Policy Name:
Laboratory & Diagnostic Tests
Approved Date:
Section:
Laboratory & Diagnostic Tests
Review Date:
Policy #:
Revised Date:
Purpose:
To establish protocol for waived testing
POLICY
Pre-procedure diagnostic testing is at the discretion of the admitting surgeon, as appropriate to the
patient’s clinical status and the planned procedure. The preoperative nursing staff is responsible for
ensuring that all pre-procedure testing has been performed as ordered and the results are documented in
the medical record.
Human Chorionic Gonadotropin (HCG) Testing
To determine the level of HCG in the urine prior to any administration of anesthetics and/or surgical
procedures in order to prevent harm to any potential pregnancies.
All females of childbearing age scheduled for the administration of anesthetics and/or surgical procedures
must have a HCG performed in the preoperative area by a Registered Nurse and the results must be
verified by the Preoperative Registered Nurse. In addition to verification by the Preoperative Registered
Nurse, the Circulating Registered Nurse must also verify that the results are documented prior to transfer
to the Operating Room. Any patient with a positive HCG according to the manufactures instructions
procedure will be canceled, unless the patient, physician, and anesthesiologist have come to an agreement
for use of localized anesthetics and no harm will be made to any viable pregnancy. Exemptions from the
HCG include, Post-menopausal women who have not have had a menstrual cycle from greater than five
(5) years and women who have had a complete hysterectomy.
Refusal of the Test
The patient has the right to refuse the pregnancy test. If the patient chooses not to have the test, they must
sign a Pre-Operative Pregnancy Testing Refusal.
Procedure

Collection of the urine sample will be completed in the patient bathroom and the sample will be
promptly obtained by the R.N.

The sample will be identified by the patient’s number.

The HCG will be performed according to the manufactures instructions.

The preoperative R.N. performing the test will verify results according to the manufactures
instructions.

The circulating R.N. will verify that the results are documented on the preoperative flow sheet
prior to transfer to the Operating Room.
Blood Glucose Testing
Performing a blood test:

Follow the instructions outlined in the manufacturer's user's manual.

Record the results in the patients chart and report them to physician.
Quality control testing
Regular quality control testing of the glucometer is to be performed daily before use, according to the
manufacturer's recommendations and recorded in a glucometer testing log book.
If the results of the quality control test are not within the acceptable range outlined by the manufacturer,
repeat the test and refer to the user's manual for further instructions.
Laboratory and X-Ray Results
When laboratory and x-ray results are received, they are placed in patient surgical chart. The physician
scheduling the procedure will review the results before the procedure.
Pathology Reports
Pathology reports are reviewed by the physician performing the procedure. He/she initials that he/she has
reviewed them. The path result is logged on the tissue log. If any discrepancies are found, they are
forwarded to the Tissue Committee for review.