Sample Policy: Reporting Test Results

This model policy is intended as guidance to be adopted or adapted consistent with the internal needs of

your organization.

Subject: Reporting Test Results

Philosophy and Purpose

 [Name of physician practice] recognizes the importance of prompt review and communication of

test results to ensure accurate diagnoses, effective attention and treatment, and optimal patient

care.

 Policies and procedures for reporting test results support effective communication among

providers and between providers and patients.

Key Definitions

Abnormal test result. Test result that requires the ordering provider’s attention as soon as possible but is not as

urgent or life-threatening as a critical result. Abnormal findings are values that are above or below the established

norms for a particular test. Typically, laboratories or testing centers judge which values are considered abnormal

(for example, a value considered abnormal for some patients may qualify as normal for a patient who previously

had a critical test result).

Critical test result. Test result for a condition that if left untreated may be life-threatening or place the patient at

serious risk. Patients require urgent clinical attention.

Critical tests. Tests that require immediate notification of results, whether critical, abnormal, or normal

(e.g., suspected retained object during surgery).

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Direct verbal communication. Communication of test results by telephone, face-to-face encounter, or

report personally handed to the ordering provider.

Electronic communication. Communication of test results by e-mail, fax, electronic health records, or other electronic

means.

Normal test result. Test result that falls within the normal parameters for the particular test established by the

laboratory. Requires patient notification but not on an immediate basis.

Ordering or referring provider. The provider who initiated a test for a particular patient. The provider is responsible

for reviewing, signing, and acting on diagnostic tests under the scope of his or her clinical practice.

Surrogate provider. A provider designated to act on test results on behalf of the ordering provider if the

ordering provider is unavailable.

Test result. Test results include the results of laboratory tests, cardiology tests, radiology, and other diagnostic

procedures.

Policy

Test results must be communicated to the ordering provider, or a surrogate provider if the ordering

provider is unavailable, within a period of time that allows prompt clinical action to be taken. The

ordering provider must communicate all test results, including normal results, to patients within

specified time frames (see the discussion, Procedures) to ensure patients are active participants in their

healthcare. This policy applies to all types of test results, such as laboratory, cardiology, radiology,

and other diagnostic tests.

Provider and Staff Responsibilities

Executive director/clinic director

 Implement written policy on reporting test results.

 Designate surrogate providers (e.g., on-call clinician, primary care physician) who will be

responsible for reviewing and acting on critical test results when the ordering provider is not

available. Establish a chain of responsibility.

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  Regularly review and reevaluate which test results qualify as critical or abnormal.

 Regularly review and reevaluate policies.

 Ensure the physician practice regularly collects data on the timeliness of reporting test

results and communicating results to patients.

 Ensure the physician practice makes necessary improvements.

Ordering provider

 Follow up on, review, and take action on ordered test results, regardless of the

ordering provider’s specialty or relationship to the patient.

 Document name, phone number, pager number, or other contact information and

surrogate provider on the order form for tests.

 Document all actions taken in response to test results in the patient’s medical record (see

the discussion, Documentation).

 Communicate test results to patients within specified time frames.

Surrogate provider

 Must have the authority to take action on critical test results. Staff members who may serve as

surrogate providers include primary care physicians, covering physicians, laboratory

directors, or the clinic director.

 When contacted with a critical result, responsible for reviewing and following up on the result

and communicating necessary information to the patient (e.g., come in to the office, go to the

emergency department [ED]).

 Document all actions taken in response to test results in the patient’s medical record.

 Communicate actions taken to the ordering provider.

Medical assistant or administrative assistant

 Keep a daily log of all tests ordered (e.g., computerized or paper log).

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  Place a check mark (hard copy or electronic) in the log with the date that results that are returned to

the physician practice from laboratory, imaging facility, or other outside testing center.

 Provide returned results to the ordering provider for review, signature, and follow up action.

 Flag results that are not returned within a reasonable period of time and notify the

ordering provider.

 Highlight results that have been communicated to the patient.

Procedures

Depending on the type of test result, ordering providers may receive results from laboratories or

outside testing centers by either direct verbal communication or electronic communication (see specific

procedures for critical, abnormal, and normal test results below).

 Ordering providers must personally acknowledge receipt of the results (e.g., by telephone, call

back from page, through verification systems in the electronic medical record). Voicemails and e-

mails, including e-mails with read receipt, are not appropriate acknowledgment systems.

 When results are reported by telephone, the person receiving the information must read back

the information to the person calling with the results. The following process should be followed:

 The recipient of the result writes down the result

 The result is read back to the caller

 The caller verifies the accuracy of the result as the recipient reads it back

Depending on the type of test result, ordering providers may communicate results to patients in-

person or by letter, telephone, or e-mail (see the discussion, Critical results).

 Ordering providers may request that another licensed or certified staff member contact the

patient with results; the name of the person contacting the patient with results should be

documented.

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  When the patient must take action in response to the results (e.g., change medications, schedule

a visit to the office), providers should use direct verbal communication and document that the

information was received and understood by the patient. Providers must not include any

identifiable patient information in e-mails or on voicemail/answering machines.

 If the patient is not competent to make medical decisions, test results will be communicated to

the patient’s designated guardian or representative.

 When the patient cannot be reached (e.g., phone number is disconnected), reasonable attempts should

be made to contact the patient and attempts should be documented in the medical record. Specific

procedures for communicating critical, abnormal, and normal tests are as follows:

Critical results

 Critical results must be communicated immediately by direct verbal communication from

the outside laboratory or testing center to the ordering provider or surrogate provider.

 In cases in which the ordering provider and surrogate are not available, results must be

communicated following the established chain of responsibility.

 The following steps should be taken when the ordering provider cannot or does not respond

to notification of a critical test result:

 If the ordering provider cannot or does not respond within 10 minutes, call/page the provider a

second time.

 If the ordering provider does not respond within 15 minutes of the second call, call/page

the surrogate provider or the patient’s primary care physician (if not the ordering provider).

 If the surrogate provider does not respond within 15 minutes, call/page the surrogate provider

a second time.

 If the surrogate provider does not respond within 15 minutes of the second call, call/page

the executive director or medical director.

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  Critical results must not be communicated over voicemail, e-mail, or to administrative

assistants or other unlicensed staff members.

 Critical results and necessary actions (e.g., come in to the office, go to the ED) should also

be communicated to patients immediately by direct verbal communication.

 The physician practice must make every attempt to contact the patient (e.g., visiting local shelter,

enlisting assistance from local authorities). All communication or attempts to communicate must

be documented.

Abnormal results

 Abnormal results may be communicated to the ordering provider by direct

verbal communication or electronic communication.

 Abnormal results must be communicated to the patient within a set timeframe but not to exceed

14 days.

 Results can be communicated to the patient by certified letter with return receipt requested or by

telephone.

 The physician practice must make every attempt to contact the patient (e.g., visiting local

shelter, enlisting assistance from local authorities). All communication or attempts to

communicate must be documented.

Normal results

 Normal results may be communicated to the ordering provider by direct verbal

communication or electronic communication.

 Normal results should be communicated to the patient within a reasonable period of time. Results

may be communicated in-person or by letter, telephone, or e-mail. Providers must not include any

identifiable patient information in e-mails or on voicemail/answering machines.

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  All communication or attempts to communicate must be documented.

Documentation

The ordering provider must document:

 Acknowledgment of receipt of results

 Actions taken related to the patient

 Patient notification, including date and time of notification, means used to communicate

results (e.g., phone call, letter), and person spoken to (if applicable)

 All attempts to contact the patient if the patient cannot be reached

 Other clinical information as appropriate

Approvals

Executive Director: ____________________________________ Date: ____________

Risk Manager: ____________________________________ Date: ____________

Chief Medical Officer: ____________________________________ Date: ____________

References

Hanna D, Griswold P, Leape L, et al. Communicating critical test results: safe practice recommendations.

Joint Commission Journal of Quality and Patient Safety 2005 Feb;31(2):68-80.

Massachusetts Coalition for the Prevention of Medical Errors. Sample draft single policy format: communicating

alert values/interpretations [online]. [cited 2011 Jun 10]. Available from Internet:

http://www.macoalition.org/Initiatives/docs/CTRexamplePolicies.pdf.

Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Joint

Commission Journal on Quality and Patient Safety 2010 May;36(5):226-32.

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U.S. Department of Veterans Affairs Veterans Health Administration (VHA). VHA directive 2009-019: ordering and

reporting test results. 2009 Mar 24 [cited 2011 Jun 10]. Available from Internet:

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1864.

All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and

nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare

laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute

urges all members to consult with their legal counsel regarding the adequacy of policies, procedures, and forms.

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