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What must be documented when a nurse receives a critical test result?


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QWhat must be documented in the medical record when a critical test result is reported from the laboratory to an inpatient nurse rather than directly to the physician?

A The critical result itself, like all testing values, must be documented in the medical record. If the result is transmitted verbally, some organizations also require that the read-back be documented, although such documentation is not specifically mandated by The Joint Commission.

Likewise, there is no requirement that the subsequent conversation (after the nurse has received the critical result from the testing department) with the physician be captured in the medical record, even though there is a common myth that such documentation is required.

Some of our clients ask, "If the nurse doesn't document the conversation with the physician, how can we collect data related to the timeliness of critical results communication?"

Here are some things to consider:

  • If a result is truly critical, it requires, by ­definition, immediate clinical intervention. That clinical ­intervention (e.g., order, medication via ­previously ordered protocol, examination, further testing) is captured in the medical record, and should you be interested in studying the overall timeliness of communication, it can be used as a surrogate for the communication itself. The conversation must have taken place since the corresponding intervention was carried out.
  • Should there be an actual delay in notifying the ­responsible practitioner, the nursing notes ­usually reflect that delay, stating "Dr. Smith did not respond to repeated pages," or "Dr. Jones in the ED was contacted at 03:00."
  • If there is nothing in the chart one way or the ­other, the result was probably not critical. It may have been a repeat test with therapy under way or something similar.

There is no specific requirement to collect this data.

In the past, hospitals spent a lot of time collecting meaningless data in response to common Joint Commission findings. However, there is usually a better way to meet these requirements. Remember, the expectation (NPSG.02.03.01, element of performance 3) is that the organization evaluate the effectiveness of critical results communication. Collecting average communication times is both difficult to do and of little or no value. What does it tell us to say, "Our average time from result to provider notification is 15 minutes"? ­Nothing, since outliers (i.e., individual failures or individual circumstances) are the real issue and are not reflected in averages.

On the other hand, what does it tell us to say, "Our average time from result to provider is 45 minutes"? It usually tells us we have a bad definition of a critical result or bad data collection processes.

So what do we recommend? Our clients find far more value in a focused approach to critical results reporting. For example, some hospitals have made a concerted effort to collect true outliers through a simple reporting process (i.e., something that does not take a lot of time). By studying outliers (e.g., instances when the ED had to be contacted for an order because the attending did not respond, failure of the on-call physician to answer a page, etc.) the hospital is better able to focus on true systems improvement while collecting provider data that might be useful in the medical staff governance process (e.g., ongoing professional practice evaluation).

Another complementary approach is to focus on specific clinical processes or conditions, such as glycemic control or radiology reporting processes. By focusing on problem-prone areas, the hospital is better poised to make true improvements in patient care and safety rather than simply collecting data for data's sake.

Additionally, by not requiring unnatural documentation practices, we ease the mounting burden of nursing documentation.