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Nigel's surgery 46: Managing test results and clinical correspondence

Categories:
  • Organisations we regulate

In our inspections of GP practices, we ask whether practices are safe and providing effective care.

This includes:

  • Is the system to manage test results in your practice robust, effective and safe?
  • How do you make sure that all test results requested have been returned to the practice?

Our relevant key lines of enquiry are:

Management of test results

Managing test results in general practice can be complex, it:

  • involves nearly every member of the practice team
  • relies on practice systems, outside providers
  • must communicate results to the patient in a timely and clinically appropriate manner.

Failure to follow up test results has been identified as a major problem in primary care settings.

The effects can be serious lapses in patient care including delays to diagnosis and effective treatment.

What does a good approach to managing test results look like?

Robust practice protocols and standardised processes can protect patients.

We expect to see that practices have an agreed and documented approach that every member of the practice team understands.

Practices can develop their own systems and protocols to safely manage test results. They must be able to demonstrate their effectiveness. 

Consider the issues below.

Systems and protocols

How does your practice make sure:

  • You document all tests requested in the clinical system.
  • There are no delays in dealing with results that require prompt action. For example, regularly tracking and reconciling tests requested against results received.
  • Clinicians, and non-clinicians where appropriate, who review results have:
    • access to the medical record and
    • training to understand the significance of the results.
      Clinicians are responsible for making sure results which alter patient management are acted on.
  • You review results in a timely manner. This includes when:
    • clinicians are absent and
    • you receive results following requests made by short-term locums.
  • That you see and action all test results if a patient has had multiple tests and you get results at different times. In these cases there is a greater risk some of the results are not actioned quickly or at all.
  • That everyone is aware of their responsibilities for managing test results. This includes clinicians and administrative staff.

All staff should have access to training. Support on the day to day implementation of the management of test results is important.

Communicating effectively

A critical part of the system is how well you communicate test results. You must keep records of communication with patients.

Also, consider:

  • Providing clear, documented, next steps to follow when results arrive. If administrative staff need to take action, they need explicit instructions.
  • A standardised set of words, terms and phrases for administrative staff to use a when telling patients common test results. Agree these between clinicians and administrators. Patients need explanations in clear, unambiguous language.
  • A clear approach and a protocol for informing patients (or families, carers and key-workers) of test results. Make patients aware of this policy.
  • Not relying solely on the patient contacting the practice. You should actively contact the patient if results need action, even if you asked a patient to contact the surgery for them. This will help prevent missing vital follow-up action.
  • How to identify a patient before giving results.
  • Have a clear policy on leaving voicemail messages if you cannot contact the patient.
  • How to maintain confidentiality when talking by telephone or face to face at the practice. For example, a busy reception area can make it difficult.

Assessing your system

Audit the system regularly to ensure that it is functioning effectively. This will help identify if you need to make any changes or improvements.

You may consider if non-clinicians could safely do certain tasks, freeing up clinicians for other work. For example, with appropriate safeguards are in place, non-clinicians can review normal test results.

Clinical correspondence management

The same safeguards need to be in place to manage clinical correspondence.

The clinician is responsible for ensuring that actions are taken when appropriate. Non-clinicians can do some tasks if there are appropriate safeguards in place.

Last updated:
24 August 2018

 


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