D21 ORDERING AND REPORTING TEST RESULTS.docx

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

G.V. (SONNY) MONTGOMERY VA MEDICAL CENTER

Policy Memorandum: F-11-82 August 21, 2018

ORDERING AND REPORTING TEST RESULTS

I. PURPOSE: To provide guidelines regarding the VHA requirements for communication of test results for laboratory testing, diagnostic imaging and diagnostic procedures to practitioners and Veterans.

II. POLICY: Clinicians at the G. V. (Sonny) Montgomery VA Medical Center will communicate test results to Veterans or the Veteran’s personal representative no later than 14 calendar days from the date on which the results are available to the ordering practitioner.

III. DEFINITION:

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

B. Critical Value or Result: A critical test result is defined as those values or interpretations that, if left untreated, could be life threatening or place the Veteran at serious risk. All emergent test results and some abnormal test results constitute critical values or results. See facility policy F-113-36, Critical Values and Other Mandatory Notifications for a table of Critical Values/Results as defined by Laboratory Services and the Medical Staff.

C. Emergent Test Results: An emergent test result is a diagnostic finding that is associated with a high likelihood of short-term poor outcome and requires either immediate therapeutic intervention or close monitoring.

D. Abnormal Test Result: An abnormal test result is a diagnostic finding that requires attention by the ordering practitioner, but not necessarily in an immediate time frame.

E. Read-back Process: A process of verifying critical test results or verbal/telephone orders. The staff member, who receives the result, either verbally or by telephone, must Read-Back the result(s) to the caller in order to verify that the result(s) reported were accurately heard. The receiver of the critical result should write down the result or enter it into the computer, then read it back and receive confirmation from the individual who gave the result that it is correct.

IV. RESPONSIBILITY:

A. The Medical Center Director is responsible for ensuring that a written facility policy regarding communication of test results from diagnostic practitioner to ordering practitioner is in place. This policy must ensure:

1. The appropriate process is followed for each individual test result (see Att. A).

In all cases when the ordering practitioner and surrogate practitioner are unavailable, a service level process must be in place for the communication of emergent test results to another practitioner who can take action.

Note: The Emergency Department should only be given primary responsibility for test results that are life threatening.

2. That critical tests, and critical results and values are defined.

3. That the acceptable length of time between the ordering of tests or collection of specimens and the availability of results or critical values is defined.

B. Chief of Staff is responsible for:

1. Ensuring that the timeframe of test result communication is monitored and reviewed.

2. Ensuring that identified deficiencies in the communication process are corrected with the appropriate service chiefs.

3. Ensuring facility clinical service chiefs establish a chain of communication within their department for receipt of, and communication of test results to Veterans.

4. Ensuring that the organization collects data on the timeliness of reporting critical tests and critical values or results to Veterans.

5. Ensuring the facility collects and assesses the monitoring data, identifies the need for improvement, takes appropriate corrective action, and measures the effectiveness of those actions

6. Ensuring that communication of test results to practitioners and Veterans is periodically monitored to document adherence to Veterans Health Administration (VHA) and local policies.

C. Service Chiefs are responsible for:

1. Establishing a chain of communication within their department for receipt of and communication of test results to Veterans.

2. Ensuring that the diagnostic and ordering practitioner or designee executes their responsibilities as outlined in this policy.

3. Ensuring that the Diagnostic Practitioner/designee:

(a) Identifies and expediently communicates all critical, emergent, or abnormal test values or results to the ordering practitioner, the practitioner’s surrogate, or the supervisor, as appropriate.

(b) Ensures that test results reports that are verified to be accurate are available in the Veteran’s electronic medical record within the required timeframe.

(c) Documents the time and means of such communication and the name of the practitioner contacted in the medical record. This documentation is not required for abnormal tests that are not critical or emergent.

4. Ensuring that the Ordering Practitioner/designee:

(a) Places the initial order and identifies the surrogate practitioner, when applicable.

(b) Initiating the appropriate clinical action and follows up the results of any orders which they have placed.

(c) Assigning a qualified surrogate practitioner to receive critical, emergent, or abnormal test result notifications when they themselves are unavailable to review results in a timely manner to prevent avoidable delays in treatment or response.

(d) Documenting treatment actions in response to critical, emergent, or abnormal test results in the patient’s electronic medical record.

(e) Communicates outpatient test results to patients in accordance with the following standards:

1) Results are communicated to patients no later than 14 calendar days from the date on which the results are available to the ordering practitioner. Significant abnormalities may require review and communication in shorter timeframes but 14 days represents the outer acceptable limit. For abnormalities that require immediate attention, the 14 day limit is irrelevant, as the communication should occur in the timeframe that minimizes risk to the patient.

Note: Separate VHA policies may set standards regarding communication of results for specific tests. When separate VHA policies exist that set standards for communication of specific test results, the shorter standard (of the separate policy or the 14 day standard of this policy) takes precedence.

5) Document that the communication was received and understood, for communications where it is important for the Veteran to quickly take some kind of 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 Veteran or appropriate representatives in person, with an opportunity for questions and discussion. Human Immunodeficiency Virus (HIV) test results should be communicated according to current VHA policy (see Handbook 1004.01).

6) Communication of the test results to Veterans outside of the setting of an outpatient visit is documented in the medical record.

7) The results are communicated by the practitioner or designated register nurse.

8) When tests are ordered by residents, the preceptor has the responsibility for ensuring that the required communication and documentation occurs.

9) When, despite best efforts, it is not possible to contact the Veteran (e.g., the Veteran has moved and left no contact information), all attempts to communicate with the Veteran are documented in the medical record.

Note: Inpatient, emergency, or urgent care often involves extensive, repetitive testing with rapidly changing clinical conditions. Therefore, for Veterans in the inpatient, emergency, or urgent care setting, it is not required or expected that each individual test result is communicated to the Veteran. The ordering practitioner or the care team the Veteran is part of should strive to effectively communicate relevant information to the Veteran about the patient's medical condition. Results of specific tests should be included in this communication as appropriate.

D. Patient care providers/physicians on duty or surrogates are responsible for timely therapeutic action on the reported critical value(s) test result(s), and ensuring any change in plan of care should be documented. The test result(s) should be communicated to the patient within the appropriate timeframe.

E. Administrative Officer of the Day (AOD) is responsible for assisting the physician on duty during off-duty hours to contact the outpatient/Community Based Outpatient Clinic (CBOC) Veteran concerning a critical test result.

V. PROCEDURES:

A. Communication of critical and emergent test results to Veterans will occur in person or by telephone.

B The ordering practitioner or care team should strive to effectively communicate relevant information to the Veteran about his/her medical condition. Results of specific tests may be included in this communication as appropriate.

C. Results from tests ordered on a Veteran while inpatient, but reported and received after the Veteran’s discharge will be communicated and documented by the ordering inpatient provider or their surrogate.

D. Communication of normal test results for Veterans in the outpatient setting is to be completed within 14 calendar days from the date the results are available to the ordering practitioner. This communication is to be documented in the Veteran’s medical record.

Note: Significant abnormalities may require review and communication in shorter timeframes that minimize the risk to the patient.

E. For Veterans who lack decision making capacity, test results will be communicated to the personal representative of the Veteran.

F. Test results will be reported to and reviewed by the ordering practitioner or designee. Critical values will be called to the designated practitioner as outlined in policy, F-11Q-62 Reporting Critical Diagnostic Test Results.

G. Communication of noncritical or non-emergent test results to Veterans may occur in person, by telephone or in writing.

1. Test results may be discussed during the Veteran’s clinic visit, if available.

2. Test results may be communicated to Veterans by secure messaging.

H. Results will be communicated by the provider or designated registered nurse.

I. The provider or designated registered nurse will attempt to contact the Veteran with critical or emergent test results by telephone twice within three (3) days of the provider being notified of the test result. If attempts are unsuccessful, a certified letter with return receipt notification will be sent to the Veteran within two (2) business days of the last telephone attempt directing the Veteran to contact the facility as soon as possible to schedule a follow-up appointment.

VI. REFERENCE:

A. VHA DIRECTIVE 2009-019, ORDERING AND REPORTING TEST RESULTS, March 24, 2009.

B. Policy F-11Q-62, Reporting Critical Diagnostic Test Results, dated June 22, 2015.

C. Policy F-113-36, Critical Values and Other Mandatory Notifications, dated May 7, 2014.

D. Radiology Policy F-114-26, Notification and Follow-up of Abnormal Radiology Findings, dated, December 18, 2013.

VII. RESCISSION: None.

/s/ David M. Walker, MD, MBA, DFAPA Medical Center Director

ATTACHMENTS:

Attachment A. Process for Communicating Test Results By Diagnostic Practitioners to Ordering Practitioners

EXPIRATION DATE: August 23, 2023

RESPONSIBLE OFFICE: Chief of Staff

ATTACHMENT A

PROCESS FOR COMMUNICATING TEST RESULTS BY DIAGNOSTIC PRACTITIONERS TO ORDERING PRACTITIONERS

1. CRITICAL VALUES OR RESULTS:

a. Critical values or results must be transmitted immediately by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner or surrogate practitioner, and this communication must be documented in the Veterans Health Information Systems and Technology Architecture (VISTA).

b. For telephonic reporting of critical values or results, the complete test result must be verified by having the person receiving the information record “read back” the complete test values or results. It is expected that:

(1) The receiver of the information writes down the complete critical values or results or enters it into the medical record system.

(2) The receiver of the information reads backs the critical values or results.

(3) The receiver of the information receives confirmation from the individual who gave the critical values or results.

2. EMERGENT TEST RESULTS:

a. Emergent Test Results must be transmitted by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, and this communication must be documented in VISTA.

b. If the ordering practitioner is not available, communication needs to be made to the surrogate practitioner, as established by facility policy. The ordering practitioner, or surrogate, must document receipt of this information, as well as any changes to the care plan. In all cases, when the ordering practitioner and surrogate practitioner are unavailable, a process must be in place for the communication of emergent test results to another practitioner who can take action, such as the medical officer of the day, the senior medical resident, or the leader of the facility’s “rapid response team,” or equivalent.

3. ABNORMAL TEST RESULTS:

Abnormal test results may be transmitted from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, by direct or electronic communication. The ordering practitioner, or surrogate, needs to document any change in care plan.

4. TEST RESULTS THAT ARE NEITHER EMERGENT NOR ABNORMAL:

Test results that are neither emergent nor abnormal may be communicated to the ordering practitioner or surrogate but must be communicated to the Veteran within 14 days.