36C24419R0052-006.pdf

Department of Veterans Affairs POLICY 115-15-320 Medical Center April 15, 2015

Wilkes-Barre, Pennsylvania 18711

REPORTING IMAGING TEST RESULTS

1. SCOPE/EFFECT: This Medical Center Policy (MCP) defines the policy for reporting Imaging test results to ordering and treating practitioners at this facility. This policy affects the following Services: Imaging Service, Medical Service, Primary Care Service, Rehabilitation and Prosthetics Service, Geriatrics and Extended Care Service, Surgical Service, and Mental Health and Behavioral Service.

2. PURPOSE:

a. VHA is committed to reporting test results in a timely manner so that appropriate and effective therapeutic action may be taken.

b. VHA is committed to providing patients with information regarding test results so they may participate in health care decisions.

3. POLICY: It is the Medical Center’s policy that imaging test results be communicated to the ordering practitioner within a timeframe that allows prompt attention and appropriate action.

4. PROCEDURE:

a. Communication of Results:

(1) All Imaging studies to be performed at this facility will be ordered electronically.

Orders will not be accepted unless they contain adequate clinical history for the study, the name of the ordering practitioner, and contact information, including a pager number. Studies will not be performed without electronic request for study. A verbal request for a radiographic study is considered unacceptable, with the exception of portable chest x-rays ordered in Code Blue or Rapid Response situations. A verbal order will be accepted by the Radiology department in these emergent response situations only. A Standard Operating Procedure for Acceptance of a Verbal Order is housed in the Imaging Service office.

(2) All Imaging studies performed at this facility will be interpreted and verified in the electronic medical record within 48 hours of completion of the procedure.

(3) Comparison with relevant previous examinations and reports should be part of the radiologic consultation and report when appropriate and available.

(4) Outside hard copy reports will be scanned into Vista Imaging and attached to a canned report that may be administratively signed by a non-physician through the outside report entry process. A diagnostic code alert is generated to the requesting provider or surrogate identifying that the report is available for viewing in Vista.

All reports will be reviewed by the Radiologist or designee for any findings that would require immediate attention. Results requiring immediate attention by a provider will trigger entry of radiology note in CPRS.

(5) Important findings that require urgent attention will be immediately and directly communicated to the treating practitioner with read back verification within 24 hours of completion of test. Direct communication consists of a face-to-face or telephone conversation. The time and means of such communication, and the name of the person contacted, will be entered in the electronic medical record within the study report. If the ordering practitioner cannot be contacted, the report will be directly communicated to the practitioner’s surrogate. Suitable surrogates include the practitioner’s supervisor or preceptor, or another practitioner who may take further, appropriate diagnostic or therapeutic action. Findings that may require direct communication and urged attention include, but are not limited to:

(a) Any findings that has the potential to be life threatening or could cause serious harm, and that requires an urgent intervention or change in patient management.

(b) Any findings that would result in the change of ongoing treatment, if known to the reading radiologist.

(c) Specific conditions [could include, for example: new unsuspected malignancy;

new pneumonia, osteomyelitis or other infection; high probability V-Q scan; unsafe position of medical device; large reversible defect on myocardial perfusion scan; acute fracture; concern for impending pathological fracture, pneumothorax, active hemorrhage, diverticulitus, appendicitis, new pancreatitis].

(6) Important study findings that may require a change in patient management, but not necessarily within an urgent timeframe, may be communicated by either direct documented communication or by a View Alert. View Alerts should be used for important findings only – excessive use diminishes the significance of alerts.

(7) If the report differs from the preliminary report or consultation, the ordering provider will be notified and the discrepancy noted in the body of the report.

b. Audits of Communication System: The Radiology service will run a report daily of carcinoma, possible malignancy, and critical outcome view alert flags. An additional radiology note will be entered in patient’s electronic medical record to ensure provider notification.

5. RESPONSIBILITY:

a. Imaging Service Chiefs is responsible for (1) instructing staff regarding policies and procedures for communication of Imaging test results;

b. Imaging Radiologists are responsible for:

(1) Ensuring that verified test result reports are available in the medical record in a timely manner; within 48 hours.

(2) Identifying and communicating emergent test results to the ordering practitioner or to the practitioner’s surrogate or supervisor as appropriate. Documenting the time and means of such communication, and the name of the practitioner contacted, in the medical record.

(3) Identifying and communicating abnormal test results using direct or electronic communication to provide or provider’s surrogate.

(4) Knowing which Diagnostic Codes trigger a mandatory View Alert.

c. Ordering Practitioners are responsible for:

(1) Placing the initial order with appropriate contact information for themselves and their preceptor if applicable.

(2) Taking responsibility for results of any orders that have been placed.

(3) Assigning a surrogate to receive abnormal test result notifications when they are not available to review results in a timely manner.

d. Imaging ADPACS are responsible for ensuring that parameters for Diagnostic Codes are appropriately set to issue mandatory View Alerts.

6. CUSTOMER SATISFACTION: Patient/family satisfaction issues were considered in the development of this policy.

7. REFERENCES: ACR standard for Communication: Diagnostic Radiology.

8. RESCISSION: Medical Center Policy 115-12-320, dated April 24, 2012, same subject.

9. DISTRIBUTION: Electronic Access to All Employees

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