Open Forum

I have worked in both the hospital and ambulatory care settings.

In my experience the reporting of critical results or values  must be documented in the EMR.

In ambulatory care you can document as a telephone encounter. Document that the patient's name and DOB  are verified and repeated back to the caller. Then also include the documentation of the first name of the person calling, the name of the particular lab or imaging center,  the name of the particular test, and the result.  Document that the particular test and result were verified and repeated back to the caller.  If the caller states that they are also sending the results via FAX document that as well. Then finally document that you will be immediately notifying the provider and route as a high priority to that provider.

Since chances are the particular provider may be busy seeing a patient make a point of physically going to speak with that provider to alert them about the critical value and that the telephone encounter was routed to them. If the provider has specific advice he wants the nurse to relay to the patient or family member then add as an addendum to the original telephone encounter to document the advice. Be sure to include that the advice is " per " that particular provider. Also document whether or not the patient/family member verbalized understanding. If the advice is for the patient to go to the emergency room, document that and which hospital they will be going to. If 911 is being called, include that.

I'm sorry for being so wordy but I have been doing this since 2015 and I have learned how important this documentation is. Charts can and will be audited. The nurse needs to not only document properly for the patient's sake, but for their own sake.

Have a great day,

Karen Hunter, BSN, RN, AMB-BC

Long Island, NY