Risk Management Tips: Tracking Test Results

The Tip:
Always follow-up after tests, both with the patient and with the appropriate medical personnel.

The Risk:
Tests may not have been completed or results may be lost, overlooked, or not received. This, obviously, would be a great oversight in the quality of medical care received by the patient.

Recommendations:
Follow-up procedures are important to ensure that patients receive the necessary testing, as ordered, and that results are returned to the office and properly reviewed.

1. Educate patients about the need for the testing, and document this conversation.
2. Implement a follow-up system in your practice to ensure that patients have undergone the recommended testing and that the results are returned to the office.
3. The follow-up system should include the patient’s name, the date the test was ordered, when the results were received, and when the patient was notified.
4. The physician should review, initial, and date the reports before they are filed in the medical record.
5. Attempts should be made to contact patients who have not undergone the recommended testing. These attempts should be documented in the medical record and, once the patient has been reached, he/she should again be urged to obtain the requested testing.
6. Include a process in your follow-up system to verify that consultations were obtained.

Risk Management Tips provide guidance to support our physicians and facilities in their ongoing efforts to improve the quality of patient care and reduce liability exposure in the practice of medicine. Please contact MLMIC’s Risk Management Department at (800) 275-6564, weekdays 9:00 AM – 5:00 PM, for guidance regarding your specific situation.