Risk Management Tip: Tracking Test Results

MLMIC Risk Management Tip #2 addresses medical professional liability risks related to “Tracking Test Results.”

The Risk

The receipt and review of test results are important aspects of patient care and safety in physician practices. Tests may not be completed or results may be lost, overlooked, or not received, leading to potential delay in diagnosis and subsequent liability exposure. Follow-up procedures should be an integral part of your practice and can help ensure that patients obtain the necessary testing, as ordered, and that results are received, reviewed and properly addressed.

Recommendations

1. Inform patients about the indications for the test(s) and document this conversation in the medical record.
2. Implement a follow-up system in your practice to ensure that patients have undergone the recommended test(s) and that the results are returned to the office.
3. The follow-up system should allow you to track the following information: patient name, test order date and the date the results were received.
4. The medical record should indicate the date of the provider review.
5. It is the provider’s responsibility to notify patients of significant test results. This should be documented in their medical record.
6. Your process should include follow-up when patients have not undergone the recommended test(s). This may include telephone and/or electronic communication. All attempts to reach the patient should be documented in the medical record.
7. A follow-up mechanism that utilizes the same process also should be in place to track consultations.

This MLMIC Risk Management Tip is available here as a PDF: “Tracking Test Results.”