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Clinical Practice Parameters: Successful Management of Diagnostic Testing
By Linda M. Blythe, RN, CPHRM, Risk Management Consultant, FPIC
Failure to diagnose continues to be one of the most prevalent allegations in malpractice claims. Among the most frequent causes are lost or misdirected diagnostic test results. A common factor in these cases is a failure to address abnormal test results in a timely manner. The unfortunate end result is often absence or delay in treatment to the point of irreversible damage to, or poor overall prognosis for the patient.
The PIAA (Physician Insurers Association of America) recently reported that 30 percent of medical office practices fail to document their review of diagnostic test results. An additional 25 percent of practices fail to note a plan of action as a result of those test results. Faulty communication of clinical concerns and stat test results contribute to a significant number of adverse events, which result in severe patient injury and costly medical malpractice claims. Inadequate documentation of the entire process often undermines the defensibility of technically good care.
Consider implementing the following risk management techniques in order to enhance the ability to respond appropriately to diagnostic results in a timely manner:
- A tracking system to monitor the completion of diagnostic studies, that the results are received, and that the physician reviews them before they are filed in the patient’s record. Follow-up communication to the patient and subsequent management of the patient’s care are also necessary components of the tracking system.
- Give directions for the communication pathway for stat diagnostic test results for both daytime office and after hours.
- Use a template stamp to capture complete follow-up documentation on all diagnostic reports when received.
- A filing and chart-flagging system to track patients needing follow-up, repeat diagnostic testing, or monitoring for chronic conditions.
- Educate patients as to the necessity of compliance for diagnostic tests, with the risks and benefits explained and documented.
- Educate office staff to ensure heightened awareness of the risk exposures related to delayed diagnosis and incomplete follow-up, and the importance of adequate tracking, communication, and documentation.
Information in this article does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. FPIC recommends you obtain legal advice from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.
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