D.10 Communication Test Results to Providers 02.pdf

D.10 COMMUNICATION TEST RESULTS TO PROVIDERS

36C25923R0040

PROVIDERS ORDERS/CRITICAL RESULTS

EASTERN OKLAHOMA VA HEALTH

CARE SYSTEM

Muskogee, OK

Signatory Authority:

Mr. Nathan Lawrence Chief Quality, SOP 11-03

Service Line(s):

All Services

Effective Date:

February 9, 2021

Safety, and Value

Responsible Owner:

Patient Safety Manager

1. PURPOSE AND AUTHORITY

Recertification Date:

February 9, 2021

a. The purpose of this standard operating procedure (SOP) is to ensure all patient care orders, reports, and notes be entered into the electronic patient record to assure complete, accurate records in a timely, safe manner. All professional personnel are accountable to appropriately use the electronic patient record when entering orders as herein described. Critical results must be communicated to the ordering practitioner, or provider’s supervisor, within a specific time frame allowing prompt attention and appropriate clinical action to be taken so the ordering practitioner can communicate such test results to patients, so they may participate in their health care decisions.

b. The purpose of this SOP is to reiterate policies and procedures concerning the writing of orders by physicians, dentists, nurses, advanced registered nurse practitioners (ARNPs), certified nurse anesthetists (CRNAs), clinical nurse specialists (CNSs) and physician's assistants (PAs), to establish the policy and requirements of critical results and verification of all, and to establish policies and procedures regarding communication of patient test results to patients.

c. The targeted goal for the turnaround timeframe for critical test results will be within 1 hour. It is the policy of EOVAHCS that test results be communicated to patients, so they may participate in their health care decisions. All test results requiring action must be communicated by the ordering provider, or designee, to patients no later than 7 calendar days from the date on which the results are available. For test results that require no action, results must be communicated by the ordering provider, or designee, to patients no later than 14 calendar days from the date on which the results are available. For abnormalities that require immediate attention, the 7-day limit is irrelevant, as the communication should occur in the timeframe that minimizes risk to the patient. The results are to be communicated by licensed or certified health care staff. It is not required for the ordering practitioner to personally communicate every result, so this task may be delegated to other licensed health care staff when clinically appropriate.

February 9, 2021 SOP 11-03

d. When tests are ordered by residents, the supervising practitioner is responsible for ensuring the required communication and documentation occurs. When, despite best efforts, it is not possible to contact the patient (e.g. the patient has moved and left no contact information), all attempts to communicate with the patient are documented in the medical record. A minimum, of two (2) attempts to call the patient must be completed and documented. If unable to contact the patient a certified letter will be sent requesting the patient to call their Provider. If the patient has not contacted their Provider in 7 days a certified letter can be sent with all test results requiring action.

2. PROCEDURES

a. Emergency verbal and telephone orders. Emergency verbal and telephone orders may only be given by a registered nurse (RN) and must be electronically signed within 24 hours by the ordering provider or designee. A Registered Respiratory Therapist (RRT) may take emergency verbal or telephone orders from a provider for ventilator settings or respiratory treatments only. The RRT will enter the complete telephone/verbal order into the EMR. The RRT is to read back the telephone/verbal order to the physician verbatim and receive confirmation from the physician that the “read back” was correct (to verify accuracy). The RRT will also initiate a VA Alert which will signal the physician to cosign the order. (See Appendix A)

b. All telephone/verbal orders. All telephone/verbal orders the RN will enter the order into the patient’s orders in the Electronic Medical Record (EMR) “read back” the order to the provider and document the “read back” process. The RN will enter all telephone/verbal orders into the Electronic Medical Record (EMR) with “read back” to verify conformation from the provider and to document the “read back” process. (See Appendix A) The RN will also initiate a VA Alert which will signal the provider to cosign the order.

c. All critical results will be reported to the ordering provider or designee.

(with a reasonable attempt to contact such provider) or provider’s supervisor (if ordering provider not readily available). The ordering provider, provider designee or provider’s supervisor will utilize the “read back” process to notify lab personnel to verify accuracy. Lab personnel will confirm such accuracy and will then enter all “laboratory pertinent information” into the EMR. Critical results from all on-site outpatient areas and community-based outpatient clinics (CBOCs) which are completed during non-administrative hours are to be called to the Medical Officer of the Day (MOD) or the current Emergency Department (ED) provider’s attention, if MOD not readily available.

The MOD, provider or ED provider will utilize the “read back” process to assure accuracy. The MOD or ED provider will advise patient to proceed to Jack C.

Montgomery VA (JCMVA) ED or the nearest ED if critical value is life threatening/emergent as appropriate.

d. Telephone/verbal orders may only be taken in the following situations (See Appendix A):

(1) If the provider is attending to a patient in an urgent/emergent situation; thus, the provider cannot leave this patient to directly enter orders into another patient with urgent/emergent needs EMR.

(2) If provider is off station or in surgery and needs to give specific orders, the delay of which would pose a threat to the patient’s wellbeing; e.g., urgent/emergent situation.

e. When a RN receives a telephone/verbal order in one of the above situations, he/she is to:

(1) Enter the complete telephone/verbal order into the EMR.

(2) Read the telephone/verbal order back to the provider verbatim and receive confirmation from the provider that the “read back” process was correct (to verify accuracy).

(3) The RN will electronically change the ordering provider to the provider who issued the telephone/verbal order; and document in the Order Entry Comment section that the “read back” process was completed. The RN will initiate a VA alert, which will signal the provider to cosign the order. If a mid-level provider has given the order, the VA alert will be sent to the mid-level provider and the supervisor working with the mid-level provider.

(4) The provider will receive an unsigned order view alert. The ordering provider must electronically sign these orders within 24 hours. (During an emergency situation, Registered Respiratory Therapists (RRT’s) may take verbal orders for ventilator setting changes from a physician. Once the emergency is over, the provider will enter those orders electronically.)

f. Items (1) through (9) below pertain to provider orders and inpatient staff.

(1) All narcotic (Schedule II) orders will be written for a period not to exceed 72 hours and will be completely rewritten for each succeeding period of 72 hours or less.

When requested by the attending physician, exceptions not to exceed 14 days may be approved by the Chief of Staff to care for patients with end of life care.

(2) Antibiotics, steroids, anticoagulants and controlled medications, Schedules III, IV and V, will be written for a period not to exceed 7 days and will be completely rewritten for each succeeding period of 7 days or less.

(3) IV fluid orders will be rewritten every 72 hours.

(4) All other non-narcotic medication orders shall be completely rewritten every two weeks.

(5) When a patient undergoes surgery requiring a general or spinal anesthetic, all orders will remain current. The provider will carefully review the orders to assure appropriateness after surgery.

(6) The following phrases are considered incomplete orders: “resume,” “renew previous orders”, etc.

(7) A provider’s order must be written, reviewed and renewed every 72 hours, when a patient’s rights to visitation, telephone and / or mail are restricted.

(8) All medication and treatment orders are automatically discontinued at 1 p.m. on the last day of prescribed period, unless a specific number of doses or treatments are ordered. The prescribed period begins the day the order is written.

(9) For inpatients, orders will be written as early in the day as possible utilizing the EMR. The written orders shall include the following: dose, route, and frequency of administration. The order must be electronically signed by a physician, dentist, PA, Clinical Nurse Specialist (CNS), or ARNP within privileges or scope of practice. No order will be altered retroactively. An order can be changed or canceled only by writing another order.

NOTE: Ordering medications through text orders is not allowed. If there are problems entering the correct order, contact Pharmacy.

g. Items (1) through (8) below pertain to inpatient and outpatient staff:

(1) Since this medical center has adopted and operates under the Formulary System, special care should be taken to ensure each member of the medical staff and other clinical staff uses and contributes to the formulary through the respective chiefs of service for final consideration by the Pharmacy and Therapeutics Committee.

Exceptions to this rule include medications for Institutional Review Board (IRB) approved clinical investigations that are subject to approved investigational protocols.

(2) Medications prescribed by medical center clinicians shall be approved by the Pharmacy and Therapeutics Committee, including medications for clinical investigations. It is VA policy to prohibit procurement of pharmaceuticals that have been deemed ineffective by the Food and Drug Administration (FDA). Further, it is VA policy to procure and dispense generic pharmaceuticals rated bioequivalent by the FDA unless there is a specific patient contraindication documented by the provider.

(3) When received by the medical staff protocols, guidelines, and pathways, (diagnostic or therapeutic), will be tailored to meet the needs of patients served after suitable consultation with members of the medical staff and other clinical staff and appropriate liaison with chiefs of other services whose work may be affected by the order. These shall be approved by the Medical Executive Committee.

(4) Prescriptions written by PAs, CNSs, Certified Registered Nurse Anesthetist (CRNAs) and ARNPs that are included in the individual’s scope of practice and general Mid-Level Provider (MLP) formulary system do not require physician co-signature. The MLP formulary system encompasses special areas of expertise and does not include any schedule II medications. All inpatient pharmaceutical orders and outpatient prescriptions written by CRNAs, ARNPs, CNSs, and PAs, which are not specifically identified in their Individual Scope of Practice, must be co-signed by a physician prior to being filled.

(5) Transcription and initiation of orders identified as "stat", "as soon as possible (ASAP)", or "now" take priority over routine orders. Such orders will be called to the attention of an RN by the provider at the time they are written.

(6) Orders are the ultimate responsibility of the prescribing provider, and that individual must always ensure that nursing personnel do not have to interpret the order.

The nursing personnel role is to double check the correctness of the order and to question the meaning of the provider's orders when needed.

(7) Additional procedural guidelines can be obtained from Medical Center Memorandum 11-4 Prohibited Abbreviations and Symbols, used in charting, and all pharmacy series policy memoranda. Routine medication hours are available for review on each inpatient care unit.

(8) Standing Operational Procedures may be developed by individual services and implemented after approval by a member of the Executive Leadership Team (ELT) under which the service is aligned.

h. Items (1) through (4) pertain to verbal Report of Critical Results for Laboratory, Respiratory Therapy, Imaging, Nursing for glucometers, and EKG:

(1) Laboratory Results:

(a) All critical results will be reported to the ordering provider, provider’s designee, or provider’s supervisor and written down by the ordering provider, provider’s designee, or provider’s supervisor. (See Appendix D). The ordering provider, providers designee, or provider’s supervisor will utilize the read back process to notify lab personnel/nursing staff to verify accuracy and the lab personnel/nursing staff will confirm this accuracy, and then the lab personnel/nursing staff will then enter all the laboratory pertinent information and documentation of read back into the EMR.

(b) Critical results from all on-site outpatient areas and CBOCs that are completed during non-administrative hours are to be called in to the MOD or provider’s supervisor.

The MOD’s provider or provider’s supervisor will utilize read back to assure accuracy and the lab personnel will confirm this accuracy. The lab personnel will then enter all the laboratory pertinent information into the EMR.

(c) The provider, provider’s designee or provider’s supervisor receiving the critical results will document this in EMR as appropriate. This individual may be Physician, PA, APRN, CRNA or CNS. The provider’s supervisor has the responsibility to document in the EMR the appropriate critical result and value and send VA alert to ordering provider for co-signing such documentation. Provider’s supervisor may assist ordering provider in further help with clinically dealing with the results as appropriate. This assistance will extend to results from on-site outpatient areas and CBOCs which are completed during non-administrative hours and are called into MOD or provider’s supervisor. This includes medical record documentation and patient notification. All such information documented in the EMR should trigger VA Alert for co-sign by ordering provider involved. For provider’s supervisor or provider difficulty in giving patient notification, help may be elicited from the appropriate case manager.

(2) Respiratory Therapy or Laboratory regarding Arterial blood gas results:

The RRT/laboratory personnel may follow exactly (a, b, c) above for critical results as pertains to arterial blood gas results. (See Appendix B)

(3) Radiology/Imaging Critical Results: The radiologist will verbally or telephonically notify the referring provider or provider’s supervisor (if acceptable to the Radiologist in his or her judgment) of all critical results. Critical results from all in-site outpatient areas and CBOCs that are completed, during non-administrative hours are to be called to the MOD or provider’s supervisor. The ordering provider or provider’s supervisor will utilize read back process to assure accuracy. Then the radiologist receives confirmation that the read back is accurate, all this radiological pertinent information will be entered into the EMR by the radiologist. (See Appendix C and Appendix E)

(4) Cardiologist Critical Results: The cardiologist will verbally or telephonically notify the referring provider or provider’s supervisor (if acceptable to the Cardiologist in his or her judgment) of all critical results. Critical results from all on-site outpatient areas and CBOCs that are completed, during non-administrative hours, are to be called to the MOD or provider’s supervisor. The ordering provider or provider’s supervisor will utilize read back process to assure accuracy. Then the cardiologist receives confirmation that the read back is accurate; all this radiology pertinent information will be entered into the EMR by the cardiologist. (See Appendix F).

3. ASSIGNMENT OF RESPONSIBILITIES

a. Medical Center Director (MCD). Medical Center Director is responsible for the development and implementation of a written policy regarding communication of test results to ordering providers and to patients.

(1) Define what test results are considered critical life threatening, the acceptable length of time between the availability of critical life-threatening results and receipt by the ordering provider or designee and associated notification and read-back verification processes.

(2) Ensure EOVAHCS accounts for the delegation of clear responsibility and accountability related to test result follow-up; especially when multiple providers are involved in the care of a patient.

(3) Ensures EOVAHCS follows practices and procedures to better manage Computerized Patient Record System (CPRS)-based notifications (sometimes known as “view alerts”) related to test results. CPRS-based notification is the most widely used method for asynchronous communication of test results from diagnostic providers to ordering providers or designees.

(4) Ensures inclusion and participation of other members of the ordering provider’s team to facilitate processes related to patient notification of all types of test results. This team could include Nurse Practitioners, Physician Assistants, Registered Nurses, Clinical Pharmacists, and other staff as appropriate within their scope of practice, functional statement, or position description.

(5) Describe how EOVAHCS:

(a) Maintains updated contact information for all patients in CPRS and all providers and their designees who have access to CPRS.

(b) Makes this contact information available to all staff involved in the test result notification processes.

(6) Demonstrate how communication of results to patients is being periodically monitored to document adherence to this policy.

b. Chief of Staff (COS). Chief of Staff is responsible for:

(1) Reviewing monitors of test result communication and ensuring that any identified performance improvement issues are addressed.

(2) Ensuring the clinical service chiefs establish a chain of responsibility within their department for receipt of critical results and communication of results to patients.

(3) Resolving with service chiefs any gaps detected in test result follow-up processes.

c. Service Chiefs. Service Chiefs are responsible for:

(1) Establishing procedures consistent with this MCM within their department or section for the receipt of test results from diagnostic providers to the ordering provider, or designee, and the communication of test results to patients by the ordering provider, or designee. These procedures should include plans for the delegation of authority and specify which team members can receive test results from diagnostic providers and/or notify patients of test results as appropriate within their scope of practice or position description. These procedures should describe processes so that each provider will always have coverage in the provider’s absence by a designee within their scope of practice or position description. If none of the previously identified personnel are available, test results should be reported to the ordering provider’s service chief or an equivalent supervisor. They will also establish a chain of responsibility within their department for receipt of critical results and communication of the results to patients.

(2) Reviewing procedures and practices for test result communication to both providers and to patients from each section or department you supervise as applicable.

(3) Monitoring the effectiveness of the patient notification process and addressing performance improvement issues as needed.

d. Provider’s supervisor. The Providers supervisor is responsible for:

(1) This individual will be a physician. If receiving critical results for a provider under their supervision, the provider’s supervisor has the responsibility to document in EMR the appropriate critical result and name of provider.

(2) The provider’s supervisor reports to and sends VA alert to the provider for co-signing the documentation.

(3) The provider’s supervisor may assist the provider in clinically dealing with the critical results as appropriate. This assistance will extend to results that are called to the medical officer of the day (MOD) or provider’s supervisor, including medical record documentation and any appropriate patient notification. All such information documented in the EMR should trigger VA alert for co-sign by provider involved. If the provider has difficulty in giving patient notification, help may be elicited from the appropriate Patient Aligned Care Team (PACT) members. It is understood that an ordering provider is ultimately responsible for his or her orders.

e. Nursing Staff. Nursing staff are responsible for:

(1) Calling results of critical glucometer glucoses results found on point of care testing to the provider/provider’s supervisor and utilizing the read back process and documenting in EMR actions taken, i.e., provider notification, completion of read back process and if the test has been repeated.

f. Pharmacists. Pharmacists are responsible for:

(1) Managing Warfarin medication management. Ordering tests and reviewing results of those tests for medication adjustment purposes. If the INR result is such that a laboratory blood test must be ordered, the pharmacist will order the blood test and critical results will be called to the pharmacist by the laboratory staff.

(2) The pharmacist will utilize the read back process when receiving results from the laboratory staff and the laboratory staff will document read back completed.

g. Diagnostic Provider. Diagnostic Provider is responsible for:

(1) Identifying and communicating all critical life threating test results and urgent non-life threating abnormal test results to the ordering provider or their designees.

(2) Documenting in the medical record the time and means of communication of critical life threating results and the name of the ordering provider of designee informed of these results.

(3) Ensuring that test results reports are available in the patient’s electronic medical record as soon as the reports are verified.

h. Ordering Provider or Designee. Ordering provider or designee are responsible for:

(1) Initiating appropriate clinical action and follow up action for results of any orders which they have placed;

(2) Assigning a qualified designee to receive test results when the ordering provider is unavailable. The designee assumes the responsibility to initiate appropriate clinical action and follow-up to ensure that patients are notified of test results in a timely manner. When tests are ordered by residents or other health professions trainees, the supervising practitioner is the designee and has the responsibility for ensuring that the required communication and documentation occurs.

(3) Ensuring their or their designee’s contact information if available and up to date.

(4) Communication of outpatient test result to patients in accordance with the following time frame standards: All test results requiring action must be communicated by the ordering provider, or designee, to patients no later than 7 calendar days from the date on which the results are available. Depending on the clinical context, certain test results may require review and communication in shorter timeframes. Patients enrolled in My HealtheVet Premium Accounts can view certain test results in earlier time frames (usually within 3 days of the date on which the results are available). All communication should occur within a timeframe that minimizes risk to the patient.

(a) Content and Method of Communication: The content of communication might vary from case to case but must be sufficiently detailed to allow the patient to be informed and engaged in their health care. When test results indicate that an action or therapeutic intervention is needed, the ordering provider is expected to discuss potential actions or therapeutic intervention options with the patient and initiate action. This discussion can occur synchronously (examples: in person or by telephone) or asynchronously (examples: in writing, through template-generated letters, or via secure messaging in My HealtheVet). For communication by telephone, reasonable steps should be taken in order to verify the identity of the person on the other end of the phone. For certain types of tests and certain types of patients, synchronous methods might be preferred. Automated test results released through My HealtheVet or other methods, such as template-generated letters, are acceptable methods of communicating results not requiring action or therapeutic intervention. These communication methods are still emerging and thus processes and good clinical practices in this area will evolve. Patient identifiable information must never be communicated via an unsecured method. Communication methods may need to be adjusted for Veterans with certain types of functional impairments.

(b) Documentation: Patient notifications and subsequent clinical actions must be documented in CPRS by the ordering provider(s) or designee(s) in response to critical, urgent, and clinically significant test results that require therapeutic intervention or action. If results are discussed within a patient visit, this should be documented within the visit progress note. The extent of documentation may vary depending on the context of the test result and resultant action plan or therapeutic intervention.

(c) Exceptions: In exceptional circumstances, it may be necessary to delay communication of test results beyond the timeframes identified above. For example, communicating a diagnosis of terminal cancer or Human Immunodeficiency Virus (HIV) in a sensitive, empathic manner may require a face-to-face visit at a time convenient to the patient, which could extend beyond the 7-day time frame. Due to the sensitive nature of certain test results, the determination of how to report these results are best made on a case-by-case basis. Review and discussion of test results need to be provided to the patient, or patient’s personal representative, with an opportunity for questions and discussion.

(5) Communicating test results to patients after discharge. When results of tests ordered and performed while the patient is inpatient become available after discharge, they are communicated to the patient by the ordering inpatient provider, or their designee, unless responsibility is transferred to an outpatient provider, or their designee, and the transfer is documented in CPRS. The transfer of responsibility to the outpatient provider may occur via synchronous or asynchronous communication. The requirements for transfer of responsibility, such as acknowledgment or acceptance by the outpatient provider, should be determined by the facility. The same principles also apply to results of tests that are ordered to be performed in the future in the outpatient setting.

(6) Communicating test results in acute care settings. Settings of acute care such as inpatient, emergency or urgent care often involve extensive, repetitive testing with rapidly changing clinical conditions. Therefore, for patients in the inpatient, emergency or urgent care setting, it is not required or expected that each individual test result is communicated to the patient. The ordering provider or the patient’s care team should strive to effectively communicate relevant information to the patient about the patient's medical condition, as needed, to ensure the patient is able to engage effectively in the treatment plan. Results of specific tests may be included in this communication, as appropriate.

(7) For patients that have a premium My HealtheVet account, the patient is registered as a VA Patient, has completed “In Person Authentication” and has “Opted In” to use Secure Messaging: a staff member, provider or registered nurse can initiate a Secure Message detailing the test or lab results. Secure Messaging allows for a two-way communication between the staff member and the patient about the results in a secure electronic environment. Secure Messages are then saved into EMR documenting the electronic communication.

(8) Documentation that the communication was received and understood, for communications where it is important for the patient to quickly take action, such as a change in medication or a return to the medical center for further evaluation. NOTE:

Due to the sensitive nature of certain test results, such as psychological tests, the determination of how to report these results are best made on a case-by-case basis.

Review and discussion of the test results need to be provided to the patient or appropriate representatives in person, with an opportunity for questions and discussion.

HIV test results should be communicated according to current VHA policy (see Handbook 1004.1)

(9) Taking additional measures in the following special situations:

(a) If the patient lacks decision making capacity, communicate results to the personal representative of the patient as defined in this Directive (see definitions section).

(b) If, despite best efforts, it is not possible to communicate test results to the patient (e.g., the patient has moved and left no contact information), all attempts to contact the patient are documented in CPRS. At a minimum, a certified letter should be sent for all test results requiring action.

(10) Communication of the test results to patients outside of the setting of an outpatient visit is documented in the EMR.

(11) The Radiologist will utilize direct communication to notify the referring provider (with a reasonable attempt to contact such provider) or provider’s supervisor (if provider not readily available) of all critical results. Critical results from all on–site outpatient areas and CBOCs that are completed during non-administrative hours are to be called to the MOD or provider’s supervisor if MOD not readily available. The MOD, provider or provider’s supervisor will utilize the “read back” process to assure accuracy. The radiologist will document completion of the read back process via the actual imaging report as well as appropriate codes to flag the requesting provider.

(12) The cardiologist reading the electrocardiogram (EKG) will utilize direct communication to notify the referring provider or provider designee (with a reasonable attempt to contact such provider) or provider’s supervisor (if ordering provider or designee not readily available) of all critical EKG results. Critical EKG results from all on-site outpatient areas and CBOCs that are completed during non-administrative hours are to be called to the MOD or provider’s supervisor if MOD not readily available. The MOD, provider or provider’s supervisor will utilize the “read back” process to assure accuracy. The cardiologist will document completion of the “read back” process on the actual EKG together with the time of interpretation.

i. Associate Director for Patient Care Service. Associate Director for Patient Care Service is responsible for ensuring that nursing staff complies with the “read back” process requirement. The Associate Director for Patient Care Service will monitor this requirement for compliance.

j. Chief, Radiology Service. Chief, radiology service is responsible for ensuring all critical results are expediently identified and communicated to the ordering practitioner or the practitioner’s supervisor; verified reports of results are available in the patient’s EMR in a timely manner, and that the radiologists comply with the “read back” process requirement. (See Appendix F). The Chief, Radiology Service will monitor this

k. Chief, Laboratory Service. Chief, laboratory service is responsible for ensuring all critical or abnormal results are expediently identified and communicated to the ordering practitioner or the practitioner’s supervisor; verified reports of results are available in the patient’s electronic medical record in a timely manner and the laboratory staff comply with the “read back” process requirement. (See Appendix D). The Laboratory Service will monitor this requirement for compliance.

l. Chief, Medicine Service. Chief, medicine service is responsible for ensuring all critical or abnormal results are expediently identified and communicated to the ordering practitioner or the practitioner’s supervisor; verified reports of results are available in the patient’s EMR in a timely manner and the medical service staff comply with the “read back” process requirement. The Chief, Medical Service will monitor this requirement for compliance.

m. Chief of Pharmacy. Chief of Pharmacy is responsible for ensuring all point of care critical results are expediently identified and managed according to the Anticoagulation Policy (MCM 119-06). The Chief of Pharmacy is further responsible for ensuring that pharmacists comply with the “read back” process requirement when receiving critical results from the Laboratory. The Chief of Pharmacy will monitor this

4. DEFINITIONS

a. Asynchronous Communication- Asynchronous communication is when parties involved in communication are not present at the same time, such as electronic notifications in Computerized Patient Record System (CPRS), secure messaging, Audio CARE, Fax, or letter.

b. Designee- For this policy, a designee is a clinical team member authorized by the ordering provider in a manner consistent with Veterans Affairs (VA) medical facility policies who acts on behalf of the ordering provider to receive information from the diagnostic provider (in the absence of the ordering provider) and/or notifies patients of test results in a timely manner and discusses such results with the patients, in accordance with this policy.

c. Diagnostic Provider- A diagnostic provider is a provider who performs or supervises the performance and interpretation of diagnostic tests either through privileges or by acting under a scope of practice.

d. Ordering Provider- An ordering provider is a provider authorized to enter and sign orders for diagnostic tests.

e. Patient Notification- Patient notification is communicating test results to patients or, if appropriate, to their personal representatives, including additional context and follow-up action as needed. Patient notification could occur through any synchronous or asynchronous method. For certain types of tests and certain types of patients, synchronous methods are preferred.

f. Personal Representative- A personal representative is a person, who under applicable law, has authority to act on behalf of the individual. This may include power of attorney, legal guardianship of an individual, the executor of the estate of a deceased individual, or someone under Federal, state, local or tribal law with such authority (e.g., parent of a minor)

g. Read back process- Process in which the receiver of the telephone/verbal order/critical lab test/critical radiological reading will document in the patient’s electronic medical record or electronically view such order/result and will read back what is written verbatim and obtain agreement of the accuracy of this information from sender.

h. Supervising Practitioner- Supervising practitioner refers to a licensed, independent practitioner, who has been credentialed and privileged at a VA medical facility in accordance with applicable requirements. NOTE: ‘Supervising practitioners’ are often referred to as ‘attendings’. See VHA Handbooks 1400.01, Resident Supervision, and 1400.04, Supervision of Associated Health Trainees.

i. Synchronous Communication- Synchronous communication is when parties involved in a communication are all present at the same time, such as in person, telephone conversations, or Clinical Video Telehealth (CVT).

j. Test Result- Test results include the results of laboratory and pathology testing, diagnostic imaging, and diagnostic procedures. Test results are categorized as abnormal or normal as determined by a clinical provider and are further defined as follows:

(1) Abnormal Test Results- Abnormal test results are results that fall outside a specified normal reference range, are unexpected, or could indicate the presence of disease. An abnormal test may or may not require action and therapeutic intervention, depending on the clinical context. There are three types of abnormal test results that require action or therapeutic intervention:

(a) Critical Life Threatening- Any diagnostic finding which must be acted upon by the ordering provider or their designee immediately or within a short window of time and could result in severe morbidity or mortality if left untreated. (Example: critically elevated Potassium).

(b) Urgent Non-Life Threatening- Any diagnostic finding which must be acted upon by the ordering provider or their designee within a relatively urgent timeframe (as clinically indicated to ensure timely, appropriate and effective therapeutic action). An example of this is a Chest x-ray with newly discovered nodule, which is categorized as “Critical Not Life Threatening” with an Equivalent Radiology code such as 1001- Significant abnormality - attention needed or 1003-Possible malignancy.

(c) Clinically Significant- A diagnostic finding that requires action by the ordering provider, or their designee, but not necessarily in an immediate or urgent timeframe.

(Example: High Cholesterol).

(2) Normal Test Results- While the significance of a “normal” test result needs to be determined clinically, in the context of this MCM it is defined as a diagnostic finding that falls within the normal reference range for the test and may or may not require immediate action or change in treatment depending on clinical circumstances

(3) Laboratory Pertinent Information- Critical results will be documented as to date, time, read back process and name of provider or provider’s supervisor notified.

(4) Radiological Pertinent Information- Critical results will be documented as to date, time, read back process and name of provider or provider’s supervisor notified.

k. Telephone order- A telephone order is an order conveyed verbally via the telephone by a Provider who is not on station or has no access to the Electronic Medical Record (EMR) with appropriate prescriptive authority to a RN.

l. Verbal order- A verbal order is an order in an emergent situation that is conveyed verbally in person by a provider to an RN who will in turn enter the order into the patient’s EMR, “read back” the order to the provider and document the “read back” process.

5. REFERENCES

a. Joint Commission Accreditation Manual for Hospitals

b. Joint Commission National Patient Safety Goals. Available at:

https://www.jointcommission.org/standards/national-patient-safety-goals/

c. Medical Center Memorandum 11-37, Medication Management

d. VHA Directive 1074 “Establishing Medication Prescribing Authority for Advanced Practice Nurses (APNs)” dated 04/04/2018.

e. VHA Directive 1063 “Utilization of Physician Assistants” dated 12/24/2013

f. VHA Directive 1088, “Ordering and Reporting Test Results” dated 10/07/2015

g. VHA Handbook 1108.11 “Clinical Pharmacy Services” dated 07/01/2015 (amended 06/29/2017)

6. RESCISSION

MCP 11-03, Providers Orders Critical Test Results, dated December 26, 2019, is rescinded.

https://www.jointcommission.org/standards/national-patient-safety-goals/

7. REVIEW

Review is required, at minimum at recertification and including when there are changes to the governing document.

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of February 2025. In the event of contradiction with national policy, the national policy supersedes and controls.

9. SIGNATORY AUTHORITY

Digitally signed by Nathan

Nathan T. T. Lawrence 3525237

Lawrence 3525237 Date: 2021.05.13 11:46:26 -05'00'

Mr. Nathan Lawrence MS, BSN, RN

Chief of Quality, Safety, and Value

Date Approved: Month Day, Year

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at: EOVAHCS SharePoint site:

https://dvagov.sharepoint.com/sites/mus/mcm/default.aspx

Attachments:

Appendix A, Read-Back Verification Telephone/Verbal Orders Appendix B, Critical Results: Labs & Arterial Blood Gases Appendix C, Critical Results Imaging Appendix D, Pathology & Laboratory Medicine Critical Results Appendix E, Radiology Critical Results Appendix F, Cardiology Critical Results https://dvagov.sharepoint.com/sites/mus/mcm/default.aspx

Provider is attending a patient in an urgent/emergent situation; is off station or in surgery without access to the

EMR

Provider verbally dictates order to

RN

Provider telephonically dictates order to RN.

RRT takes order in emergent situation only.

RN/RRT writes down complete order, verbatim as received and enters it into electronic medical record (EMR).

RN reads back order to provider and provider verifies the order as correct.

RN documents in EMR date and time order received, read back, verified by provider, and implementation and initiates VA alert for provider signature, and in the case of mid-level providers the supervising physician’s signature.

APPENDIX A

READ-BACK VERIFICATION

TELEPHONE/VERBAL ORDERS

RRT/Lab/Cardiology personnel/nursing telephonically notifies ordering provider or designee.

Ordering providers document in medical record – date, time of read back and Provider or provider’s supervisor accepting result and sends

VA alert.

MOD and if not available then ED provider

APPENDIX B

CRITICAL RESULTS:

LABS AND ARTERIAL BLOOD GASES

DAYTIME/BUSINESS HOURS

AFTER HOURS/WEEKENDS

Radiologist verbally/telephonically notifies referring provider or provider’s supervisor of all imaging test

Read back will be utilized to assure accuracy.

Radiologist receives confirmation that read back is accurate, s/he will document the read-back via the actual imaging report as well as appropriate codes to flag the requesting provider

APPENDIX C

CRITICAL RESULTS IMAGING

APPENDIX D

LABORATORY CRITICAL RESULTS

TEST CRITICAL LOW CRITICAL HIGH

Plasma/Serum Sodium 125 mmol/L 150 mmol/L

Plasma/Serum Potassium 2.8 mmol/L 5.7 mmol/L

Plasma/Serum Glucose 50 mg/dl 400 mg/dl

Plasma/Serum Calcium 6 mg/dl 14 mg/dl

BUN 100 mg/dl

Creatinine 5 mg/dl

Arterial Blood P02 54 mmHg

Arterial Blood PC02 25 mmHg 60 mmHg

Arterial Blood PH 7.30 7.55

Plasma/Serum CO2 Content 15 mmol/L 45 mmol/L

WBC 2,000 k/cmm 50,000 k/cmm

Fibrinogen 50 mg/dl

Platelet Count 20,000/cu.mm

Hemoglobin, Blood 8 gm/dl 20 gm/dl

PTT 136 sec

INR 3.5

Lithium 1.3 meq/L

Gentamicin (Trough) 2.1 mcg/ml

Gentamicin (Peak) 10.1 mcg/ml

Digoxin 2.0 ng/ml

Theophylline 25 mcg/ml

Phenytoin (Dilantin) 20.1 mcg/ml

Phenobarbital 40.1 mcg/ml

Vancomycin Trough >25 mcg/ml

Reference Lab Result any critical low any critical high

REPORTABLE

RESULTS

AFB Smear or Culture Blood Positive

Blood Culture Positive

India Ink Prep Positive

Malaria Smear Positive

Spinal Fluid Culture Positive

Spinal Fluid Gram Stain Positive

Transfusion Reaction Positive (Hemolytic)

Sterile site infections gram stain and culture (sterile fluids)

Positive

NOTE: All these results are critical and must follow the Critical Read Back Policy.

APPENDIX E-1

RADIOLOGY CRITICAL RESULTS

All Code 201s and 202s will be monitored for timeliness. Each medical center must establish a system to track the length of time between when the abnormality was discovered (not the time of the actual exam) and when the clinician was notified.

Table 1

Code

Diagnostic Reporting Code Definition

Verbal

Notification

Electronic

Notification

201 Critical Abnormality: Urgent Follow-Up Action Needed

Y Y

202 New Reportable Infectious Abnormality- Active TB or Other Reportable Communicable Infectious Disease: Urgent Follow-Up Action Needed

Y Y

203 Finding Suspicious for New Malignancy:

Follow-Up Action Needed

Provider Judgment

Y

204 Abnormality: Follow-Up Action Needed Provider Judgment

Y

Code 201—Critical Abnormality: Any new radiology/nuclear medicine finding that may be considered life threatening or could result in severe morbidity and require urgent or emergent clinical attention will be coded as 201. Examples of the types of critical abnormal findings that fall into the code 201 category may include cerebral hemorrhage/hematoma, acute stroke, unstable spinal fracture, pneumothorax (unsuspected or tension), pneumoperitoneum (not post op), aortic dissection, major pulmonary embolism, ruptured or leaking aneurysm, and significant misplacement of tubes or catheters (i.e., enteric tube in lungs). Use of this code requires both electronic and verbal notification to the ordering provider within 1 hour of discovering the major abnormal result. This notification will be documented in the written report. If the ordering provider is not available, the service chief or designee (such as the physician covering on-call) or MOD will be notified. It is always better to communicate findings directly with the ordering provider (physician, physician assistant or advanced practice nurse). If the ordering provider is unavailable, any other staff communication requires that they write down the findings and read them back to the diagnostic imager communicating the abnormal results. This read-back interaction must be documented in the imaging report or progress note by the interpreting radiologist.

APPENDIX E-2

Code 202—New Reportable Infectious Abnormality: Any new abnormality considered suspicious of active tuberculosis or other reportable communicable infectious disease that is a significant public health risk will be assigned Code 202.

Both a verbal and electronic notification will be made to the ordering provider within 3 hours of the finding. If the provider cannot be reached, the service, chief, or designee, will be contacted. In addition, a local mechanism will be established for the Infection Control Officer to be notified. These notifications will be documented in the report or progress note.

Code 203—Finding Suspicious for New Malignancy: Any abnormality that is suspicious or highly suggestive of new malignancy will be coded 203. The ordering provider will be alerted electronically for appropriate follow-up action. A mechanism will be established at each facility for the ordering provider or other designee to assure follow-up action is taken and documented.

Code 204—Abnormality: An abnormality that is not considered to be an urgent and immediate life-threatening finding but needs attention and follow-up action as soon as possible will be coded 204. Examples of such abnormalities may be acute fractures, new pneumonias, aortic aneurysms, etc. The ordering provider will be alerted electronically for appropriate follow-up action.

Studies performed by Community Mammography Providers must meet VHA and MQSA standards, policies, and procedures. Community mammography providers are responsible to meet all requirements within this policy for communicating the results of significant abnormal studies that they performed on patients referred to them by EOVAHCS. This includes the interpreting radiologist communicating to the ordering provider “suspicious or highly suggestive for malignancy” reports, within 3 working days and to the patient within 5 working days.

Diagnostic reporting codes will be applied to all abnormal Mammography studies.

Automatic electronic alert messages will be generated by the assignment of codes as defined below.

Appendix E-3

Table 2 Crosswalk

Code

Mammography Diagnostic

Reporting Code Definition

Verbal Notification

Electronic Notification

BI-

RADS

Codes

VHA

Handbook

1104.1 Category

21 CFR

900.12

Category

BI-RADS

CATEGORY 4

Suspicious

(4)

(D)

CATEGORY 5

Highly Suggestive of Malignancy

(5)

(E)

CATEGORY 6

Known Biopsy Proven Malignancy

(7)

No Categor y

APPENDIX E-4

Code 1104—BI-RADS CATEGORY 4 Mammogram: Suspicious abnormality – Biopsy should be considered. Mammogram findings with suspicious abnormalities (BI-RADS Category “4”) will be communicated directly by the interpreting radiologist to the ordering provider within 3 working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the 3-day limit. The interpreting radiologist will document this communication in his/her report. Additionally, a View Alert about the radiological report shall be sent via CPRS to the ordering provider. Prompt verbal notification to the patient should be made within 5 working days and does not obviate the need to provide written communication to the patient within 30 days. The provider that makes the communication is responsible to ensure it is documented in the patient record.

Code 1105—BI-RADS CATEGORY 5 Mammogram: Highly suggestive of malignancy – Appropriate action should be taken. Mammogram findings highly suggestive of malignancy (BI-RADS Category “5”) will be communicated directly by the interpreting radiologist to the ordering provider within 3 working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the 3-day limit. The interpreting radiologist will document this communication in his/her report. Additionally, a View Alert about the radiological report shall be sent via CPRS to the ordering provider. Prompt verbal notification to the patient should be made within 5 working days and does not obviate the need to provide written communication to the patient within 30 days. The provider that makes the communication is responsible to ensure it is documented in the patient record.

Code 1106—BI-RADS CATEGORY 6 Mammogram: Known biopsy – Proven malignancy – Appropriate action should be taken. Mammogram findings proven for malignancy (BI-RADS Category “6”) will be communicated directly by the interpreting radiologist to the ordering provider within 3 working days. If verbal communication to the ordering provider is not possible, the provider’s designee or service chief shall be notified within the 3-day limit. The interpreting radiologist will document this communication in his/her report.