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.”
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!