Policy Manual sample

MDT Home Health Care Agency, Inc. CRITICAL TEST RESULT REPORTING POLICY: Critical test are communicated to the MD regardless if the results are too high, too low or normal because of the type of test: VANCO level results, Protime results, STAT order results. * Test results are received in this Agency 24 hours a day, seven (7) days a week. * All critical test results/values are reported to the physician within two (2) hours of receipt the results by the Agency. DEFINITION: Critical test results are those results/values deemed critical by: * The laboratory and/or diagnostic center reporting the results/values, or * The physician ordering test(s) PROCEDURE: * When verbal critical test results are received by an appropriately qualified Agency staff member, the result are verified by the individual receiving the results reading them back to the reporting individual. * The critical test results are documented in the patient’s medical record along with the date and time the results were received in the Agency. The following statement accompanies the documented test results: “Critical test results read back to and verified with (full name and title of the individual providing the results)”. * The physician is notified of the critical test results, regardless of whether the laboratory and/or diagnostic center notified the physician, and the physician asked to read back the results. * The date and time of physician notification and response is documented in the patient’s medical record, along with the following statement: “Critical test results read back by Dr. (name of physician)”. * If the initial physician contacted is not the ordering physician, the ordering physician is notified of the critical test results/values as soon as possible and/or feasible and the above- mentioned information is again documented in the patient’s medical record. * Verbal orders received in response to physician notification of critical test results/values are documented in the patient’s medical record, as per the Agency Verbal/Telephone Orders Read-Back policy. * Read-back of critical test results/values is tracked and trended as part of the organization’s performance improvement program (QAPI), and aggregated results are reported monthly to the Director of Nursing, Clinical Manager, and quarterly to the Board of Directors and QAPI Committee. * Root cause analysis is conducted on any identified variances, and a plan of correction is developed, implemented and evaluated. Home Health Agency Policies A-156