Claims against doctors often involve the mismanagement of test results, which is why meticulous documentation is so beneficial. These tracking tips can help you better manage results—and risk.
Posted in Articles on Friday, February 7, 2025
Some of the most frequent allegations filed against doctors who practice office-based care include failure to follow up, failure to diagnose, failure to act, and delayed diagnosis related to lack of follow-up on tests and/or referrals ordered.
That’s why meticulous tracking of lab tests, imaging results and referrals is extremely important. Every practice should implement the following to ensure results are received, reviewed, and followed up on in a timely manner.
A Reliable System for Follow-Ups
Maintain a system in your office that provides alerts if a result or report is not received so prompt follow-up can occur.
A Verification Process
Among other things, you should verify that the results you have received are for the test that was ordered. You should also verify that the test/report was properly reviewed. Do not file reports, tests, or correspondence of a clinical nature without the provider’s initials or a signature verifying that he/she has reviewed the information.
An “Out of Office” Process
Following a defined process for reviewing results that come in while the provider is away from the office so there is no delay in addressing results that may require urgent action.
Outcome Documentation
When a test or referral is ordered, two outcomes should be documented depending on whether the results were completed.
When results/referrals are completed:
- Include health care provider or designated person, initials, and date results were reviewed
- Document actions/instructions
- Communicate and document instructions/advice to the patient
When results and referrals are not completed:
- Tickler system (whether paper or via EHR tracking alert) is reviewed regularly
- Notify provider that results are outstanding. Take action.
- Call patient to advise results are still outstanding. Document the call and what the patient shares.
- Document non-compliance
- Address non-compliance at subsequent visit or sooner, if appropriate
Keeping these detailed records will not only benefit your patient and their care, but also you and your practice should allegations arise.
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