Results Management Procedure

Policy

Refer to guidance Te Whatu Ora| Health New Zealand: Transfer of Care and Test Results Responsibility.

We have appropriate procedures in place to manage results and clinical correspondence arriving at the practice within an appropriate timeframe.

All incoming test results or other investigations are sighted and actioned by the practice team member who requested them, or by a designated deputy.

Urgent test results are reviewed immediately or as soon as possible.

Clinicians review patient results and clinical correspondence daily. Another clinician will be tasked to do this if the clinician is away.

We audit results management to see where improvements can be made.

Results management procedure

When clinicians receive results or clinical correspondence:

1. Review the result/report/correspondence.
   • The ordering clinician is responsible for following up on test results. If they will not be available to receive results and take any necessary actions, they must delegate another clinician to do so. The ordering clinician should also check the results when they are next on duty.
   • If a clinician is copied into results they did not order, they have a duty of care to ensure significant results have been acted upon in a timely manner. This includes gaining any necessary knowledge of the patient and clinical circumstances.
   • All hospital discharge summaries or specialist letters should be reviewed by a clinician within one working day.
2. Identify whether action is required.
   • If action is required.
     • Record any action taken in the patient record, including if the result is handed over to another clinician to action. If the patient has access to their record via ManageMyHealth, the wording of the comment should take this into account.
     • Any abnormal results are followed up, regardless of who ordered the test.
     • Notify the patient of the result.
     • If the patient is difficult to contact, the effort made to contact them should be proportional to the significance and urgency of the result. Document all efforts to contact the patient.
     • If medication has changed, or needs to change, ask the patient to come in for a consultation.
   • If no action is required, add a comment and file the result in the Patient Inbox.
3. Update the patient record.
   • Add appropriate information to the patient record.

     Add or update:

     • discussions with other clinicians and/or patient
     • attempts to contact patient
     • screening information
     • recalls
     • classifications
     • warnings or alerts
     • medicines reconciliation.
   • Add electronic results, paper results, and emails to the patient record.

   Significant results should not be made available to the patient in ManageMyHealth until after they have discussed the result with a clinician.

Copying clinicians into test results

Only copy someone in on a test result when all of the following apply:

• the recipient needs to act on the result
• the recipient has already been informed that they need to act on the result
• copying the person in is meaningful and necessary for continuing care
• the recipient has the necessary understanding to interpret the result.

Copying another clinician into results is not a transfer of care.