Specialty operations

A specimen record points to an encounter and carries its type, collection date, accession number and processing status. The team can see whether an order was collected, received, tested or rejected. That progression makes the specimen’s current operational state visible alongside the visit that led to it. The accession number gives staff a reference when coordinating with the laboratory that processes the sample.

A pharmacy dispensation also points to an encounter. It records the medication, lot number, quantity, unit and authorizing person. This is a record of a dispensation, not a general prescribing history. Keeping the lot and quantity with the visit helps staff check what was supplied in a particular episode of care. The authorizing person points to a staff record, which can be reviewed against professional privilege information when required by clinic policy.

• Specimen progress. The Licensed Clinician records collection details and updates the specimen’s status as processing proceeds.
• Dispensation evidence. The clinician records medication, lot, quantity, unit and authorizer against the encounter.
• Review. The Clinical Reviewer sees specialty evidence in the context of the encounter and its signed note.

Agree who enters specimen orders and who records collection, receipt and test completion. Define when a rejected specimen needs a new record and how the accession number is obtained. For dispensations, decide how the team confirms the lot and unit at the point of supply. Make the authorization check explicit in the clinic’s operating procedure. A named authorizer is useful only when staff verify that the person is right for the work.

For a visit that includes a specimen, the clinician records the specimen against the encounter. The collection date and accession number travel with its status as it moves through receipt and testing. If the sample is rejected, the team leaves that state visible and coordinates a replacement through the clinic’s usual process. If medication is dispensed during the same visit, its lot and quantity are captured in a separate record against that encounter.

Use an encounter with one collected specimen and one dispensation. Confirm both records point to the intended visit and patient through the encounter. Move the specimen through receipt and testing, then rehearse a rejection on a separate sample. Check that the dispensation shows its lot, quantity, unit and authorizing person. Have the reviewer read these records alongside the signed clinical note before the encounter is closed.

• Specimens in transit — Find ordered, collected and received samples that need the next processing update.
• Encounters awaiting review — Examine specialty evidence with the visit before completion.

See specimen and dispensation review, then encounter review. The data model shows the encounter links.