Point of Care Testing - Oxygen Saturation - AVOX
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.
Submit 1 POCT audit per month using the Point of Care Testing -Oxygen Saturation (AVOX) audit tool.
Updated 11-10-14
QUESTION
STANDARD
Has all testing performed in this patient care area been approved by the
Diagnostic Laboratories?
NOTE: All POCT Testing must be approved prior to implementation. If
WT.01.01.01, EP 4
WT.02.01.01, EP 1 & 2
1 unsure of area approval, contact Point of Care personnel.
Is there a designated trained trainer with documented current
2 competency?
WT.03.01.01, EP 2, 3, 4,
&6
LOCATION
POCT testing book
YES
Yes means you are NOT doing
any lab tests that you have not
been approved for. Approval
comes from the POCT
committee.
Manager/Educators Person trained by POCT in the
office training records last year to train other staff.
Emails
Has the patient care area notified the Laboratory (POC) of changes in
3 the list of testing personnel?
Are current documentation records for training and competency
4 records readily accessible?
Can staff produce a copy of the current procedure (hard copy or
5 online)?
Has the manager performed a documented review of patient chart
documentation to verify that patient results are properly documented
6 per procedure? (Review of Manager log)
7 Are all reagents, controls, and kits stored at proper temperature?
WT.02.01.01, EP 1
WT.02.01.01, EP's 1 & 2
WT.03.01.01, EP 3
WT.01.01.01, EP 5
Manager/Educators Orientation records must be
office training records kept permanently, annual
recertifications must be kept for
2 years.
Computer/POCT
Can find procedure
manual
POCT testing book
Manager has done quarterly
chart audits.
WT.05.01.01, EP 4
Where supplies are
kept
WT.01.01.01, EP 2 & 6
Where supplies are
kept
Are all reagents, controls, and kit boxes labeled with an appropriate
8 expiration date and initials?
Have sent POCT updates when
someone leaves work area or
new staff comes to work area.
WT.01.01.01, EP 2
Controls are kept at RT for 12
months or refrigerated,
cartridges are kept at RT
Controls are labeled with 1 hour
altered exp and initials when
reconstitued. Labeled with 12
month altered date once
removed from refrigerator
Have QC documentation logs been completed as required by
9 procedure?
10 Have corrective actions been documented?
11 Are all QC records kept for a minimum of 2 years?
QC is run weekly, on all new lots
or shipments of cartridges,
Optical QC is done daily
Problem log
QC Log Book
QC Log Book
If had problem it is noted
Yes, if you have your records
There is a signature to indicate
reviewed weekly.
patient log book or
Edocs
POCT testing book
Are they accessible for last 2
years
All CAP proficiency samples have
been run and results returned to
POCT
Optical filters are checked
WT.04.01.01, EP 1 & 2
WT.05.01.01, EP 1
WT.01.01.01, EP 2
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?
15 Are maintenance records available and complete?
QC Log Book
WT.03.01.01, EP 1, 4, & 5
WT.05.01.01, EP 4 & 5
Maintenance Log