Laboratory Policies
Policy #1/ version #04
Effective Date: 11/1/13
Laboratory Policies
Assigned Duties
Duties are assigned by the Laboratory Supervisor. However, they
are subject to change during the day since staffing is limited and
flexibility is needed at times to get the daily work accomplished.
Laboratory Test
Performed at CCHD
(In-House Tests)
Culture, Presumptive for Gonorrhea
Glucose (HemoCue® 201)
Glucose (HemoCue® 201)
Gram Stain (Male Urethral Smears for Gonorrhea)
Hemoglobin (HemoCue® 201)
Urine Chemical Analysis (Clinitek 50)
Urine Pregnancy Test
Wet Mount (Vaginal)
Amine Test
Urine (Microscopic)
Ordering of Test
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Specimen Handling
Collections
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No oral request will for testing will be accepted at CCHD
Laboratory.
Standing orders for clinics (see appendix).
Outside Doctors orders for lab test will be accepted at CCHD
Laboratory with the proper documentation.
Refer to collections procedures in the CCHD Laboratory Procedure
Manual.
CCHD Laboratory does not accept outside collected specimens for
in-house testing.
Outside specimens collected by home health nurses are accepted.
These specimens are prepared by CCHD Laboratory personnel and
picked up by the LabCorp courier daily.
All Laboratory specimens will be transported to and from the
CCHD Laboratory in Biohazard transport bags. Specimens
transported to the CCHD Laboratory will be dropped off in
designated areas marked within the Laboratory.
Reference Specimens
Specimens for referred tests must be labeled with patient’s legal
name, date of birth, test to be performed, and date of specimen
collection. All information on specimen must match the
accompanying requisition.
Columbus County Health Department Laboratory, Whiteville NC 28472
Laboratory Policies
Policy #1/ version #04
Recording of Results
Effective Date: 11/1/13
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Report Handling
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All results of in-house tests (including repeats) are recorded on the
lab form and entered into the EMR. The lab forms are retained in
the lab for five years.
The lab will keep a log of the gonorrhea cultures on file for two
years.
Red ink will be used to record on the patient log the date results of
specimens sent to reference laboratories were received back in
CCHD Laboratory.
If the time of performing an in-house test is more than 15 minutes
from the time of specimen collection, the time of testing must be
indicated on the lab form.
The initials of the person collecting and/or testing a specimen must
be recorded on the lab form.
Results of in-house tests are communicated to Nursing Staff via
CureMD.
Laboratory personnel, using red ink as directed above in
“Recording of Results”, will write the dates results for referred test
are received on the Laboratory Log.
All reports of referred tests will be stamped with the date received
and scanned into the patient record.
Errors in Documentation
When there is an error made on a lab document, draw a single line
through the incorrect information and initial. Do not erase, use
white-out or pencil over the error.
Panic values
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Normal Values
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Listed in test procedures and appendix.
Panic levels are repeated, circled on the requisition, and initialed
by the person performing the test.
Upon completion of the panic value repeat, report orally to the
clinic nurse or clinician.
Document in comments the date, time, and clinic nurse or clinician
that took the oral panic value report.
In-house
o Listed in CureMD.
o Listed in the appendix.
Reference Lab
o Listed on test report.
Columbus County Health Department Laboratory, Whiteville NC 28472
Laboratory Policies
Policy #1/ version #04
Effective Date: 11/1/13
Proficiency Testing
Columbus County Health Department participates in the North
Carolina County Health Department Area C CLIA certificate.
Proficiency Testing is rotated amount the participating counties. If
Columbus is chosen, instructions in the proficiency testing policy
will be followed.
Competency Assessment
The Columbus County Health Department Laboratory personnel
participate in the Competency Assessment program offered by the
NCSLPH.
Continuing Education For Testing Personnel
 Inservice Training: See Columbus County Health Department
Personnel Policies.
 Other: Required to attend 6 hours of lab-related continuing
education per year (APPLIES TO PERSONNEL PERFORMING
MODERATE COMPLEXITY LABORATORY TESTS).
Personnel of Columbus County Health Department performing
waived-only testing need only 3 hours of lab-related continuing
education per year.
Quality Control
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Supplies
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Levels and Frequency (See appendix)
The CCHD Laboratory will follow the manufacture’s instructions
when running control specimens.
Only assayed control material meeting the manufacture’s
specifications will be used for moderate complexity test.
Tolerance levels for assayed controls are verified before new lot
numbers of controls are used.
Control specimens will be treated the same as patient specimens.
All control values must be within range before any patient results
are released.
Control values are documented on appropriate logs and kept on
record for two years.
CCHD Laboratory will use +/- 2SD from mean for tolerance levels
of controls.
All out of range controls will undergo troubleshooting (see
appendix).
All corrective action taken while troubleshooting will be
documented and retained on record for two years.
All supplies must be labeled with a received date.
All supplies will be stored according to manufacture instructions.
Columbus County Health Department Laboratory, Whiteville NC 28472
Laboratory Policies
Policy #1/ version #04
Effective Date: 11/1/13
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Any unusual conditions must be noted on the item upon receipt
and, where applicable, noted on the Quality Control sheet for that
product.
Each time a kit or bottle of reagent is opened, that date and initials
of the person opening it must be written on the container. If the
expiration date after opening the container is different from the
manufacture’s expiration date, the new expiration date must also
be written on the container.
All manufacture’s procedural instructions will be followed.
A correlation study will be completed prior to the implementation
of a new instrumentation or test kit. See CCHD Laboratory
Correlation Policy located in the Correlation Study book in the
main laboratory.
Free Standing Clinics
See CCHD Laboratory Policy For Freestanding Clinics located in
the CCHD Laboratory Off Site Policy & Procedure Manual in the
main Laboratory.
Reference Laboratories
AFP Screening Laboratory
216 MacNider Bldg. CB# 7570
Department of Obstetrics & Gynecology
University of North Carolina
Chapel Hill, N.C. 27599-7570
CLIA # 34D0655124
Routine test sent: MSAFP (Maternal Serum Alpha-Feto Protein)
North Carolina State Laboratory of Public Health
4312 District Drive
Raleigh, NC 27607
Postal Address: P.O. Box 28047
Raleigh, NC 27611-8047
Routine tests sent:
CLIA# 34DO692393
Gonorrhea Confirmation
Hemoglobin Electrophoresis (Sickle Cell Screen)
Hepatitis Status HIV
Lead Screening
Newborn Screening
Parasitology
Thin Prep
Rubella Immune Status
Stool Cultures
Syphilis Serology (TRUST)
Thyroid Profile
Tuberculosis (TB) Cultures and Acid Fast Staining
Columbus County Health Department Laboratory, Whiteville NC 28472
Laboratory Policies
Policy #1/ version #04
Effective Date: 11/1/13
Viral Cultures – Herpes
Chlamydia Antigen
Consult the NCSLPH website if other tests are needed.
LabCorp
1447 York Court
Burlington, NC 27215
Routine Test sent:
CLIA # 34D0655059
ABO Blood Typing and Antibody Screening
Complete Metabolic Panel (CMP)
Lipid Panel
CBC
GC cultures (Thursday, Friday, and Holidays)
Urine Cultures
Group B Strep Cultures
Beta hCG Quantitive
Culture, Throat, Comprehensive
T3
T4
Consult LabCorp Directory of Services Reference Guide on
non-routine test.
Columbus County Health Department Laboratory, Whiteville NC 28472