IV.C REVIEWING DIAGNOSTIC TEST RESULTS

Effective Date: 
Sun, 09/01/1996
Reviewed: 
Tue, 06/30/2015
Revised: 
Mon, 06/01/2015
Policy: 

Incoming diagnostic test results (lab, radiology, EKG, etc.), clinical summaries from consultants, and other medical records are reviewed, addressed, initialed, and routed by licensed personnel in a timely fashion.

Procedure: 

Laboratory and x-ray results are downloaded into the EMR (PNC).  Laboratory results are directly loaded from Quest into the EMR with a patch program.  Radiology reports on imaging performed in the SHC is transmitted via a secure interface from the outside Radiology Medical Group directly into the EMR.

These results appear in a "folder" in the EMR called the Provider Task Summary.

Clinicians are responsible for reviewing contents of the Provider Task summary at least daily.  Part time and per diem clinicians have their lab and x-ray results reviewed by a career clinician assigned to cover them when they are not working on site.

Once diagnostic test results have been reviewed, the clinician clicks the "acknowledge" button below the result.  This creates a dated, electronic signature indicating that the clinician has reviewed the result.

Additional options for acknowledgement are available in the EMR.  These options allow the clinician to put a note on the lab or indicate that the clinician called or sent a secure email message to the patient regarding their results.  The clinicians are expected to review all lab results and notify the patient by secure message, phone contact or in person unless other arrangements have been made. For very common labs, a variety of pre-written text messages are available to clinicians to send to patients regarding test results.

Some diagnostic test results, letters from consultants, or copies of past medical records come to the Student Health Center by fax or mail.  These results are logged on arrival in Medical Records, date stamped, and each result placed in an individual red folder.

The CAPS administrative assistant reviews fax and paper results and delivers them to the clinician working with the patient.  If no clinician is identified then the result goes to the Psychiatric case manager.

Fax and paper results are initialed by the CAPS/Psychiatry clinician, returned to CAPS Medical Records, and then scanned into the EMR.  These results appear in the section of the EMR called Scanned Documents.  These results are not in the sections called Laboratory or Radiology.

To assure that no results are lost both lab and x-ray track tests from collection through to results.   Each department maintains a daily log of all tests done.  Each log entry is maintained as an active manifest until results for every test have been entered into the EMR.  This allows rapid identification of results which exceed the expected turnaround time and may have been delayed.  Labs sent out to reference laboratories which do not return within the expected turnaround time will be tracked by the UCSC SHC  lab staff.  The UCSC SHC Lead Clinical Lab Scientist or designee will contact the reference lab and expedite transmission of the final lab result.  In the case of a delay in the X-ray reports, the Lead Radiology Technician will contact the Radiology Medical Group administrator to expedite the final report if not received within one business day.

Key Points: 

 

  • All laboratory and radiology diagnostic test results drawn or performed in the SHC appear in the ordering provider’s inbox or provider task summary list.
  • The EMR allows the clinician to electronically acknowledge test results and generate secure email messages to notifying patients of their results.
  • Fax and paper reports are logged, date stamped, and sent to the appropriate clinician for review.  The clinician signs the paper report and returns it to Medical Records where it is scanned into the EMR.
  • Both lab and x-ray maintain daily logs which track all studies sent out from the Student Health Center and their status.  This prevents inadvertent delay of a lab or x-ray final report.

     

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