Laboratory Reports - Date and Time of Reporting

We are working with our software vendor to include the date and time of reporting on our laboratory reports, as required by DC.02.03.01 EP 10. If we receive a finding on survey and are unable to get the problem fixed before our evidence of standards compliance (ESC) due dates, will we fail the ESC?

Any examples are for illustrative purposes only
No, you will not fail the ESC. The long term objective should be to ensure all versions of the laboratory report (hard copy or electronic) contain all the required fields. As it may be a challenge to comply with the specific requirement to print the date and time of reporting on the laboratory report, we have two approaches to support realistic options for laboratories. First, we will accept the standard as compliant if the date and time of reporting is present on any single version of the report in the patient's permanent medical record (hardcopy or electronic). Second, when the corrective action involves a software solution, we will accept an ESC as compliant if the laboratory has an implementation plan, provides a reasonable timeline for implementing the plan (depending on the cost, anticipated software upgrades, etc.), and the date and time of reporting is electronically retrievable in the interim through the Laboratory Information System. This is acceptable even if implementation exceeds the usual timeline for an ESC. If the plan cannot be fully implemented before the ESC  is due, we will advise your account executive to accept the ESC in anticipation that the corrective action will be implemented as set out in the timeline of the approved ESC.
 
On a related topic, hospital leaders should also be aware of the various elements required by federal regulation to be present in the patient record (electronic or hardcopy) when displaying a laboratory report. Information on this topic is available in the hospital FAQ titled "Laboratory Report Requirements in the Medical Record."
 
Note: This interpretation was first published in The Joint Commission's Lab Focus newsletter, 2009 Issue #4.
 
Last updated on June 17, 2020
Manual: Laboratory
Chapter: Document and Process Control DC

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