>Users:   login   |  register       > email     > people    


The Proper Way to Document Study Results!
By Jeffrey E. Keller MD
Published: 06/10/2019

Chest xray So let’s say you order a lab test on a patient. Or an X-ray. Or let’s say you order old records. When the results are returned to you, how do you document this? What I have often seen is the practitioner documenting by initialing and dating the hard copy, as has been done on the lab order in the picture. I see this commonly.

But this is poor medical practice. Notice on the lab report that there is a critical lab abnormality. Did the practitioner who initialed the lab report see this? What does it mean? What is he going to do about it? Initials and date tell you nothing, other than the practitioner actually held the lab slip. I have seen colleagues go through a stack of lab reports by folding down a corner so that they could initial and date each one. They did not actually read any of them. Your malpractice insurance carrier holds a dim view of this, of course. But if all you do is initial and date the lab slip, you cannot prove that you did more than this.

The proper way to document study results is to interpret them

Interpretation means three things: stating why the test was ordered in the first place, whether the result is normal or abnormal and how the result will affect the patient’s treatment plan. Unanticipated abnormal results also should be explained.

The first part is stating briefly why the test was ordered in the first place Each study should have been ordered for a specific reason, and this reason should be clear from the medical record. For example, a CBC is ordered to see if the patient is anemic. A patient has a fever and a cough and so a chest x-ray is ordered to see if she has pneumonia. A patient states that her last PAP smear was abnormal, so old records are ordered to see exactly what the abnormality was. An EKG is ordered on a patient with chest pain to see if he is having acute ischemia.

In part two of the documentation, the practitioner should interpret the study results in light of why they were ordered. For example, “UA shows pyuria.” “No evidence of active TB on chest x-ray.”

In part three, the practitioner should mention whether the study warrants any changes in patient therapy. Is any further testing needed? How about changes in the patient’s prescribed medical treatment? For example, “Liver function tests are normal. No change in therapy indicated.” or “UA shows pyuria. Antibiotics for UTI ordered.”

Let me give some examples to demonstrate what I mean.
  1. A patient states he is anemic. A CBC is ordered. The results are normal. Proper documentation: “CBC ordered due to history of anemia. Results are normal. No treatment needed.” Or maybe the CBC results do show anemia. “CBC ordered due to history of anemia. Results show mild anemia with microcytic indices consistent with iron deficiency. Plan: will follow with iron studies and begin iron therapy.”
  2. A patient has a fever and a cough and so a chest x-ray is ordered to see if he has pneumonia. Proper documentation: “CXR ordered to R/O pneumonia. It is normal. No change in therapy needed. Follow up in clinic one week.” Or “CXR ordered to R/O pneumonia. It shows hazy infiltrate in the RML. Plan: 1. Begin antibiotics. 2. FU in clinic two days.”
  3. A patient states that her last PAP smear was abnormal, so old records are ordered. Proper documentation: “Old records ordered for last PAP results. This was done 11/24/11 and showed ASC-US. Will schedule repeat PAP smear at six months (late May, 2012).”
  4. An EKG is ordered on a patient with chest pain to see if he is having acute ischemia. Proper documentation: “EKG done for atypical chest pain shows no evidence of ischemia. Will repeat the EKG in 3 hours.”
Unexpected abnormalities also must be interpreted.

Sometimes, studies ordered for one reason come back with significant abnormalities unrelated to the original reason for ordering the study. I’m not talking here about test results that are just a little bit off of what is defined as normal. Those are just a statistical phenomenon that does not have to be mentioned. I am talking about significant abnormalities that have to be explained. Like a chest x-ray ordered to rule out active TB, but which shows a pulmonary nodule.

The metabolic panel in the picture was like that. It was ordered on a patient with persistent abdominal pain mainly to look at the liver enzymes. But his potassium was very high at 6.3. This was unexpected but can’t be ignored. It also must be interpreted: “Metabolic panel ordered to evaluate abdominal pain shows normal liver enzymes. No change in therapy indicated. Incidental finding: Potassium is quite elevated, but is probably due to specimen hemolysis. Will repeat.”

Summary

Documentation of studies, including labs, x-rays and old records reviews, properly includes these three things:
  1. Why the study was ordered.
  2. What the result showed, including any unexpected abnormalities.
  3. Whether any changes in the patient’s treatment plan are warranted.
Proper documentation of study results, whether labs, x-rays, old records, does not take much time. It is a habit well worth developing.

As always, comments are appreciated!

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical care to inmates in several jails throughout Idaho. He is also the author of the "Jail Medicine" blog

Other articles by Keller


Comments:

  1. hamiltonlindley on 01/14/2020:

    that's important to have the right documentation. Hamilton Lindley

  2. xnxxiraqsexy on 11/12/2019:

  3. افلام جنسية حيوانات
  4. افلام جنسيه
  5. افلام جنسيه مع الحيوانات
  6. افلام حيوانات سكس
  7. افلامسكس
  8. افلام سكس
  9. افلام سكس xnxx
  10. casinoonline38 on 10/07/2019:

    تور پاتایا را با آژانس مسافرتی گلفام سفر تجربه کنید. گلفام سفر مجری مستقیم و تخصصی تور پاتایا می باشد پرواز ها و هتل ها گارانتی بوده و ما تضمین بهترین کیفیت و قیمت تور پاتایا را به شما مسافران عزیز می دهیم. تور پاتایا به همراه گشت شهری می باشد - قیمت تور پاتایا .

  11. keatonjefferson on 09/30/2019:

    Great initiatives by following these proper guidelines for using the documents. I hope they continue on doing so, hence to have a knowledgeablemind is as it is prominent enough.. And suitable ideas should result to follow.

  12. casinoonline38 on 09/30/2019:

    Thanks for posting this info. I just want to let you know that I just check out your site and I find it very interesting and informative. I can't wait to read lots of your posts - hardware wholesaler.

  13. jahangirkhatri on 08/18/2019:

    메이저놀이터 brilliant web website online, outstanding comments that i can undertake. Im upsetting adopt and might follow to my contemporary process as a pet sitter, that is extremely courteous, but I yearning to toting going on cross beforehand. Regards.

  14. samuelddarden on 07/14/2019:

    Thank you for sharing your knowledge and experience with me. I can used it to my thesis. endless horse.

  15. jahangirkhatri on 07/06/2019:

    먹튀 I wanted to thanks for this notable proper to apply!! I really loved all tiny little bit of it. I have you bookmarked your web site to test out the introduced belongings you pronounce.

  16. jahangirkhatri on 07/04/2019:

  17. jahangirkhatri on 07/04/2019:

    home page Wow! this may be one of the maximum useful blogs we've ever stumble upon upon thesubject. genuinely exquisite information! Im moreover an expert in this subject matter consequently i will control to pay for a favorable appreciation your effort.

  18. jahangirkhatri on 06/28/2019:

    papolar.com Love what you'in excuse to charity right here men, shop it taking location!..

  19. jahangirkhatri on 06/24/2019:

    vmate apk we are in fact thankful in your weblog declare. you will locate a lot of approaches after journeying your screen. i was exactly attempting to find. thanks for such say and make smile shop it taking region. incredible take steps.

  20. alux on 06/22/2019:

    We are organizing an online community to elevate trusted voices on all sides so you can be fully informed. Experience the News

  21. Kristen Brown on 06/17/2019:

    Very informative post. I think the detail information mentioned here will be very handy for the person working on the diagnostics field. And it is true that making a study report is a very sensitive task. Not only in the medical field but documentation of a study report in research paper writing is also very tough. I am also working as a freelance writer at https://paperleaf.ca/buy-essay-online/ So we know it very well as they have to deal with documentation very often writing an essay for the college students.

  22. jahangirkhatri on 06/16/2019:

    we are in fact thankful in your weblog declare. you will locate a lot of approaches after journeying your screen. i was exactly attempting to find. thanks for such say and make smile shop it taking region. incredible take steps. Permainan PKV Games

  23. annajohnsn on 06/12/2019:

    It's really good to read the articles on this corrections.com site. It is so good for the latest news and stories diamonds rings for cheap. Each article is so worthy for our time. Each one of them contains so many new facts. Thanks a lot for this.


Login to let us know what you think

User Name:   

Password:       


Forgot password?





correctsource logo




Use of this web site constitutes acceptance of The Corrections Connection User Agreement
The Corrections Connection ©. Copyright 1996 - 2024 © . All Rights Reserved | 15 Mill Wharf Plaza Scituate Mass. 02066 (617) 471 4445 Fax: (617) 608 9015