Sometimes physicians lament about receiving diagnostic test results they have not ordered. Other times, when unsolicited test results are received, physicians will request that additional copies of the reports be sent to providers involved with their patient's care, even if they have not seen the patient for a while.
What exactly are you required to do when you receive unsolicited diagnostic test results? California's regulatory requirements for physicians, or other licensed providers, are as follows:
- When an established physician-patient relationship, or contract to provide health care services, exists at the time diagnostic test results are received, the physician is obligated to review them in the same manner as if ordered by the provider. It is suggested that the medical record documentation include provider initials (or signature), review date, and plan, including notification and discussion with the patient and other providers, if indicated.
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For persons who are not patients, however, different rules apply. This is especially true when results come from a "multi-phasic screening unit," a facility that does not prescribe or treat patients, but only performs diagnostic testing, e.g., an MRI center or a stand-alone laboratory. Specific California requirements apply to receipt of unsolicited diagnostic test results from these units on a person who is not a patient.
- If the provider does not wish to evaluate the results, or evaluates them and takes no further action, the provider must either notify the testing facility of that fact or return the test results within twenty-one (21) days of receipt.
- If the provider actually reviews the test results and determines that they indicate a substantial risk of serious illness or death, the provider must make a reasonable effort to notify the person tested within fourteen (14) days after the date the provider received the test results.
- In either case, it is advisable to send the notification by signed return receipt and retain the documentation.
- These requirements do not apply if the unsolicited test results came from a testing facility that also delivers patient care and/or treatment. However, CAP Risk Management & Patient Safety advises that physicians take the same actions when unsolicited test results are received from any facility for someone who is not a patient.
CAP recommends each physician develop a written policy that gives staff instructions for proper and timely processing of unsolicited diagnostic test results.
Authored by
Jackie Gellis Server, RN, MHA
Senior Risk Management & Patient Safety Specialist
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.