Proficiency Testing Evaluation
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1 Facility/Contact Phone: (573) PCRMC Medical Group - Forest C Fax: (573) N Jefferson St (primary): odean@pcrmc.com; (secondary): (Please add pt@aafp.org to your electronic address book) AAFP ID: Saint James, MO, USA, CLIA ID: 26D Lab Director: Hugh Schuetz Attention: Deanna COLA ID: JCAHO ID: STATE ID: MO PT Central: Login Name: word: Copies of this report have been sent to: 1. Centers for Medicare and Medicaid Services 2. Certification and Licensing 3. COLA, if applicable Modules: 609, Waived/PPM Tests Specimens: CM-(19-27), HD-11, IM-11, OC-3, RS-11, UA-3, WBG-11 Subspecialty: Urinalysis CMS Analyte Score: 50% Vaginal Wet Prep (Non-Regulated) Microscopy Vag Wet Prep ABC Test/Your Method(s) Spec Your Result Subspecialty: Hematology CMS Analyte Score: 100% CM-23 Trichomonas vaginalis, Vaginal Trichomonas vaginalis, Vaginal AG CM-24 White Blood Cell (WBC) Squamous epithelial cell, AG (Leukocyte), Vaginal Vaginal Target Mean Group SD Your SDI Acceptable Range Fail Group* Comments Hemoglobin (Waived) (Non-Regulated) in g/dl HemoCue 201 ABC HD PG Fecal Occult Blood (Non-Regulated) Occult Blood ABC / Guaiac methods OC-3 Negative Negative Subspecialty: Bacteriology CMS Analyte Score: 100% Strep A Ag Det. (Waived) (Non-Regulated) Biostar Acceava ABC RS-11 Positive Positive AG Subspecialty: Urinalysis CMS Analyte Score: 0% Urine Sp Gravity (Non-Regulated) UA Fail * PG - Peer Group - Method Group SG - Special Group AG - All Method Group GO - Gross Outlier Page: 1 of 5
2 Urine ph (Non-Regulated) UA Urine Protein - Qual (Non-Regulated) UA-3 >/= 1000 (4+) >/= 1000 (4+) (3+) Urine Glucose (Reducing Sub) (Non-Regulated) UA-3 >/= 1000 mg/dl >/= 1000 mg/dl 250 mg/dl 500 mg/dl Urine Ketones (Non-Regulated) UA-3 Large (3+) / 80 mg/dl Large (3+) / 80 mg/dl / 40 mg/dl Urine Bilirubin (Non-Regulated) Urine Urobilingen (Non-Regulated) UA-3 >/= 8.0 mg/dl >/= 8.0 mg/dl Urine Blood/Hemoglobin (Non-Regulated) Urine Leuk Esterase (Non-Regulated) Small (1+) UA-3 Trace Large (3+) Small (1+) Urine Nitrite (Non-Regulated) UA-3 Positive Positive UA-3 Positive Positive * PG - Peer Group - Method Group SG - Special Group AG - All Method Group GO - Gross Outlier Page: 2 of 5
3 Urine hcg (Non-Regulated) Beck Coulter ICON 20 HCG ABC UA-3 Positive Positive AG Test/Your Method(s) Spec Your Result Target Mean Subspecialty: General Chemistry CMS Analyte Score: 100% Group SD Your SDI Acceptable Range Group* Comments Glucose Wh Blood (Waived) (Non-Regulated) in mg/dl Roche AccuChek Aviva ABC WBG PG * PG - Peer Group - Method Group SG - Special Group AG - All Method Group GO - Gross Outlier Page: 3 of 5
4 CMS Summary. Regulated Analytes This report summarizes your performance for this current test event and your cumulative performance (current and two previous test events). Pursuant to the CLIA 1988 federal regulations, your performance has been reported to the federal government (CMS). Specialty Subspecialty Analyte Current Score Current 2015-B 2015-A Cumulative * PG - Peer Group - Method Group SG - Special Group AG - All Method Group GO - Gross Outlier Page: 4 of 5
5 Summary. Non-Regulated Analytes This report summarizes your performance for this current test event and your cumulative performance (current and two previous test events) for Non-Regulated Analytes. Your performance for the following Analytes has not been reported to the federal government (CMS). Specialty Subspecialty Analyte Current Score Current 2015-B 2015-A Cumulative Chemistry General Chemistry 100% Satisfactory Satisfactory Satisfactory Successful Glucose Wh Blood (Waived) 100% Satisfactory Satisfactory Satisfactory Successful Hematology Hematology 100% Satisfactory Satisfactory Satisfactory Successful Hemoglobin (Waived) 100% Satisfactory Satisfactory Satisfactory Successful Microbiology Bacteriology 100% Satisfactory Satisfactory Satisfactory Successful Strep A Ag Det. (Waived) 100% Satisfactory Satisfactory Satisfactory Successful Urinalysis Urinalysis 88% Satisfactory Satisfactory Satisfactory Successful Vaginal Wet Prep 50% Unsatisfactory Unsatisfactory Unsatisfactory Unsuccessful Fecal Occult Blood 100% Satisfactory Satisfactory Satisfactory Successful Urine Sp Gravity 0% Unsatisfactory Satisfactory Satisfactory Successful Urine ph 100% Satisfactory Satisfactory Satisfactory Successful Urine Protein - Qual 100% Satisfactory Satisfactory Satisfactory Successful Urine Glucose (Reducing 100% Satisfactory Satisfactory Satisfactory Successful Sub) Urine Ketones 100% Satisfactory Satisfactory Satisfactory Successful Urine Bilirubin 100% Satisfactory Satisfactory Satisfactory Successful Urine Urobilingen 100% Satisfactory Satisfactory Satisfactory Successful Urine Blood/Hemoglobin 100% Satisfactory Satisfactory Satisfactory Successful Urine Leuk Esterase 100% Satisfactory Satisfactory Satisfactory Successful Urine Nitrite 100% Satisfactory Satisfactory Satisfactory Successful Urine hcg 100% Satisfactory Satisfactory Satisfactory Successful * PG - Peer Group - Method Group SG - Special Group AG - All Method Group GO - Gross Outlier Page: 5 of 5
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Step 1: Please review the Facility/Contact information. If any of the information is incorrect, please make the appropriate changes below: Facility/Contact Phone: (850)474-3660 Fax: (850)474-3659 6431
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