The Basics of Laboratory Data - Flagging

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Lab data
As alluded to in the closing statement of the previous article in this series, appropriately flagging laboratory values can be just as important, if not more-so at times, as transcribing normal values when it comes to providing quality patient care.

While normal values are an integral component of the medical record, assisting in ruling out diseases, indicating recovery, proving a healthy appearing person is actually healthy, and so on, critical values—whether critically low or critically high—quickly alert healthcare providers to health concerns, some of which may be life-threatening. Transcribing a critical value dictated in error could lead to misdiagnosis or at least entertaining medical problems that aren’t really there, a time-consuming and costly journey. Transcribing an abnormal or critical value that’s accurate but that the healthcare provider seemingly fails to notice could delay proper treatment. For example, if a healthcare provider dictates “TSH of 74.4” in the laboratory section but doesn’t mention thyroid function anywhere else in the report, including in the diagnosis, the TSH value should be flagged, as either the statement was dictated in error or it is accurate but ultimately overlooked. Either way, it could greatly affect the patient’s health and plan of care.

Sometimes the need to flag has more to do with the ears of the medical language specialist than the words of the healthcare provider. It’s very easy, especially as the day wears on and sounds start to blend together, to confuse abbreviations and values that sound similar. For example, BNP and BMP or TSH and PSA can sound amazingly the same if not well enunciated, during the 8th hour of a work shift, not to mention numbers such as 2 and 3 or 50 and 60. Context can help. Obviously a 64-year-old man with urinary incontinence and an enlarged prostate visiting a urologist is going to have his PSA tested, not his TSH. However, a 64-year-old man with mild symptoms of fatigue and dry skin could just as reasonably be having his PSA tested as his TSH, and stand-alone generic statements such as ‘such-and-such was normal last year’ won’t provide any real clues. The bottom line is don’t leave a flag just to emphasize that Dr. Mushymouth should pronounce his A’s and H’s more distinctly just in case your ears are tired, but if you can’t confidently conclude what abbreviation, test name, or value is dictated, you MUST leave a flag.

On rare occasion, math skills come into play, specifically with the differential blood count. A tip to put in your back pocket is that the numbers must add up to 100. For example, a differential of 59 segs, 7 bands, 25 lymphs, 7 monos, 2 eos, and 1 baso is incorrect, no matter how clear the dictation is and how carefully you transcribed the numbers, because its sum is 101. There’s no question about it, a flag would be necessary to ensure accurate medical records.

As you can see, there are different scenarios that will pop up from time to time that warrant a flag. Properly using flags sets mediocre medical language specialists apart from masterful ones, and who wouldn’t want to be masterful?

As promised, here is another cheat sheet to decorate your office with:

Thyroid Function Tests or Thyroid Panel                                                                                       
Thyroid-stimulating Hormone (TSH)0.4 to 4.2 mcU/mL
Triiodothyronine (T3)70 to 190 ng/dL
Free T3 (FT3)260 to 480 pg/dL
Thyroxine (T4)5 to 13 mcg/dL
Free T4 (FT4)260 to 480 pg/dL
Thyroxine-binding Globulin (TBG)1.1 to 2.1 mg/dL
Antithyroid Peroxidase (Anti-TPO) Less than 35 IU/mL
Thyroglobulin Antibody (TgAb)Less than 20 IU/mL

Tips
• It is extremely common to have only the TSH value dictated for a patient who has no thyroid-related diagnosis yet or whose thyroid disease is under control.
• Triiodothyronine and thyroxine are almost exclusively dictated as “T3” and “T4.”
• Anti-TPO may also be called thyroid peroxidase antibody (TPOAb).
• Thyroid antibodies are helpful in evaluating autoimmune thyroid problems such as Hashimoto thyroiditis and Graves disease, going beyond simply hypo- or hyperthyroid.
• Other antibody tests include thyroid-stimulating immunoglobulin antibody (TSI) and thyroid-binding inhibitory immunoglobulin (TBII).


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