Download REV-1-FINAL-CNHC-Diagnostic-Tracking-Policy-

COMMUNITY NURSE HEALTH CENTER
RISK MANAGEMENT SYSTEMS: CLINICAL TRACKING POLICY And PROCEDURES:
DIAGNOSTIC TESTING
Effective Date: February 1, 2015
Review Date: January 2015; December 2015
Revision Number and effective date: Revision #1, effective January 15, 2016
Review Authority: Medical Director, Dental Director, CEO
Corporate Authorization: Board of Directors________________________________
I. PURPOSE
Community Nurse Health Center recognizes the importance of prompt review and
communication of test results to ensure accurate diagnoses, effective attention and treatment, and
optimal patient care. Policies and procedures for reporting test results support effective
communication among providers and between providers and patients.
II. POLICY
Test results must be communicated to the ordering provider or a surrogate provider if the
ordering provider is unavailable, within a period of time that allows prompt clinical action to be
taken. The ordering provider must communicate all test results, including normal results, to
patients within specified time frames to ensure patients are active participants in their healthcare
(see below, Procedures).
III. SCOPE
This policy applies to all patient testing and includes laboratory, radiology, cardiology,
pathology, vascular and other diagnostic testing.
IV. DEFINITIONS
Abnormal Test Result: Test result that requires the ordering provider’s attention as soon as
possible but is not as urgent or life-threatening as a critical result. Abnormal findings are values
that are above or below the established norms for a particular test. Typically, laboratories or
testing centers judge which values are considered abnormal (for example, a value considered
abnormal for some patients may qualify as normal for a patient who previously had a critical test
result).
Critical Test Result: Test result for a condition that if left untreated may be life-threatening or
place the patient at serious risk. Patients require urgent clinical attention.
Direct Verbal Communication: Communication of test results by telephone, face-to-face
encounter, or report personally handed to the ordering provider.
Electronic Communication: Communication of test results by e-mail, fax, electronic health
records, or other electronic means.
Normal Test Result: Test result that falls within the normal parameters for the particular test
established by the laboratory. Requires patient notification but not on an immediate basis.
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Ordering or Referring Provider: The provider who initiated a test for a particular patient. The
provider is responsible for reviewing, signing, and acting on diagnostic tests under the scope of
his or her clinical practice.
Surrogate Provider: A provider designated to act on test results on behalf of the ordering
provider if the ordering provider is unavailable.
Test Result: Test results include the results of laboratory tests, cardiology tests, radiology, and
other diagnostic procedures.
V. CROSS REFERENCES
CNHC Risk Management Systems: Referral Tracking Policy
CNHC Risk Management Systems: ED and Hospitalization Tracking Policy
VI. POLICY AND PROCEDURE
A.
PROVIDERAND STAFF RESPONSIBILITIES
CEO or designee
 Implement written policy on reporting test results.
 Regularly review and reevaluate policies.
Medical Director and/or Dental Director
 Designate surrogate providers (e.g., on-call clinician, primary care physician) who will be
responsible for reviewing and acting on critical test results when the ordering provider is
not available. Establish a chain of responsibility.
 Regularly review and reevaluate which test results qualify as critical or abnormal.
 Ensure the health center regularly collects data on the timeliness of reporting test results
and communicating results to patients.
 Ensure the health center makes necessary improvements.
Ordering provider
 Follow up on, review, and take action on ordered test results,
 Document all actions taken in response to test results in the patient’s medical record (see
the discussion, Documentation).
 Communicate test results to patients within specified time frames.
Surrogate provider
 Must have the authority to take action on critical test results. Staff members who may
serve as surrogate providers include primary care providers including physicians, nurse
practitioners, physician assistants , covering physicians, laboratory directors, or the clinic
director.
 When contacted with a critical result, responsible for reviewing and following up on the
result and communicating necessary information to the patient (e.g., come in to the health
center, go to the emergency department [ED]).
 Document all actions taken in response to test results in the patient’s medical record.
 Communicate actions taken to the ordering provider.
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Medical Assistant, Dental Assistant, or lab assistant or RN or LPN
 Keep a daily log of all tests ordered (e.g., computerized or paper log).
 Place a check mark (hard copy or electronic) in the log with the date that results that are
returned to the health center from laboratory, imaging facility, or other outside testing
center.
 Provide returned results to the ordering provider for review, signature, and follow up
action.
 Flag results that are not returned within a reasonable period of time and notify the
ordering provider.
 Enter in the electronic record results that have been communicated to the patient
B. PROCEDURES
1. Ordering:
a) Medical: Orders for labs and diagnostic testing will be placed into the electronic health
records. Providers will order labs and diagnostic tests at the time of the office visit. If
any labs need to be ordered after the time of the visit for a follow up lab, the provider will
instruct the nurse/MA in the electronic health record as to the specific lab that needs to
be ordered or diagnostic test. Labs and diagnostic tests ordered by health care providers
outside of Community Nurse can be entered into the system by the nurse/MA. In-house
labs can be entered by the Nurse/MA before the provider visit according to the patients
symptoms and per in-house lab protocols
b) Dental: The provider will evaluate the patient and determine the need for a panoramic
radiograph. The provider will instruct the Dental Assistant in the electronic health record
as to the specific radiograph that needs to ordered and the referring provider.
An assigned staff member will be responsible for contacting the referring dentist with
panoramic x-ray equipment to inform them of the referral. The patient will schedule for
the radiograph, and the dentist (referral source) will send the film digitally to our office..
2. Results Review: Depending on the type of test result, ordering providers may receive
results from laboratories or outside testing centers by either direct verbal communication, in
the case of critical results, electronic communication (see specific procedures for critical,
abnormal, and normal test results below) or, in the case of x-rays, may receive films or
digital radiographs..
a) Ordering providers must personally acknowledge receipt of the results (e.g., by
telephone, through verification systems in the electronic medical record). Voicemails and
e-mails, including e-mails with read receipt, are not appropriate acknowledgment
systems.
 When results are reported by telephone, the person receiving the information
must read back the information to the person calling with the results. The
following process should be followed:
The recipient of the result writes down the result
The result is read back to the caller
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The caller verifies the accuracy of the result as the recipient reads it back
b) Providers will review and sign-off on lab and test results within 14 days of receipt for
normal and abnormal results and critical results within 24 hours.
c) The Community Nurse dental provider will read the film to diagnose dental disease and
render the treatment that is needed and acknowledge review in the electronic health
record.
d) When the patient must take action in response to the results (e.g., change medications,
schedule a visit to the health center), providers have written orders in the electronic
health record so that the appropriate staff can inform the patient and document the
changes in the electronic record. Nursing staff should use direct verbal communication
and document that the information was received and understood by the patient.
Providers/staff must not include any identifiable patient information in e-mails or on
voicemail/answering machines, unless patient has so consented in writing. When the
patient cannot be reached a letter should be mailed to contact the clinic regarding
abnormal test results (e.g., phone number is disconnected), reasonable attempts should be
made to contact the patient and attempts should be documented in the medical record.
3.
Communication of Test Results to Patient:
Depending on the type of test result, ordering providers may communicate results to
patients’ in-person or by letter, telephone, or electronic health record portal (see below,
Critical results). Ordering providers may request that another licensed or certified staff
member or Medical Assistant contact the patient with results; the name of the person
contacting the patient with results should be documented. If the patient is not competent to
make medical decisions, test results will be communicated to the patient’s designated
guardian or representative. Test results may be communicated in any manner and to any
person so authorized and approved by the patient in a consent form.
Specific procedures for communicating critical, abnormal, and normal tests are as
follows:
a) Critical results
i.
Critical results must be communicated immediately by direct verbal
communication from the outside laboratory or testing center to the ordering
provider or surrogate provider.
ii.
In cases in which the ordering provider and surrogate are not available, results
must be communicated following the established chain of responsibility.
iii. The following steps should be taken when the ordering provider cannot or does
not respond to notification of a critical test result:
a. If the ordering provider cannot or does not respond within 10 minutes,
call/text the provider a second time.
b. If the ordering provider does not respond within 15 minutes of the second
call, call/text the surrogate provider or the patient’s primary care
physician (if not the ordering provider).
c. If the surrogate provider does not respond within 15 minutes, call/page the
surrogate provider a second time.
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iv.
v.
vi.
d. If the surrogate provider does not respond within 15 minutes of the second
call, call/page the medical director.
Critical results must not be communicated over voicemail, e-mail, or to
administrative assistants or other unlicensed staff members. Critical results and
necessary actions (e.g., come in to the health center, go to the ED) should also be
communicated to patients immediately by direct verbal communication.
The health center/ must make every attempt to contact the patient. Call the
emergency contact information then enlist local authorities (e.g., enlisting
assistance from local authorities). All communication or attempts to communicate
must be documented.
If above communication attempts are not successful, clinical staff will send the
patient a certified letter, return receipt requested, within 24 hours.
b) Abnormal results
i.
Abnormal results may be communicated to the ordering provider by electronic
communication.
ii. Abnormal results must be communicated to the patient within a set timeframe but not
to exceed 14 days.
iii. Results can be communicated to the patient by certified letter with return receipt
requested or by telephone.
iv.
The health center must make every attempt to contact the patient (e.g., enlisting
assistance from local authorities). All communication or attempts to communicate
must be documented. The health center must call the patient. If the patient cannot be
reached by phone then a letter must be sent. If the patient does not respond to the
letter within 4 weeks then a certified letter needs to be mailed with return receipt. If
the patient does not respond to the certified letter within 2 weeks then the provider
needs to be notified as the whether the abnormal result can be filed away or further
action needs to be taken. All communications must be documented (and written
communications must be scanned) scanned in to the patient’s record.
v. If provider documentation that no further action needs to be taken, we will assume
abnormal result has been appropriately addressed. If further action needs to be taken,
provider will take appropriate actions.
c) Normal Results
i.
Normal results may be communicated to the ordering provider by or electronic
communication.
ii. Normal results should be communicated to the patient within a reasonable period of
time, not to exceed 21 days.
iii. Patients who register with the patient portal will receive notification of their normal
results thru the patient’s healthcare portal
iv.
Results may be otherwise communicated in-person or by letter, telephone, or portal .
Providers must not include any identifiable patient information in e-mails or on
voicemail/answering machines, unless patient has so consented.
v. All communication or attempts to communicate must be documented.
4. Documentation
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a) The ordering provider must document in the electronic record, acknowledgment of
receipt of results and if further action is needed and if needed, specify the action needed
and to whom the task was assigned.
b) The staff must document in the electronic record:
 Actions taken related to the patient
 Patient notification, including date and time of notification, means used to
communicate results (e.g., phone call, letter), and person spoken to (if applicable)
 All attempts to contact the patient if the patient cannot be reached
 Other clinical information as appropriate
5. Tracking
a) All diagnostic medical testing, including laboratory order, are to be tracked in a log
(paper or electronic) independent of the EMR as well as tracked electronically in the
appropriate electronic “bin” by RN and Medical Assistants as assigned by the
Nursing Manager. Every patient communication is noted in the tracking log.
b) All diagnostic dental testing (radiographs) are also to be tracked in a log (paper or
electronic) independent of the EMR as well as tracked electronically in the
appropriate electronic bin by a Dental Assistant as assigned by the Assistant Director
of Dental Services.
c) Critical lab results must be separately logged and tracked independent of the EMR.
Diagnostic tests are to be tracked in a paper or electronic log independent of the EMR
that will include: the patient’s name, date of service, type of diagnostic test,
provider’s name who ordered the test, dates of follow-up including what information
was communicated to the patient, date the results were received, date the provider
reviewed the results, and the date that the results were communicated to the patient.
Follow up on diagnostic testing is to happen at 30, 60, and 90 days.
d) The Clinical Nurse Manager and Dental Clinic Manager must audit the tracking
tools to assure the log is being completed and labs and diagnostics have been
reviewed and communicated to patients in compliance with this policy. They will
report on tracking audit results to the Continuous Quality Improvement Committee.
Action plans will be developed based on the Plan, Do Study Act process for audit
results that are less than 100%.
e) Audit can exclude routine diagnostic imaging tests such as screening mammograms
and colonoscopies as access to, and completion of these tests by patients may take as
long as 3-6 months, but these still must be tracked as specified in this policy.
f) Provider compliance with this policy will be tracked through the peer review process
and results will be reported through the CQI Committee.
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VI. IMPLEMENTATION
A. The Medical Director, Dental Director and Quality Improvement Manager are responsible for
education and training of all clinical staff about this policy. All current and new staff with a
responsibility as defined in this policy are to receive and copy of this policy and sign an
acknowledgement that they have read it and understand their responsibilities as wet forth herein.
Such documentation shall be maintained in the Human Resources training files. Thereafter, all
affected staff will have annual compliance training.
VII. OTHER
This policy takes precedence over any prior version of the same and shall be reviewed at least
once per year. This policy has an a effective date of January 15, 2016.
REVIEW APPROVALS
CEO:_________________________________________Date:_______________
Medical Director:_____________________________ Date:__________________
Dental Director _____________________________ Date:__________________
CORPORATE AUTHORIZATIONS
This policy was duly adopted by the Board of Directors on the __- day of_______, 2015.
_________________________________________________, Ed Farrell, Secretary/Treasurer
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