Page 43 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

the list to determine if the test was completed or if the patient

failed to appear for the ordered tests.

Some choose to continue utilizing a paper method such as a
log or tickler file to track labs, diagnostic tests, referrals, and

appointments that are not being electronically tracked. This is
especially important if the EHR does not interface with all

testing facilities.

If you decide to utilize an electronic tracking system, successful
implementation requires that you work closely with your EHR

vendor to ensure that the key elements of the tracking process

are incorporated.

Paper Records

Although the vast majority of healthcare providers utilize EHR,
the lack of interoperability requires handling paper records on

a daily basis. Lab and imaging results, consultant reports,
after-hours calls, etc. often are relayed to providers via paper

and need to make their way into the EHR. Data affecting
clinical decision support components should be manually

entered into those fields.

Tests or reports should be reviewed, dated, and initialed by the
provider and his/her patient notified of results (including any

follow-up instructions) before they are filed in the record; or, if

they are scanned into the EHR, they should be tasked to the
provider. It is critical to have uniform processes in the office so

that these incoming test results are always handled the same

way for all providers.

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