contacting a patient to report lab results

If you’re having trouble contacting a patient concerning their lab or diagnostic results, MagMutual typically recommends contacting the patient on three separate, and timely occasions; twice with a phone call and message; and once with an e-mail or letter.

Full Answer

Can I get my test reports directly from the laboratory?

While patients can continue to get access to their laboratory test reports from their doctors, these changes give patients a new option to obtain their test reports directly from the laboratory while maintaining strong protections for patients’ privacy.

What is the patient access to laboratory test reports?

As part of an ongoing effort to empower patients to be informed partners with their health care providers, the Department of Health and Human Services (HHS) has taken action to give patients or a person designated by the patient a means of direct access to the patient’s completed laboratory test reports.

How is a positive lab result sent to a nurse?

Per a standard protocol, the positive laboratory result was sent through the electronic medical record (EMR) to a nurse who worked in the OB/GYN clinic. She followed standard procedure and tried to call the patient using the contact number in the EMR.

What is the new rule for lab test reports?

HHS Strengthens Patients’ Right to Access Lab Test Reports. At the same time, the final rule eliminates the exception under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to an individual’s right to access his or her protected health information when it is held by a CLIA-certified or CLIA-exempt laboratory.

How do you communicate results to patients?

How to Communicate Negative Test Results to a PatientAsk How They Prefer to Hear Them. Determine how the patient would like their results communicated, whether it be through email, phone, or in person. ... Understand Your Patient's Mental State. ... Ensure Their Comfort. ... Be Clear. ... Provide Resources. ... Show Empathy. ... Document Everything.

Can a nurse tell a patient their lab results?

Although there are no “laws” (other than HIPPA regulations related to confidentiality) about something like this, it is understood that the primary care provider, physician or advanced practice nurse, (whoever ordered the tests) should see the results first — they usually sign off on them to indicate he or she saw the ...

What method should be used to communicate lab results?

Mail and Fax. Many pathology labs still use mail and fax machines in order to relay results to patients and medical facilities.

What are the three methods for reporting laboratory results?

Three Common Reporting Methods for Patient Lab ResultsDo you ever get frustrated from not hearing back from the doctor about your test results? Have you ever waited a long time before caving and contacting your physician to get your lab test results? ... Phone Calls. ... Web Portal. ... Mail and Fax.

Can a nurse disclose pathology results to their client?

Pathology laboratories are bound by privacy laws regarding the use and release of personal information. This means pathology test results can only be released to health practitioners directly involved in the person's care.

Can medical assistants interpret results?

Medical assistants are not allowed to read, interpret, or diagnose symptoms or test results.

How closed loop communication works in a healthcare setting?

Closed-loop communication is the process of acknowledging the receipt of information and clarifying with the sender of the communicated message that the information received is the same as the original, intended information. In essence, it is the process of confirming and cross-checking information for accuracy.

When reporting a critical value what type of clear communication should be used?

verbal communicationDespite verbal communication has been for long considered the preferred procedure for notifying critical values, emerging non-verbal means of transmission may also be acceptable (19), provided that some essential criteria are fulfilled (e.g., timeliness of reporting, monitoring the impact of automated systems on ...

What does clinically effective mean?

Clinical effectiveness is defined as "the application of the best knowledge, derived from research, clinical experience, and patient preferences to achieve optimum processes and outcomes of care for patients.

Do lab results need to be signed?

Ordering or Referring Services These records may be housed at another location (for example, a nursing facility, hospital, or referring physician's office). While a signature isn't required on the physician order, the physician must clearly document in the medical record their intent to perform the test.

Why is it important for the physician to give test results?

Test results are conveyed sensitively, in a way that is understandable to the patient/surrogate, and the patient/surrogate receives information needed to make well-considered decisions about medical treatment and give informed consent to future treatment.

How do you write a test report?

How to prepare test reportgenerate detailed project report easily.track test cases coverage of the functionality.track the defect count and their types.track team members activity.track spent time.receive additional info and statistic data about the project status.

Can nurses give pregnancy results?

With a nurse-verified test, one of our CAPS nurses will read the results with you so you know for certain whether it's positive or negative. Many of our patients come in after taking an at-home pregnancy test because they're unsure of whether the test was truly positive.

Why does my doctor want to talk about my blood test?

Sometimes you need to know more than just "positive" or "negative." At an appointment, your healthcare provider can explain options and tell you whether more testing is needed. Plus, if a disease is contagious, your provider will want to talk in person about how to help you avoid future risk and protect other people.

How long does it take for a lab to provide a report?

Under the HIPAA Privacy Rule, laboratories will be required to provide patients with their completed test reports within 30 days of a request, but they will not be required to explain the results to patients.

How many states have not allowed direct access to CLIA labs?

Thus, in the 26 states that lacked laws authorizing direct disclosure of test reports to patients, and in the 13 states that expressly prohibited such access, patients did not have direct access to their completed test reports through CLIA laboratories. The final rule removes unintended barriers for patients to their own health information.

How long does it take for a lab to be HIPAA compliant?

HIPAA-covered laboratories will have 180 days from the effective date of the final rule to come into compliance. This policy maintains strong protections ...

Can a CLIA lab provide a patient's personal representative?

The CLIA regulations now allow CLIA-certified laboratories to provide the patient, his or her personal representatives, and/or a person designated by the patient, as applicable, with copies of completed test reports upon the patient’s or personal representative’s request. In addition, the above-described exception to an individual’s right ...

Who is responsible for HIPAA privacy?

The final rule is being issued jointly by three agencies within HHS: the Centers for Medicare & Medicaid Services (CMS), which is generally responsible for regulatory laboratory oversight under the Clinical Laboratory Improvement Amendments of 1988 (CLIA); the Centers for Disease Control and Prevention (CDC), which provides scientific and technical advice to CMS related to CLIA; and the Office for Civil Rights (OCR), which is responsible for administering the HIPAA Privacy Rule.

Can a lab release a completed test report?

Prior to this final rule, under CLIA regulations, a laboratory could only release completed test reports directly to a patient only if: (1) the ordering provider expressly authorized the laboratory to do so at the time the test was ordered; or (2) state law expressly allowed for it.

Does HIPAA restrict access to test reports?

In addition, the above-described exception to an individual’s right of access in the HIPAA Privacy Rule is now removed, and contrary state laws that limit individuals’ access to completed test reports are preempted by the rule. The CLIA regulations do not change the role of providers in ordering tests and explaining test reports to patients.

What is the obligation of a physician to be considerate of patients?

Physicians have a corresponding obligation to be considerate of patient concerns and anxieties and ensure that patients receive test results within a reasonable time frame. When and how clinical test results are conveyed to patients can vary considerably in different practice environments and for different clinical tests.

How to ensure that test results are communicated appropriately to patients?

To ensure that test results are communicated appropriately to patients, physicians should adopt, or advocate for, policies and procedures to ensure that: The patient (or surrogate decision maker if the patient lacks decision-making capacity) is informed about when he or she can reasonably expect to learn the results of clinical tests ...

How are test results conveyed?

Test results are conveyed sensitively, in a way that is understandable to the patient/surrogate, and the patient/surrogate receives information needed to make well-considered decisions about medical treatment and give informed consent to future treatment.

Who is notified of the disclosure of a patient's results?

The ordering physician is notified before the disclosure takes place and has access to the results as they will be conveyed to the patient/surrogate, if results are to be conveyed directly to the patient/surrogate by a third party.

Why is it important to tell a patient their blood sugar is normal?

1. Telling a patient their results are NORMAL, and then the physician realizing that something is off takes away a lot of trust from the patient. The doctor-patient relationship is one of the most important aspects in healthcare. This relationship keeps patients taking their medication and prevents lawsuits. So telling the patient their levels are normal, and then backtracking to say, “Oh, actually Mrs. Jones, your blood sugar is high and we’re going to have to start you on insulin,” is not great for the patient or the practice.

Why do patients get nervous about lab work?

They might not have been educated on why they needed to have their blood analyzed and will question what their results mean. It’s helpful to ease patient’s anxiety by explaining that this was a routine test that was done as part of the physical examination, to get a baseline for their values, or to understand if there was a specific reason for their illness that could be explained by any aberration in the blood levels of their electrolytes. In the case of everything being normal, you can move on and say something along the lines of “Your blood did not show any abnormalities that the doctor is worried about. If you have any specific questions, we can give you some more information.” Or, if the doctor has time and hasn’t seen the patient yet, there is the chance he/she will be able to give a bit more information. This depends on the day, the doctor’s preference, and their schedule.

What is the diagnosis for upper respiratory infection?

Most times, the provider diagnoses the patient with an upper respiratory infection with no need for lab work or imaging. Other times, lab work is ordered, which means a Basic Metabolic Panel (BMP) or a Complete Blood Count (CBC).

What is the algorithm for breaking bad news to patients called?

There is an algorithm for how to break bad news to patients, even, called SPIKES. It’s best for the patient to hear both good and bad lab results from the physician, but if you as the medical assistant are tasked with this, it’s helpful to know how to handle it.

Do medical assistants give lab work?

Other times, the medical assistant will briefly educate the patient on their lab work, with permission from the provider. It’s important not to give information to the patient unless given the go-ahead from the physician. This is extremely vital to remember.

Can you diagnose patients with a medical assistant?

This is extremely vital to remember. When becoming a medical assistant, one of the first things you’ll learn is that you should not diagnose patients or give them information on blood work, imaging studies, biopsy results, or anything of that sort unless told by a provider that it’s okay.

Who is the first to see the results of a medical test?

In many cases, the physician receives the results and has assessed them for changes or abnormalities. However, at some medical facilities, medical assistants are the first to see the data, and can point out potential problem areas to the physician before he or she sees the patient.

What is a 5 point Likert score?

Five-point Likert scores were used to gauge each physician's interest (1=not at all interested to 5=very interested) in scenarios pertaining to the direct reporting of 3 diagnostic tests of low (DXA scan), intermediate (genital herpes testing), and high (breast biopsy) “emotional impact” and whether interest varied with each test's result (normal vs abnormal). Physicians were also asked to cite specific advantages and disadvantages of direct reporting.

How to notify patients of mammography results?

Another potential solution is for testing centers to directly notify both patients and providers of important test results via mailed letter (a.k.a. direct result reporting); there are a number of potential advantages to such a system. First, many clinicians and patients already have experience with direct result reporting as a consequence of the 1998 Mammography Quality Standards Act.11This congressional legislation requires all mammography centers to report mammography results to both providers and patients in writing within 30 days of the examination. Available data suggest that the mammography system has been successful, resulting in more timely patient notification and greater patient satisfaction.12Second, a number of studies suggest that patients are interested in the enhanced access to their test results that direct reporting would provide.13–17Third, direct result reporting systems could be implemented rapidly using currently available technology, pending the development of more comprehensive computerized health information systems to assist in this task.18

Why are providers less interested in abnormal results?

Our finding that providers were less interested in the assistance of an automated result reporting process for abnormal test results (which are likely to require some sort of action and thus can least afford to be “missed”), as opposed to normal results, creates an interesting paradox: providers appear more accepting of automation of the mundane task of notifying patients of their normal results when, in actuality, automating the reporting of abnormal results may be far more important to patients' welfare. Likewise, providers appear less interested in direct notification for test results with greater emotional impact such as breast cancer, despite the fact that tests with greater emotional impact are likely to be the results that patients most want to be informed of.

What are the benefits of direct results?

The median number of benefits of direct result reporting identified by physicians was 3 (mean 2.9, standard deviation 1.4); only 5 providers (3%) identified no benefits. The most common advantages cited were more rapid patient notification of results (selected by 79% of respondents), reductions in workload (75%), and making patients feel more involved in their care (42%) (Table 2) . The median number of specific concerns cited by physicians was 4 (mean 3.6, standard deviation 1.3); only 7 physicians (4.7%) had no concerns. The most common concerns cited by physicians were that patients would become unnecessarily frightened (selected by 70% of respondents), patients would seek unreliable information (65%), and that patients lacked necessary expertise to interpret their test results (52%) (Table 2).

Why is direct reporting important?

Direct reporting of selected test results to patients is one system for insuring that important results are not missed, but implementation should consider the specific test in question, the test result, and provider preferences.

Is failure to follow up on abnormal test results a common medical error?

There is growing evidence that the failure to follow-up on abnormal test results is a common medical error that can compromise patient safety.1–3For example, Roy et al.4found that approximately 6% of patients hospitalized in a major academic medical center had potentially actionable test results return after their discharge without the knowledge of the responsible physician. Similarly, Schiff et al.5,6have found clinically significant rates of missed hypothyroidism and hyperkalemia that were uncovered by laboratory testing in an urban county hospital.

Lab Results Letter

You had a blood test to measure your cholesterol levels on June 25, 2009.

Table of Contents

You had a blood test to measure your cholesterol levels on June 25, 2009.

What does HHS stand for in health care?

As part of an ongoing effort to empower patients to be informed partners with their health care providers, the Department of Health and Human Services (HHS) has taken action to give patients or a person designated by the patient a means of direct access to the patient’s completed laboratory test reports.

Who is responsible for the HIPAA Privacy Rule?

The final rule is issued jointly by three agencies within HHS: the Centers for Medicare & Medicaid Services (CMS), which is generally responsible for laboratory regulation under CLIA, the Centers for Disease Control and Prevention (CDC), which provides scientific and technical advice to CMS related to CLIA, and the Office for Civil Rights (OCR), which is responsible for enforcing the HIPAA Privacy Rule.

When did the HIPAA rule end?

At the same time, the final rule eliminates the exception under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to an individual’s right to access his or her protected health information when it is held by a CLIA-certified or CLIA-exempt laboratory.

When did the CLIA change?

The final rule amends the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations to allow laboratories to give a patient, or a person designated by the patient, his or her “personal representative,” access to the patient’s completed test reports on the patient’s or patient’s personal representative’s request.

Who can see a copy of a patient's health information?

Under the HIPAA Privacy Rule, patients, patient’s designees and patient’s personal representatives can see or be given a copy of the patient’s protected health information, including an electronic copy, with limited exceptions.

What is the final stage of the diagnostic process?

After an important test result is produced, the final stage in the diagnostic process itself involves several steps. The clinician must see the test result, interpret it correctly, and determine an appropriate response, and that response has to be effected—which includes contacting the patient and ensuring the patient carries out the treatment plan. We already know this process has flaws—a recent AHRQ WebM&M commentary addressed the significant proportion of abnormal test results received by office physicians that are not seen or acted on, mainly as a result of system problems including time pressure and cognitive workload. ( 4) In particular, in one study of primary care practices, 6.8% of errors in the testing process involved failure to inform the patient of the result. ( 5)

What is the final step of diagnosis?

It is perhaps most frustrating and tragic, however, when the ball is dropped in the final step: the patient presents in a timely manner, the clinical evaluation is performed well, appropriate tests are ordered, the tests are performed correctly within an appropriate interval, the results are diagnostic and transmitted to a clinician, and then the final step—the clinician and patient executing a treatment plan —does not take place.

What to do if a patient cannot be reached?

Health care organizations can do the same. If the patient cannot be reached by the available contact information, try other means including online sources as warranted by the clinical importance of contacting the patient. Assess how reliably individual patients are likely to be contacted and customize your approach.

How to contact a patient who cannot be reached by the available contact information?

Health care organizations can do the same. If the patient cannot be reached by the available contact information, try other means including online sources as warranted by the clinical importance of contacting the patient.

Why use electronic medical records?

Use an electronic medical record to provide an alert when the patient needs to be contacted. The alert could appear when a patient contacts the facility for any reason. In this case, there was a lost opportunity when the patient came to the radiology department a week later for an ultrasound, because the radiology personnel did not know there was an important clinical need that needed to be addressed.

What means should be used to try to reach a patient?

What means should be used to try to reach a patient? The standard of care requires one to utilize the means that a reasonably careful health care provider or organization would use in a similar situation. In this case, the patient's address was correct, and a letter did eventually reach her. When she could not be contacted the first day by phone, a letter should have been sent then, rather than 11 days later. If the telephone and mail contact information are insufficient, and the need is important enough, what else should providers try? I am unaware of any malpractice cases that have addressed the Internet specifically, but future juries might well conclude the Internet is a readily available source of information and communication that a reasonably careful health care facility should utilize. Internet phone and address directories could be consulted just as printed ones can be. Search engines can uncover an individual's online footprint, and social media and other sites might provide clues to a patient's contact information or whereabouts (e.g., place of work). Some sites might even enable a message to be transmitted without violating HIPAA. Whatever is done should be documented in the medical record for the usual reasons: to communicate to others what has been done and to provide written or electronic documentation in case the failure to contact becomes the subject of a lawsuit.

How to follow up on pending tests?

Engage patients in following up on pending tests, by educating them about the tests and their importance, when the results will be available and how to obtain them, and what to do after that. The ED discharge instructions given to Rory Staunton's parents contained a line for pending tests and a phone number to call to obtain the results, but the line was left blank. Electronic personal health records can permit patients to view their test results directly, along with a message or instructions from the doctor when appropriate, an important advance. ( 13) Enlisting the patient's participation in the diagnostic process may be the single best method of reducing the harm from failure to act on abnormal test results.