained for a minimum
13 of 2 years?
WT.05.01.01, EP 5
Where appropriate, has proficiency testing been performed per
14 procedure, reported within deadlines?
WT.03.01.01, EP 5 & 6
QC Log Book
QC Log
Book/downloaded
document
Yes, if you have your records
There is a signature to indicate
reviewed weekly.
Instrument
printouts/Log book
POCT testing book
Are they accessible for last 2
years
All CAP proficiency samples have
been run and results returned to
POCT