As healthcare continues to shift towards the outpatient setting, more and more testing and invasive procedures require tracking and follow-up to assure important medical information is not “falling through the cracks.” In our legal system, physicians are considered “experts” on medical conditions and the consequences of non-treatment or delayed test reporting rest. The failure to notify a patient of an abnormal study or test result and/or of the need for appropriate follow-up is difficult to defend. The days of telling a patient “no news is good news” have passed.
In a study by the American Academy of Family Physicians, 72% of physicians didn’t report “normal” results to patients. This coincides with findings from the Agency for Healthcare Research and Quality. Their findings showed problems with processing test results accounted for 47% of all reported medical errors. Two of the more common “process errors” include:
- Failure to notify patients of results
- Failure to document physician reviews of results
Policies and procedures should be in place to assure all tests or consults, especially those defined as “urgent”, are immediately communicated to the appropriate staff. Don’t assume others will follow-up with the patient; identify who is responsible for communicating the results. Build redundancies into your office systems:
- Set up follow-up appointments to discuss results
- Inform patient and family to expect results by an appropriate time
- Inform patient and family to call if no result is received
File only dated and signed lab reports, radiology reports, dictation, consults and letters.
Patients should be notified of all test results, normal and abnormal. Normal results can be communicated via:
- Personal contact from the provider or staff
- Results communicated in a form letter
- Copies of test results sent via U.S. Mail
Providers who order abnormal tests should be the ones to communicate the results to the patients. Through personal contact or by telephone, the provider can ensure the patient’s questions are answered and a follow-up plan can be discussed.
Consider these recommendations:
- Don’t mail or leave a voicemail citing abnormal results
- Don’t have staff call with abnormal results
- This erodes the patient-physician relationship
- Staff can’t answer pertinent questions
- Don’t leave serious medical information for the patient late in the day or prior to the weekend; this can cause distress because the patient can’t follow-up
- Don’t delay bad news
If a provider is unable to communicate directly with the patient, leave only contact information, not specifics. Recommend the patient come to the office to discuss the results. If providers are still unable to reach the patient, send a certified letter with a return receipt. Be sure to DOCUMENT ALL STEPS and note any patient or family CONTACT in the medical record.
plppoh.com 