Best Practices: Documenting Labs & Diagnostic Imaging

Complete and thorough documentation of laboratory and diagnostic imaging studies is an important part of the clinical record. Laboratory and diagnostic imaging studies performed and/or interpreted by the provider must be documented. The clinical history and examination findings should document the indications for the lab tests and imaging that is ordered. Findings should have an impact on the clinical decision making process.

Reports of studies that are conducted within a provider’s office should always incorporate complete identifiers including:

  • Patient name, age/date of birth, sex
  • Facility name, address
  • Ordering provider name
  • Date of study
  • Views or tests obtained

In-house lab and imaging studies and interpretation of tests obtained from outside sources (facilities, other providers) should be an accurate description of all significant laboratory and diagnostic imaging findings. An “impression” contains a summary of important findings and should contribute to the diagnosis and guide the treatment plan. Recommendations for further imaging studies, other tests or specialty referral should be noted.

Studies that are conducted and interpreted at another facility should be documented by reports from that facility. If outside studies are not documented, interpretation should be obtained from a qualified clinician.

Initial or sign lab, X-ray, or consultants’ reports upon receipt as evidence of having reviewed them. A number of patient injuries and malpractice cases are traced to a provider’s failure to review and act upon abnormal laboratory and X-ray results. It is not fail-safe only to file these reports in the chart with the assumption the provider will review them the next time the patient is seen. For instance, if the patient does not return, as some patients do not, the doctor may not discover significant findings that require action until the patient suffers an injury.

Every liability insurer has had cases in which un-reviewed reports somehow managed to get filed in the record, but were never documented as having been reviewed by the responsible clinician. A safer approach is for the reviewing clinician to initial all reports as an indication that each item has been reviewed and taken into consideration in treatment planning.

Documentation of lab and imaging studies is important in quality patient care, appropriate clinical decision making and effective malpractice risk management. Tests conducted within a provider’s own office must be completely identified and significant findings documented. Lab and diagnostic imaging reports from outside facilities also should be clearly documented as having been reviewed by the responsible clinician.