REVIEWING DIAGNOSTIC TEST RESULTS

Effective Date: 
Sun, 09/01/1996
Reviewed: 
Fri, 05/15/2015
Revised: 
Tue, 11/22/2016
Policy: 

Incoming diagnostic test results (lab, radiology, EKG, etc.),clinical summaries from consultants, and other medical records are reviewed and acknowledged by the ordering clinician or designated coverage in a timely fashion. Patients are informed at the time tests are ordered how they will be notified. Unless otherwise arranged, lab and x-ray results will be communicated by secure electronic messaging.

Procedure: 

Laboratory and x-ray results are downloaded into the EMR (Point and Click or PNC).  Laboratory results are directly loaded from Quest into the EMR with a patch program.  Radiology results are electronically sent from the Radiology Medical Group and are uploaded 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 their individual Provider Task Summary at least daily and manage as clinically appropriate. Clinicians are responsible for notifying patients of all of their diagnostic test results.

For self-directed testing for Sexually Transmitted Infections, RNs review results.  Pre-written text messages are sent for negative test results.  Positive STI test results are forwarded to the Medical Director or Patient Care Coordinator for management.

After reviewing diagnostic test results,  the clinician clicks the "send message" button below the result and attaches an note explaining the significance of the result and any follow up that is indicated.  This creates a dated, electronic signature indicating that the clinician has reviewed the result and the patient has been sent a secure message.

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 send all lab results, both normal and abnormal, to the patient using secure message unless other specific arrangements have been made.  For 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 charge nurse 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 Patient Care Coordinator.

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.

Fax and paper results are initialed by the clinician, returned to 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, the Lab and X-Ray Depts track all studies from collection through to results.   Each department maintains a daily log of all tests done.  Each log entry is maintained as an active send out list until results for every test have been entered into the EMR.  This allows timely identification of any results exceeding the expected turn around time.

  • Labs sent out to reference laboratories which do not return within the expected turn around 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.
  • The daily list of X-rays sent out to for interpretation to the consulting Radiology Medical Group is maintained and monitored by the X-ray technologist.  In the case of a delay in receipt of an X-ray report, the R.T. will contact the Radiology Medical Group administrator to expedite the report.
Key Points: 

 

  • All diagnostic test results appear in the ordering providers inbox.
  • The EMR allows the clinician to electronically acknowledge test results and generate secure email messages to patients about those results.
  • Patients are notified of all lab and X-ray results via secure electronic messaging unless other arrangements are documented.
  • Fax and paper reports are logged, date stamped, and sent to the appropriate clinician for review.  The clinician initials and dates the paper report and returns it to Medical Records where it is scanned into the EMR.
  • Both lab and X-ray maintain daily logs to track the status of all studies sent out from the Student Health Center.  These logs are monitored to prevents inadvertent delay or loss of a lab or X-ray final reports.
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