Microbiology — Findings (organism classifications) for preliminary results

Use the Findings form to predefine organism classifications and related observations that are selected during preliminary result entry (before definitive identification). Examples include “Gram-negative bacilli,” “Gram-positive cocci in clusters,” “No organisms seen.” Predefined Findings speed entry, standardize wording, and reduce errors.

What Findings are used for

• Preliminary reporting on cultures (e.g., Gram stain, wet prep, KOH, AFB smear)
• Structured statements that appear on interim/preliminary reports and HL7 messages
• Consistent language across technologists and benches prior to organism ID and susceptibility

Typical examples

• Gram stain morphology
  • Gram-negative bacilli
  • Gram-positive cocci in clusters
  • Gram-positive cocci in chains
  • No organisms seen
• Quantity/quality qualifiers
  • Rare/Few/Moderate/Many PMNs
  • Few/Moderate/Many epithelial cells
• Flora descriptors
  • Mixed bacterial flora
  • Normal respiratory flora
  • Skin flora
• Fungal/AFB/parasite findings
  • Yeast present
  • Hyphal elements seen
  • Acid-fast bacilli seen
  • Ova and parasites observed/not observed

What you can configure

• Finding name (report/display text)
• Category/type (e.g., Gram stain, Cell morphology, Quantity qualifier, Flora descriptor, AFB, Fungal)
• Abbreviation/short text (optional) for compact views
• Default comment to print with the finding (e.g., interpretive note)

How Findings work in the workflow

• During preliminary entry, technologists select one or more predefined Findings relevant to the specimen/test.
• Quantity qualifiers can be combined with morphology (e.g., “Moderate PMNs; Gram-negative bacilli observed”).
• Findings print on preliminary/interim reports and can be sent via HL7; final reports may supersede or retain them as addenda per your policy.

Best practices

• Keep the vocabulary concise and standardized; avoid free-text duplicates.
• Include quantity scales (e.g., Rare/Few/Moderate/Many) and define their usage in your SOP.
• Align wording with your report templates and any client/EHR expectations.
• If interfacing, map Findings to consistent codes (SNOMED/HL7) to improve clarity downstream.
• Review and approve the list with your laboratory director; deactivate deprecated entries instead of deleting to preserve history.

📘 Instructions: Add findings

Follow the steps below to add findings.

1. Click Microbiology.
2. Click Findings.
3. When the form opens, fill in the fields marked with asterisks.
4. Click Add.

Tip: After adding, you can adjust display order and categories, and (if supported) limit availability by specimen type or test so technologists see only relevant Findings during entry.

Troubleshooting

• Finding not available during entry: Ensure it’s Active and, if your LIS supports scoping, linked to the appropriate specimen types/tests.
• Duplicates or inconsistent wording: Consolidate to a single preferred term and deactivate the rest.
• Finding not printing or not in HL7: Verify the report template includes preliminary Findings and that HL7 mappings are configured if required.