Results and Clinical Correspondence
Policy
Managing test results, significant investigations, reports, and clinical correspondence appropriately is an important part of achieving the best health outcomes for our patients.
Refer to RNZCGP: Managing patient test results, Te Whatu Ora | Health New Zealand: Transfer of Care and Test Results Responsibility, and Cole's Medical Practice in New Zealand: The management of clinical investigations
- We aim to review and action all incoming correspondence and results within appropriate time frames (usually two to three working days).
- Our "Management of Provider Inbox" process includes daily monitoring of provider inbox to ensure all urgent correspondence and results are managed in a timely manner, and that any correspondence for a clinician on leave is also managed without any delays.
- All potentially significant tests and investigations are tracked by the ordering practitioner. For significant results, the ordering clinician generates a task to themselves or the nurse in Indici.
- The clinician who initiates any test, report, or other medical correspondence is responsible for tracking the test, managing the results, and ensuring there is a clear plan of care.
- Patients are provided with information about:
All relevant communication with patients or other providers is documented in the patient record.
See also Results Management Procedure.
Audits
We carry out regular
audits of our processes for managing results, and encourage staff to raise any concerns. Any issues that arise are reported to the clinical governance group so that opportunities for process and service improvements can be identified.
Any medical investigations requested by the practice must have a clear pathway to an outcome (request, results, communicate results, record results, patient informed, action taken, dated, time limit identified).
Auditing these processes allows the practice to see where improvements can be made. Key areas to focus on:
- identify missing results, i.e. not received from the laboratory, or ordered but information not complete.
- Provide information about the status of medical investigations that have been returned to the practice.
- Appoint a clinical team member responsible for monitoring the review and action of all incoming tests, results and medical reports (see clinical governance below).
- Appoint a designated deputy, for example a locum, to process the reports if that requester is not available or is on leave.
- Track specialist referrals.
Source: RNZCGP Indicator 5.1
Clinical governance
Q15
We ensure that all clinical correspondence has been actioned and nothing missed. Results or reports are assigned to specific staff members, who are responsible for managing and tracking them.
The nurse manager oversees in box management each day to ensure all correspondence has been actioned, and follows up any outstanding issues.
Any issues identified with clinical correspondence are monitored as part of clinical governance to ensure they are addressed in a timely manner.
Clinicians on leave or unavailable
Our inbox management process ensures the timely management of any correspondence for a clinician on leave or unavailable.
Handovers should occur prior to the clinician going on leave and after they return to ensure that clinically significant information is transferred.
Results coming into the practice
Results can arrive at the practice in different ways, e.g. electronic results, email, or paper results. All results are directed to the right person within an appropriate time frame.
Q16
Type of correspondence
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Guidelines
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Electronic results
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- The inbox management process ensures all inbox documents are moved to the designated provider in Indici, including any unassigned documents.
- All results not matched to a practice patient are directed to admin to contact the sender or forward to the appropriate destination.
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Emails
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- The practice mailbox is monitored by the administration team and mail forwarded to the relevant clinician/staff member to action or follow up.
- The administration team are responsible for returning to sender, or forwarding to the appropriate person, any emails received in error. Actioned emails are copied to the relevant patient inbox, with a copy archived in the email mailbox.
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Paper correspondence
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- Reception or admin staff scan all clinical paperwork immediately into Indici, and task the relevant clinician or hand to them directly.
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Reports of Concern
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- If the practice receives a Report of Concern, (or communication regarding an Integrated Safety Response), for an adult or child:
- advise the patient's GP and send a task to the clinical team
- add a "vulnerable person" alert against the patient
- do not scan the letter into the patient record as this is not recommended.
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Telephone calls
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- Reception staff alert the relevant clinician to clinically significant phone calls verbally, through the PMS, or with a note.
- If the call is urgent, reception staff speak directly to a clinician.
- All clinically significant telephone conversations are documented in the patient record.
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Urgent results
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- Forward to the appropriate clinician immediately.
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Once the result has been received by the appropriate clinician, follow the practice's results management procedure.