Specialty records

When a visit includes a specimen, the team can record its type, collection date and accession number against the encounter. The specimen status distinguishes ordered, collected, received, tested and rejected work. A pharmacy dispensation records medication, lot number, quantity, unit, encounter and authorizing person. Those fields connect specialty evidence to the care episode the Clinical Reviewer examines.

• Specimen trail. Type, collection date, accession number and status stay with the encounter.
• Dispensation detail. Medication, lot, quantity, unit and authorizer identify what was recorded.
• Case review. The reviewer can read both kinds of evidence alongside the encounter.

Agree who assigns accession numbers and who updates specimen status after collection or receipt. Define which unit staff use for each medication quantity and how they verify the lot number. The authorized person on a dispensation should be selected from the right staff record. When staff compare these records with an outside laboratory or pharmacy service, keep the encounter and accession or lot references consistent.

Rehearse one visit that needs a specimen and a medication dispensation. The clinician creates the specimen against the encounter, captures collection time and accession number, and follows its processing state. For the dispensation, the clinician checks the medication, lot, quantity, unit and authorizing person. The reviewer opens the same encounter and can inspect both specialty records in context.

Accession numbers and medication lot numbers support different handoffs. The accession number helps staff follow a specimen after collection; the lot number helps identify the medication recorded in a dispensation. Neither should be inferred from the encounter identifier. For a rejected specimen, keep its rejected state visible and decide whether a new collection is needed. For a dispensation correction, have the clinician verify the quantity and unit with the person named as authorizer before the reviewer relies on it.

The clinician should check the encounter before choosing an authorizer or updating a specimen state. A specimen marked received still needs its own processing decision; a rejected one should remain visible to the reviewer. Use the accession number and lot number to compare the correct outside records when those services are involved.

• Specimens in processing — Open the relevant records and check their current status before work begins.
• Encounter review inbox — Inspect the linked person, date and evidence before the next handoff.

Follow the care process and the access model. For setup sequence, see implementation.