Criterion PoCT3.3 – Data management

Maintaining appropriate records is a way of managing risks. It allows for recording of results in the context of a patient’s history and examination, allowing for a record of clinical decision making that is essential for safe and quality care. Records of PoCT results and associated processes must be kept with the relevant patient’s health information, in accordance with relevant legislation and guidelines.    

Your practice needs to demonstrate that you can readily retrieve from your record systems all data related to a patient testing cycle.  

If your practice needs to investigate the reliability of a test result, you may need to: 

• identify the PoCT practitioner who conducted the test 
• identify the kit or batch of reagents used 
• identify whether quality control results were within the acceptable range 
• review the transcription so that you can rule out errors and non-conformance events.         

Therefore, this includes retaining records of the following: 

• patient identifiers 
• the PoCT practitioner 
• who requested the test  
• date and time of specimen collection 
• test results
• relevant reference information 
• relevant quality control results 
• external quality assurance results. 

Ensure the results are accessible for future consultations, trend determination and quality improvement activities by coding the information you need to record appropriately, rather than entering it as free text in the patient record.

Related Criteria 

Criterion C6.2 – Patient health records systems 

Criterion C7.1 – Content of patient health records 

PoCT3.3►A Our practice records results relating to PoCT in the patient’s notes. 

You must: 

• keep PoCT records, including who performed the tests and the date.

You could: 

• record results in a way that are readily accessible for future consultations, trend determination and quality improvement.