D.39 Reporting Imaging Test Results 02.pdf

DEPARTMENT OF VETERANS AFFAIRS (VA)

SALT LAKE CITY HEALTH CARE SYSTEM

Salt Lake City, Utah

MEMORANDUM 114.07 November 15, 2016

REPORTING IMAGING TEST RESULTS

1. PURPOSE:

To define the policy for reporting imaging test results to referring providers at the VA

Salt Lake City Health Care System (VASLCHCS).

2. BACKGROUND:

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

3. POLICY:

It is the VASLCHCS's policy that imaging test results be communicated to the ordering provider within a timeframe that allows prompt attention and appropriate action. This policy defines appropriate timeframes for reporting of imaging exam results based on the urgency of the request and defines expectations for communication of critical test results and critical abnormal findings.

4. PRODEDURES:

a. Imaging studies performed at this facility will be ordered electronically in CPRS.

Orders must indicate the reason for the study, the name of the ordering provider, and contact information.

b. Reports for imaging studies performed at this facility should be entered and verified in the electronic medical record within 48 hours of the completion of the exam.

c. Reports for STAT exams should be available, either in preliminary or final status, in the electronic medical record within 2 hours of the exam being completed. Reports for

URGENT exams should be available, either in preliminary or final status, in the electronic medical record within 12 hours of the exam being completed.

d. Important or critical abnormal radiographic findings shall be communicated in accordance with Memorandum 114.06, “Reporting of Critical and Other Significant Radiology and Nuclear Medicine Results.”

D.39 REPORTING IMAGING TEST RESULTS

36C25923R0008

MEMORANDUM 114.07

e. Results of radiology exams designated as “Critical Tests” which are STAT

Operating Room exams to rule out retained surgical instruments or retained foreign material shall be called verbally to the requesting provider no later than 30 minutes after completion of the exam. Documentation of this contact shall be made in the radiology report.

5. RESPONSIBILITIES:

a. Chief, Radiology Service is responsible for:

(1) Instructing staff regarding policies and procedures for communication of imaging test results.

(2) Monitoring the reporting of critical test results and critical abnormal findings in accordance with Memorandum 114.06 and the 2015 Joint Commission National

Patient Safety Goals.

b. Radiology physicians are responsible for:

(1) Ensuring that verified test result reports are available in the electronic medical record in a timely manner;

(2) Identifying and communicating results of STAT and URGENT exams.

(3) Identifying and communicating critical test results and critical abnormal results and adequately documenting the communication of these results where required.

c. Ordering providers are responsible for:

(1) Placing the initial order with appropriate contact information and with appropriate clinical history;

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

(3) Assuming responsibility for any critical test results and critical abnormal findings that are communicated by the radiology staff.

MEMORANDUM 114.07

6. REFERENCES:

1. ACR Standard for Communication: Diagnostic Radiology

2. 2015 Joint Commission National Patient Safety Goals

7. RESCISSION: Medical Center Memorandum 114.07 dated November 19, 2012.

8. RECERTIFICATION DATE: This Policy is scheduled for recertification on or before last work day of November 2019.

9. FOLLOW-UP RESPONSIBILITY: Chief, Radiology Service (114)

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Shella Stovall, MNA, RN, NE-BC

Acting Director