I have a ten-year-old Yorkie named Ed. Ed is experienced and knows the daily routine of our house. Last year, we got a Yorkie puppy named Midge. She initially knew nothing. It has been entertaining to watch Ed educate Midge on what to do. Midge watches Ed closely and then does whatever Ed does. She is a true Ed Mini-Me. If Ed lays down, Midge lays down. If Ed asks to go out, Midge wants to go out, too. If Ed begs for a treat, so does Midge.
Since Ed is a pretty good dog, most of what he has taught Midge have been good things, like ask to go outside when you need to potty and sit to say “please” when you want a treat. But Ed also has some bad habits that he has imparted to Midge. Ed still has the Yorkie propensity to yap at the door when the doorbell rings, and so Midge has also learned to also sound the alarm.
Medical education is like this. I remember being a young dog medical intern and watching my heroes, the senior residents. Not everything in medicine is taught in medical textbooks and didactic lectures! Much of what we actually learn as medical practitioners is an imitation of our elders. For example, I watched what the senior residents ate (junk), when they slept (rarely) and how they treated nurses (some good, some poorly), among other things. Like Ed, most of what my senior residents taught me by example was good. But there are a few sketchy practices handed down from medical resident to medical student that can become bad habits.
One of these is how to document results of tests, like lab tests and x-rays. I can still see one of my old senior residents sitting at a desk back in the day with a large stack of lab tests. He would scan each of them for a milli-second and then scrawl his initials and the date at the bottom of the page. This supposedly “showed” that the resident had reviewed the lab results. But it really showed no such thing! Perhaps the resident also scrawls WNL to mean “Within Normal Limits. One old joke from my residency days is that what WNL really meant was “We Never Looked!”
Instead, the proper way to way to document lets results is to interpret them! Interpreting test results actually does not take much more time that the old signature/date scrawl but conveys much more information. Interpreting test results consists of three parts.
First, state briefly why the test was ordered in the first place. Each test should have been ordered for a specific reason (otherwise, why did you order it?). This takes one sentence:
- CBC and CMP done as part of yearly wellness exam.
- CXR done to check for pneumonia in a patient with fever and cough.
- Leg ultrasound done to look for DVT in a patient with swelling.
Second, interpret the test in light of why it was ordered.
- PAP smear shows resolution of previous LSIL.
- No active TB seen on CXR.
- Clean catch UA shows hematuria.
Third, state what will be done about the test result. Will it change the patient’s treatment plan?
- No anemia found. No change in therapy needed.
- U/A shows pyuria. Will start antibiotics and FU in clinic one week.
- TSH low. Will decrease levothyroxine dose and recheck three months.
Finally, studies ordered for one reason sometimes come back with significant findings unrelated to the original reason for ordering the study. I’m not talking about a CMP with a couple of values barely out of range. Almost every lab panel will have a couple of mild abnormalities due to simple random fluctuations. I mean important unexpected findings that you also need to mention, interpret and create a follow up plan. A good example would be a CXR done because of a positive PPD that is negative for active TB but shows an unexplained pulmonary nodule.
CXR done for positive PPD shows no active TB. There is a pulmonary nodule. The radiologist recommends Chest CT, which I will order.
So that is the process! It is not hard. Here are some complete examples:
A new patient at a jail says her last PAP smear was abnormal. Proper interpretation of the records when they arrive: “Old records ordered for last PAP results. This was done on 6/15/2020 and showed ASC-US. Will schedule FU PAP six months from last test (12/2020).”
An EKG is ordered because a patient is having chest pain to see if he is having acute ischemia. Proper Note: “EKG done for atypical chest pain shows no evidence of acute ischemia. Will repeat in three hours.”
“Metabolic panel ordered to assess renal function in a diabetic. BUN and Creatinine show normal renal function. Will repeat in Chronic Care Clinic one year. Incidental finding is a markedly elevated liver enzymes. Hepatitis screen ordered.”
“CBC ordered due to history of anemia. Results are normal. No treatment needed.”
This may seem like a lot, but is really not. Once you get into the habit of documenting like this, it becomes second nature. This method works especially well in electronic medical records, where it is easy to type the study interpretation into a chart note or appendix to the original clinic note.
If we all get into the habit of documenting in this way, the younger practitioners we train will naturally pick it up, just like Midge and Ed!
What I have written here is my opinion, based on my education, experience and research. I could be wrong! Keep that in mind . . .
How do you document test results? Please comment!
A version of this was first published in Corrdocs, the Journal of the American College of Correctional Physicians.
Excellent! These are good examples of “defensible” medicine and not “defensive” medicine. Don’t get tests out of fear. Document why a test was or was not not ordered.
Quick thought for those without benefit of e-record. Get in the habit of using Order form that is split into 3 columns. Use one for test, 2nd for results, 3rd for action / plan – hold the form out of the record in a ‘suspense’ file and complete on receipt of results – this will also act as a mechanism to ensure there are no ‘lost’ results – which can be costly to the patient & provider.