Requisition Completion Audit

An internal audit was performed by ASQ Certified Auditors to assess the level of compliance in meeting requirements of JCAHO and CAP (College of American Pathologists) for the completion of test requisitions.  Findings of this audit showed that required information was often omitted from the requisition.  The following information is REQUIRED on all requisitions:

   1. Patient’s full name, hospital number and birthdate clearly visible
   2. Nursing station or clinic
   3. Time and date sample collected/drawn
   4. Ordering physician’s name and code

 The information missing most frequently is: 

     patient birthdate (if requisition hand-written)
     nursing station or clinic
     time and date sample collected (if addressograph used and requisition not fully inserted) 

The Department of Pathology needs assistance from all areas to improve compliance with requisition completion.  Accountability for this task rests with the ordering areas.  Audits will be performed on a regular basis so that areas not in compliance with this requirement can be identified/notified.

Thank you for your cooperation and attention to this important requirement.  If you have any questions, please feel free to contact Kathleen Eyres at 6-8620.