Background

The process for tracking laboratory and X-Ray results, and also consultants’ reports, is that which I have chosen to describe here, and subsequently remodel in future assignments. It is crucial to the delivery of quality health care that results of any test or consultant opinion be delivered to the patient through the ordering physician in a timely manner so that the results can be acted upon to achieve the best possible outcome for the patient. Although the majority of the tests that are ordered are normal, those that are not have the greatest potential for impacting the patient’s care and quality of life. In my role as Medical Director for a physician management company, I am responsible for the quality of care that is delivered to our patients, but am also responsible for managing the risk that results from the delivery of poor care. Thus, I am interested in improving the quality of care by assuring that test results are available to the physicians in a timely manner so that quality of care and service do not suffer and that the physicians and the company are not exposed to increased malpractice and financial risk when test results are not available or are delivered too late to intervene. Test results and consultant reports that do not return in a timely manner, need to be tracked down and retrieved, so that medical care is not interrupted.

• The most common causes today for malpractice lawsuits are missed diagnosis and delay in diagnosis. The most commonly missed or delayed diagnoses are cancer, primarily breast and lung, heart attack and stroke. In the case of breast cancer, a misread mammogram or a delay in reporting, reviewing and acting upon an abnormal mammogram spells disaster for both the patient and the physician. For lung cancer, the same is true for an abnormal chest X-Ray. This underscores the need to assure that ordered tests or consultations are actually performed and the results are returned to the physician in a timely manner so the he/she can review them and take appropriate actions.

Most Common Cancers

Most Common Female Cancers	Breast Lung Colon
Most Common Male Cancers	Prostate Lung Colon

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Current Process

The current process for tracking these tests and consultant reports in our medical centers, as it was developed several years ago, is manual. It is requires extensive amounts of time from the nursing staff in order to complete. Because of cutbacks in support staff within the medical centers, including the nursing staffs, this process has created even greater burdens on the remaining nurses. The nurses have responded in multiple ways ranging from neglecting the process entirely to rearranging it to accommodate their own needs or time constraints. In many cases, when modified, the ‘new’ process does not perform well and the outcome that we had originally sought by using this process is lost.

The process begins with the physician who orders the lab test or X-Ray or requests the referral to the consultant. The nurse completes each request form after the physician has completed the medical information section of the requisition and gives the original copy to the patient. The patient then has the test/X-Ray done or makes the appointment with the specialist. The nurse logs the request in a log book with all of the pertinent information, which includes patient name and ID number, specific test(s) ordered, and the ordering physician. The log also has space for acknowledging return of the results, action taken by the physician and approval to file the results within the medical records.

Test results and consultant reports return to the medical center and are processed in the medical records department. Here they are sorted by physician and delivered to the physician’s nurse. The nurse then delivers them to the physician for review and action. Once the physician’s orders, if there are any, have been completed, the nurse then matches the results with the log book entries, completes the log entries for acknowledging return of the results, the physician action taken and initials the log as complete and approves the results to be filed within the medical record. These steps complete the logging process.

It is the nurse’s responsibility to review the log book on a daily basis to determine which tests or consultant reports previously ordered have not returned. Through experience, we have developed standards by which we judge whether or not a test/X-Ray/consultant report should have been returned to us. For example, routine laboratory tests like Complete Blood Counts(CBCs), should be returned within 2-3 days. A specialist report might take a month to return based upon when the appointment was actually made and how prompt the specialist is in dictating and mailing his/her reports. If these tests are not returned in an appropriate period of time, we then investigate. Reasons that results do not return are numerous and include: the patient never had the tests done or never went to the specialist, lost specimens, canceled appointments, lost reports, reports filed into the medical record but never reviewed by the physician and many others. Once the investigation is done, it is again the responsibility of the nurse to make any arrangements that are needed in order to secure the results of the ordered test/specialist referral. It is also his/her responsibility to document within the log book the actions taken. The entry remains open which allows the nurse to continue to follow the request until the test/referral is completed and the results are returned.

From the various logging responsibilities of the nurse described above, it can be seen why this process is so labor intensive and why there have been attempts to modify it or neglect it. To review, the nurses must enter all requests with the appropriate information into the log books, review the logs on a daily basis for outstanding results and investigate those that should have been returned based upon our standards, arrange intervention with patients to complete the tests/referrals based upon the investigation and document this intervention, and follow the physician orders for action to be taken based upon the results that he/she receives and reviews on a daily basis. All of this must be done on a daily basis in order to keep pace with the large numbers of lab tests, X-Rays and referrals that the physicians generate. This also must be done in addition to other responsibilities that the nursing staff carries out on a daily basis. When given the choice of direct patient care and maintaining the log books, there is no question which choice is made. Patients present in the medical center come first, and rightly so; however, if the entire scope of the patient’s care is considered, the tracking of their test results is important to assure that completeness of their medical care is delivered.