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Nigel's surgery 46: Managing test results and clinical correspondence
We have updated this mythbuster and advice about clinical correspondence.
In our inspections of GP practices, we ask whether practices are safe and providing effective care.
- 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:
- E1. Are people's needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?
This includes how practices manage test results and clinical correspondence.
- S6. Are lessons learned and improvements made when things go wrong?
This includes incidents where test results or clinical correspondence have not been managed appropriately.
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 and 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.
- Failure to follow-up test results for ambulatory patients: a systematic review
- Safe and reliable systems for managing test results, Scottish Patient Safety Programme.
This can seriously affect 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 these issues:
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.
A critical part of the system is how well you communicate test results. You must keep records of communication with patients.
- 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. This includes any changes required to a patient’s medication.
The clinician is responsible for making sure that actions are taken when appropriate. Non-clinicians can do some tasks if there are appropriate safeguards in place. Usually medication changes should be made by the GP or an appropriate prescriber. Trained non-clinical staff can make medication changes providing there is an effective system in place for an appropriate prescriber to review the changes before the prescription is issued.
- Last updated:
- 05 August 2019