Following-up on Diagnostic Tests

Carolyn Buppert

Disclosures

Dermatology Nursing 

In This Article

Were the Results Abnormal and if so, was Follow-up Performed?

Adopt one of these three systems for follow-up of abnormal diagnostic tests.

System A

Telephone call, followed by letter, stating the risks of failing to follow-up.

  • Every abnormal lab result triggers a telephone call to the patient from the clinician who ordered the test. The clinician explains what the results mean, the recommendation, and the time frame for action. The patient is invited to return to the office in the following 2–3 days for a face-to-face meeting with the clinician. Time spent = 5 minutes.

  • The clinician documents the telephone call and gives the chart to an assistant assigned to maintain the tickler file. Time spent = 30 seconds.

  • The assistant enters the patient's name, abnormal test, date performed, follow-up needed, and date due on a 3" x 5" card and places it in a tickler file, under the due date. Or, an electronic tickler system may be used. Time spent = 30 seconds.

  • Twice a week, the assistant checks the tickler file and determines whether follow-up has occurred for all patients due. If a patient has come in and follow-up has been completed and documented, the assistant obliterates the card. If not, the assistant generates a letter to be signed by the clinician, stating, "On ___, I informed you by telephone that your ___ test was abnormal. I advised you of the importance of further tests, consultation, or treatment and asked you to come to the office to discuss the matter. I note that no follow-up has occurred. Without attention, you are at risk for injury, complications, or even early death. I urge you to come to the office for a visit within the next 2 weeks." A copy of the letter is placed in the patient's file. Staff time spent = 30 minutes or less, depending upon the size of the practice, the number of lab tests generated, and the health of the patients.

System B

Mailed notices (whether or not the patient has a return visit scheduled).

  • When collecting samples, the clinician explains that the office policy is to notify patients of normal and abnormal test results. The clinician tells the patient to call the office if he or she does not receive notice of a result within 2 weeks. The clinician provides an envelope, and has the patient self-address it at the time the test is done. The clinician places the envelope in the patient's chart. Time spent = 10 seconds.

  • If results are normal, the clinician fills in the blanks — the name of the test, date done, date further screening is due — on a pre-printed card, signs the card, puts it in the self-addressed envelope, and drops it in the outgoing mail box. Time spent = 10 seconds per lab test.

  • If abnormal, the clinician fills in the blanks of a form letter, including the abnormal result, further testing or consultations needed, and time frame. The letter advises the patient to call for an appointment to discuss the results face-to-face, by a specified date. The clinician places one copy of the letter in the patient's chart and a second copy in a tickler file. The clinician goes through the tickler file once a week, and sends a certified letter to any patient who has not presented for follow-up by the due date.

System C

Face-to-face visits scheduled for all patients for whom tests have been ordered.

When ordering lab tests, schedule all patients for a return visit to review labs. Asking the patient to call is not a sufficient system to avoid malpractice. A clinician may argue that it is the patient's responsibility to call, but the patient's attorney will argue that it is the clinician's responsibility to follow-up abnormal tests. If the patient's lab tests are normal, use the opportunity to talk about risks, schedule for additional screening, diet, exercise, or other habits. Bill the visit on the basis of time spent, face-to-face, document the subjects counseled, and bill a "counseling visit."

The most common reasons for lawsuits against physicians and nurse practitioners is missed diagnosis and the most common reason for missed diagnosis is failure to follow-up. It makes sense to approach follow-up aggressively to prevent patient injury and the lawsuits which follow.

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