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5.13 – Laboratory Tests

Monitoring of laboratory results is an essential component of caring for all individuals at Open Door in order to:

  • Assess treatment and medication effects
  • Assess current medical condition
  • Early detection or indication of acute issues
  • Identify early signs of clinical deterioration
  • Baseline data for vital tracking for report to treatment professionals


Laboratory tests that must be obtained for new admission within first 30 days after admission date include:

  • CBC with differential
  • SMAC
  • Hepatitis screening A&B
  • VDRL
  • Urinalysis with culture and sensitivity

Laboratory tests to be completed annually include:

  • Hepatitis screening A&B (Hep B every 6 months If test positive HBgAG)
  • PSA-male individuals
  • CEA

ICF and Waiver

Other on-going laboratory tests should be ordered by physician.  Nursing staff (or Certified DSP staff in Waiver settings) are responsible for arranging and ensuring completion of laboratory tests as ordered by physician and/or care plan.  If an order is received for on-going monitoring of labwork (ie: annually, quarterly, etc…), the nursing staff and/or designee will enter into the care plan and ensure that the lab reminder is placed on medical appt calendar for the ordered frequency.  Lab completion dates and information should be entered into medical appointment tracking software (Advisor) within 3 days of receipt so that they will alert when due. 

All Laboratory results and documentation MUST be reviewed by physician and copy maintained in individual records.  Laboratory results should be forwarded for review during appointments with physicians and for Behavior Support Committee, when requested.  

Last Revised: 8/25/21

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