D20 NMVAHCS Memorandum 11-81 Ordering and Reporting Test Results.pdf

ORDERING AND REPORTING TEST RESULTS

New Mexico VA Health Care System

Albuquerque, NM

MCP 11-81

Signatory Authority

Director NMVAHCS

Rescinded Document

MCP 11-81, Ordering and Reporting Rest

Results dated August 8, 2019

Service Line

Chief of Staff

Effective Date

April 20, 2022

Responsible for Updates

Chief of Staff

Recertification Date

April 20, 2027

1. POLICY

This medical center policy (MCP) establishes New Mexico VA Health Care System

(NMVAHCS) Policy on the ordering and reporting of Test Results.

2. JUSTIFICATION

This policy exists due to a local policy mandate in VHA Directive1088

Communicating Test Results to Providers and Patients.

3. SUMMARY OF CHANGES

a. Updated into new mandated Template.

b. Updated requirements to include enrollment in the Automated Lab Letter.

4. DEFINITIONS/ACRONYMS

a. Clinician. For this MCP Clinician includes Physicians, Dentists, Psychiatrists, Residents/Interns, Fellows, Nurse Practitioners (NP) and Physician Assistants

(PA) and students.

b. 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.

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

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3148

April 2022 MCP 11-81

d. Test Result. Test results include the results of laboratory testing, diagnostic imaging, and diagnostic procedures.

5. RESPONSIBILITIES

Clinical Service Chiefs. The Clinical Service Chief is responsible for:

Implementing this policy within their respective Service.

6. REQUIRED STANDARDS

a. Test Results.

Test results and reports should be available to a practitioner within individual time frames established by the performing diagnostic service and available by contacting that Service via the Electronic Health Record (EHR).

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

(2) All Clinicians will enroll in the Automated Lab Letter with CAC POC.

NOTE: The Emergency Department Service is currently exempted from enrollment, as their current practice includes notification of abnormal labs via the discharge note given to patients.

(3) Each clinical service chief will 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 clinician that will be unavailable to receive test results for any period.

(b) Clinicians are responsible for identifying the Surrogate within the EHR.

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

b. Patient Communication.

Each clinician must ensure that test results are communicated to patients in accordance with the following standards:

(1) Time Frames. Permitted time frames for communicating test results to patients include:

(a) 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. NOTE: For abnormalities that https://dvagov.sharepoint.com/sites/VHAABQDCS/ABQ%20Active%20Library/Forms/AllItems.aspx require immediate attention, the 7-day limit is irrelevant, and the communication should occur within a timeframe that minimizes risk to the patient.

(b) 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.

(2) Inpatient Tests. 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.

(3) Communication of test results. 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. NOTE: no patient identifiable information is to be communicated to patients by email. All communication must meet the following standards:

(a) 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.

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

(c) 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) Establishing a Surrogate. To establish a surrogate each clinician must adhere to the following:

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

c. Emergency of Urgent Care Settings.

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 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.

d. 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.

7. REFERENCES

a. VHA Directive 1088, Communicating Test Results to Providers and Patients.

b. Joint Commission National Patient Safety Goals.

8. RESCISSION

MCP 11-81, Ordering and Reporting Test Results dated August 8, 2019, is rescinded.

https://dvagov.sharepoint.com/:b:/r/sites/VHAABQDCS/ABQ%20Forms%20Library/Request%20for%20Special%20Delivery%20Service.pdf?csf=1&web=1&e=aKwM6D https://dvagov.sharepoint.com/sites/VHAABQDCS/ABQ%20Active%20Library/Forms/AllItems.aspx

9. REVIEW

This MCP will be reviewed 120 days before recertification or sooner if when there are changes to documents cited in references above.

10. RECERTIFICATION

This MCP is scheduled for recertification before the last day of April 2027. This MCP will continue to serve as a local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

SIGNATORY AUTHORITY

/S/ Robert McKenrick Director

NOTE: Signature remains valid until rescinded by appropriate administrative action.