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

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 3, 2011

Q: What 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?

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.

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