D.20 NMVAHCS Memorandum 11-81 Ordering and reporting Test Results.docx

Memorandum 11-81 Subj: Ordering and Reporting Test Results August 8, 2019 1.

ORDERING AND REPORTING TEST RESULTS

1. Policy: The Veterans Health Administration (VHA) is committed to reporting test results in a timely manner so that appropriate and effective therapeutic action may be taken. Furthermore, the VHA is committed to supporting the Joint Commission National Patient Safety Goal of improving the effectiveness of communication among providers. Timely notification of diagnostic test results to patients is essential to the provision of quality care.

a. Definitions:

(1) Ordering Practitioner: An ordering practitioner is a practitioner authorized to enter and sign orders for diagnostic tests by privileges or acting under a scope of clinical practice.

(2) Diagnostic Practitioner: A diagnostic practitioner is a practitioner who performs or supervises the performance and interpretation of diagnostic tests by privileges or acting under a clinician.

(3) Test Result: Test results include the results of laboratory testing, diagnostic imaging, and diagnostic procedures.

b. Statement of Policy: It is the policy of New Mexico Veterans Affairs Health Care System (NMVAHCS) to establish processes that diagnostic test results must be communicated to the ordering practitioner, or surrogate practitioner, within a timeframe allowing prompt attention and appropriate clinical action to be taken, and that the ordering practitioner further communicates such test results to patients, so that they may participate in health care decisions.

2. Responsibility: All Clinical Service Chiefs are responsible for implementing this policy for their respective Services.

3. Procedure:

a. Test results reports should be available to a practitioner within individual timeframes established by the performing diagnostic service and available by contacting that Service via the Computerized Patient Record System (CPRS).

(1) Critical test results should be communicated under the guidelines established in Medical Center Memorandum (MCM), 11-64, Critical Tests Results.

(2) Each clinical service chief must establish a chain of responsibility within their department for receipt of test results and communication of results to patients.

(a) A qualified surrogate must be established for every practitioner that will be unavailable to receive test results for any period of time.

(b) The surrogate will be responsible for communicating test results within established protocols for their service.

(c) All Clinicians, including Physicians, Dentists, Psychiatrists, Residents/Interns, Fellows, Nurse Practitioners (NP) and Physician Assistants (PA) students are responsible for establishing a surrogate.

b. Each provider must ensure that test results are communicated to patients in accordance with the following time frame standards:

(1) All test results requiring action must be communicated by the ordering provider, or designee, to patients no later than seven calendar days from the date on which the results are available.

(2) 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.

(3) For abnormalities that require immediate attention, the 7-day limit is irrelevant, as the communication should occur within a timeframe that minimizes risk to the patient.

c. Tests ordered while the patient is an inpatient, but with results reported after discharge, are treated as outpatient tests and should follow the above reporting time frames. These test results are communicated by the ordering inpatient provider or surrogate to the patient.

d. Communication of test results with patients can occur in person, by telephone or in writing. The content of the communication may vary from case to case but must be sufficiently detailed to allow the patient to be informed and engaged in his or her health care. When an action or therapeutic intervention is indicated, the responsible provider will discuss potential actions or therapeutic interventions. Complete documentation must also occur. Secure messaging through My HealtheVet is an acceptable method of communication. Until approved secure messaging systems have been established by VHA, no patient identifiable information is to be communicated to patients by email.

(1) Results are communicated by licensed or certified health care staff. It is not required that the ordering practitioner personally communicate every result, but this task may be delegated to other licensed health care staff when clinically appropriate.

(2) When residents, interns, fellows, or students order tests, the preceptor/attending has the responsibility for ensuring that the required communication and documentation occurs.

(3) When, despite best efforts, it is not possible to contact the patient (e.g., the patient has moved and left no contact information) and three or more attempts to communicate with the patient are documented in the medical record, then the ordering provider (with the authorization of Service Chief) will utilize a certified letter for all test results requiring action. To request this service, use Rept. FL 90B-200, Customer Request for Special Service for certified letters.

(4) To set up a surrogate, Take the following steps:

(a) Click on the Menu Bar and select “Tools.”

(b) Go to the “Options” menu and select

(c) Click on the “Notification” Tab

(d) Select the “Surrogate Settings.”

(e) Choose a Surrogate from the drop-down bar.

(f) Click the “Surrogate Date Range” to specify a specific date range.

(5) See MCM 11-64, Critical Test Results, for guidance on test values.

e. For patients in emergency or urgent care settings, the ordering provider will strive to effectively communicate relevant information to the patient about the patient's medical condition. Under conditions where there is extensive repetitive testing with rapidly changing medical conditions, it is not required or expected that each individual test result is communicated to the patient. Results of specific tests may be included in this communication as appropriate. Communication of test results to patients under these circumstances will be documented in the medical record.

f. Monitoring: All Clinical Services will incorporate appropriate monitoring of patient notification of test results and proper surrogating of providers through their ongoing quality assurance process.

4. References: The Joint Commission Hospital Accreditation Standards, National Patient Safety Goal 2, pages 114-116; VHA Directive 1088, Communicating Test Results to Providers and Patients.

5. Rescission: Medical Center Memorandum (MCM) 11-81, Ordering, and Reporting Test Results, dated November 23, 2009.

6. Expiration Date: August 8, 2022.

Signed MCM in D/FMO Files Andrew M. Welch, MHA, FACHE Director

Distribution: “M”