19.1 Documentation, Critical Values, Corrected Reports, and Public Health

19.1 Documentation, Critical Values, Corrected Reports, and Public Health

Quick Answer: Record who did what and when. Call urgent microbiology results—positive blood-culture Gram stain, CSF Gram stain, AFB smear, malaria smear, sterile-site positives—obtain a read-back, and document the call. Autoverify only when locked rules fit (some negatives); never autoverify a first-positive blood-culture stain. Corrected reports keep the original line, explain the change, and notify the clinician. Report TB, meningococcus, measles, STEC, Salmonella, and other notifiable conditions to infection control and public health. Antibiogram construction and antimicrobial stewardship programs are SM-only.

Official outline IV.A Postanalytic Procedures sits inside Domain IV, Laboratory Operations (10–15% of M). The content guideline revised 2025-09-25 tests documentation practices, urgent and critical value reporting, result review and autoverification, issuing corrected reports, and reporting to infection control/prevention and public health. IV.A.6 Preparation of antibiogram and IV.A.7 Antimicrobial stewardship are SM ONLY and are not M-tested. IV.F Laboratory Administration is entirely SM ONLY. This section is bench reporting, not management theory.

Documentation practices: who, what, when

A microbiology result is not finished when the colony is named. CLIA and accreditors treat the permanent record as part of the test. Capture who performed, reviewed, and released the work, what was reported (organism or stain morphology, method, comments, notifications), and when (date and time of testing and of release). Initials or an electronic signature on the worksheet or LIS action assign responsibility; a shared department stamp does not.

Document at the time of the work. Blood-culture Gram-stain logs, malaria smear worksheets, and AFB smear records are frequent exam settings because the verbal call and the LIS entry drift apart if someone charts at the end of the shift from memory.

Use current, defensible organism names the clinician will recognize, and always keep the source with the name. Klebsiella pneumoniae in blood is not the same event as the same name in sputum. Do not back-date, white-out paper worksheets, or edit an LIS line so the first result vanishes. Those actions are not documentation; they are a missing corrected-report process.

Urgent and critical value reporting

The medical director defines the laboratory's critical and urgent list. In microbiology the list is built around results that change isolation or therapy now:

• Positive blood-culture Gram stain — call the morphology on the first positive bottle; do not wait for a species name
• CSF Gram stain with organisms
• Positive AFB smear
• Malaria (or other blood-parasite) smear
• Sterile-site positives on stain or significant culture (CSF, synovial, peritoneal, pleural, pericardial, vitreous, intraoperative tissue, bone marrow)
• Other locally defined items such as cryptococcal antigen or a suspected select agent

The M action is the same for each: call the responsible licensed caregiver immediately, obtain a read-back, and document the recipient's name, the date and time, the exact information read, and that read-back occurred. Read-back exists because "I told the nurse" does not prove the morphology was heard as gram-negative diplococci rather than gram-positive cocci. Voicemail, a sticky note, and an unread inbox flag are not completed notification.

Do not delay a blood-culture Gram-stain call for MALDI, biochemicals, or susceptibility. The stain is the critical result; the name follows. Do not skip the call because it is 02:00, because the organism "looks like a contaminant," or because infection control will see an electronic banner in the morning. Contaminant interpretation is a documented comment after the call, not a reason to stay silent on a first-positive bottle.

Result review and autoverification

Result review is a second set of trained eyes, or a validated computer rule, before release. Manual review is the default for culture interpretation: mixed flora versus pathogen, stain–culture correlation, and an ID that matches the susceptibility pattern.

Autoverification releases a result without human review when predefined, locked, validated rules are met. Chemistry uses it heavily. Microbiology uses it narrowly. Appropriate examples, if the laboratory has validated them: a negative urine culture with no growth on standard media at the protocol time; some negative NAAT panels with valid internal controls; a negative blood-culture status after the full instrument protocol. Inappropriate examples: a first-positive blood-culture Gram stain, CSF or other sterile-site growth, unusual or highly pathogenic organisms, mixed cultures that need a judgment comment, AST profiles that contradict the identification, or any run whose QC failed.

Autoverification is not a staffing shortcut. If the rules are not documented and tied to in-control QC, the exam answer is manual review.

Issuing corrected reports

Issue a corrected report when a released result is wrong or incomplete in a way that could change care: misidentified organism, wrong patient identity, a pathogen found on a plate already reported as no growth, transcribed morphology, or an amended susceptibility interpretation.

1. Leave the original result visible in the permanent record.
2. Issue a corrected report that states the new result and that it is a correction, with the reason (further testing, clerical error, instrument correction).
3. Notify the ordering clinician when the change is clinically significant, and notify infection control if isolation or public-health action already used the first result.
4. Do not silently overwrite, delete, or "fix" the first line so the audit trail disappears.

A same-day add-on that was never released is an additional result, not a correction. A corrected patient identity is both a corrected report and an identity investigation (Chapter 2).

Infection control and public health

Infection prevention uses microbiology for isolation and outbreak control: new Mycobacterium tuberculosis complex, invasive Neisseria meningitidis, measles, influenza/RSV/SARS-CoV-2 per policy, Clostridioides difficile, locally defined MRSA/VRE/CRE, and clustered identical isolates. The laboratory's job is timely notification, not designing the isolation cart.

Public health reporting is required for notifiable diseases. State and territorial lists vary; the exam tests the concept and classic organisms, not a fifty-state table. Typical laboratory-reportable findings include M. tuberculosis complex, invasive N. meningitidis, measles, Shiga toxin–producing E. coli (STEC), Salmonella spp., and, in many jurisdictions, Shigella, Listeria, Legionella, Bordetella pertussis, N. gonorrhoeae, C. trachomatis, and syphilis. Select-agent suspects follow the Laboratory Response Network pathway (Chapter 13).

Report according to the current state or local list and the laboratory SOP, often at confirmed result and, for some diseases, at a defined presumptive result. Do not wait for susceptibility to report stool Salmonella. Do not treat a single-bottle contaminant coagulase-negative Staphylococcus as a notifiable disease. Do not study antibiogram construction or antimicrobial stewardship program design as M items—those are SM-only (IV.A.6 and IV.A.7). Knowing that a carbapenem-resistant isolate may also be locally notifiable is an M reporting task; building the annual percent-susceptible table is not.

Exam traps

1. Waiting for a species name before calling a positive blood-culture Gram stain.
2. Documenting the call without a read-back.
3. Autoverifying a sterile-site positive.
4. Overwriting a wrong ID instead of a corrected report plus clinician notification.
5. Treating public-health lists as optional courtesy copies.
6. Drilling antibiogram worksheets as if they were M-tested.

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