Best Practice: Diagnostic Testing and Laboratory Follow-Up

Improving Patient Safety Through Effective Test Result Management

Timely follow-up on diagnostic testing and laboratory results is a critical component of safe, high-quality patient care. When test results are not appropriately reviewed, tracked, or communicated, delays in diagnosis and treatment can occur, potentially placing patients at risk. Establishing clear and consistent processes for managing diagnostic testing helps ensure that results are received, reviewed, communicated, and acted upon in a timely manner.

Healthcare practices should implement standardized workflows that track diagnostic testing from the time the test is ordered through result review, patient notification, and any necessary follow-up care. A reliable process reduces the risk of missed or overlooked results and supports improved clinical outcomes.

Timely Follow‑Up on Diagnostic Testing and Laboratory Results

Accurate documentation plays an essential role in this process. Practices should ensure that all ordered tests are documented in the patient’s medical record, including the type of test, the date it was ordered, and the clinical reason for the test. Once results are received, they should be reviewed and authenticated by the ordering provider as soon as possible. Maintaining a structured tracking system that records the patient’s identifying information, the ordered test, and the date results were received can help practices identify outstanding or delayed results before they impact patient care.

Effective Communication with Patients on Diagnostic Testing and Laboratory Results

Effective communication with patients is equally important. Patients should be notified of all test results, both normal and abnormal, in a timely manner, and documentation should reflect when results were communicated, the method used, and any attempts made to reach the patient if initial contact is unsuccessful. Practices should also follow up with patients who have not completed recommended testing, documenting outreach efforts and encouraging timely completion of the diagnostic study.

When results require additional care, providers should document all actions taken, including treatment decisions, additional testing, or referrals to specialists. Discussions with patients regarding results and next steps should also be recorded in the medical record, particularly when shared decision-making occurs regarding treatment options or further evaluation. If referrals are generated as a result of diagnostic findings, practices should implement processes to track those referrals and ensure that patients successfully connect with the appropriate specialist or service.

Leveraging the capabilities of electronic health record (EHR) systems can further strengthen diagnostic follow-up processes. Many EHR platforms include tools that assist with test ordering, automated tracking, alerts for abnormal results, and workflows that prompt provider review. Using these tools can improve efficiency and reduce the risk that important results go unaddressed.

Supporting Patient Safety Through Reliable Diagnostic Follow‑Up

From a risk management perspective, it is generally recommended that the provider who orders the diagnostic test remain responsible for reviewing the results and ensuring appropriate follow-up occurs, even if the results are received after the patient’s visit. Practices should also establish protocols for communicating critical or urgent test results, particularly in situations where the ordering provider is unavailable or results are received outside of normal office hours.

Additionally, assigning designated staff to monitor outstanding test orders can help identify tests that have not been completed, results that have not yet been received, or results that have not been acknowledged by a provider. Periodic reviews or audits of these processes can help identify workflow gaps and support continuous improvement in patient safety practices.

Implementing structured processes for diagnostic testing and follow-up helps prevent breakdowns in communication, strengthens care coordination, and supports timely diagnosis and treatment. By prioritizing clear documentation, consistent communication, and effective tracking systems, healthcare practices can significantly reduce the risk of missed or delayed test results and improve the overall quality of patient care.

Resources:

Core Elements of Hospital Diagnostic Excellence (DxEx) | Patient Safety | CDC