36C24419R0074-011.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 111-28 September 6, 2011

PATIENT NOTIFICATION OF CRITICAL TEST RESULTS

I. PURPOSE: To establish a notification system for patients with test results that meet "critical values" criteria or that yield values indicating a potential risk to the patient as determined by the attending/requesting physician.

II. POLICY: When test results meet the description in Paragraph I, purpose, notification of the attending/requesting physician will be accomplished immediately.

III. RESPONSIBILITY:

A. The attending/requesting physician, upon notification of the subject test values, will evaluate the need for immediate contact with the patient. In the event of urgency, the physician will attempt to make contact with the patient. If this is unsuccessful, the physician will write a note in the patient chart advising appropriate intervention and designating a nursing staff co-signature. The provider must then provide a verbal hand-off with the designated nursing staff members alerting them of the need for patient notification.

B. The Chief of Staff and Chief of Clinical Services will be responsible for having a mechanism in place that will ensure the patient's notification as an emergent/urgent priority task.

C. The Medical Director for Primary Care, Medical Director for Surgery and the Medical Director of the ER will perform oversight, evaluation, and corrective action, as necessary, to ensure the process promotes quality patient care.

IV. PROCEDURES:

A. This memorandum applies to any test performed by this medical center.

B. In Radiology, the radiologist interpreting the film should notify the attending/requesting physician or designee directly, or through a radiolology technician, of any unexpected, new and/or significant abnormalities requiring emergent/urgent intervention, e.g., pneumothorax, free air in the abdomen, a new lesion, etc.

C. Critical lab results are those diagnostic, abnormal findings that require rapid

Attachment I

MCM 111-28, Patient Notification of Critical Test Results communication for immediate intervention or close clinical monitoring.

Following confirmation of critical lab results by the medical technologist, the patient’s healthcare provider or designee, will be notified. For critical result communication outside of administrative hours, the Medical/Surgical back up or MOD will be contacted. The notification path will include the provider receiving the verbal report, writing down the information and reading back the information to the medical technologist. It is expected that this notification process will be completed within 30 minutes from the time in which the result was known. Following notification, the laboratory result will be released into the VistA system with complete documentation of the notification path. These results will be flagged in VistA with a “*” designating a critical value. In addition, a View Alert will automatically generate in CPRS.

D. The primary care provider who contacts the patient will document the communication in the patient’s medical record, including the date and time of the scheduled notification appointment.

E. Unsuccessful attempts to contact the patient by the physician should also be documented in the medical record.

F. HCT/PSA/RN/LPN/PCF, as appropriate, will comply with the physician’s order in the time frame specified by the order. A social worker may be contacted as appropriate. Telephone, telegram, local police, VA driver, etc., may be utilized to notify a patient when time is of the essence.

V. REFERENCES:

A. MCM 115-05, Communication of Critical Values for Laboratory Tests (current edition).

VI. FOLLOW-UP RESPONSIBILITY: Chief of Clinical Services

VII. REPORTING REQUIREMENTS: None

VIII. RESCISSIONS: MCM 111-28, Ambulatory Care Recall of Patients, March 13, 2007.

(Original Signed 09/06/2011)

MICHAEL D. ADELMAN, M.D.

Medical Center Director

Attachment I