Record information about all phases of the diagnostic testing process in the patient’s healthcare record. Accurately document diagnostic activities and procedures during the pretest, intratest, and posttest phases because of legal, budgetary, reimbursement, and diagnosis-related group and CPT code implications and constraints. Standardized forms are becoming more common.
The patient’s healthcare record is the only way to validate the need for diagnostic care, the quality and type of care given, and the patient’s response to the care and to ensure that current standards of medical and nursing care and diagnostic testing are being met. The medical record may also be the basis for reimbursement for diagnostic tests by Medicare (government) or private insurance programs. Accuracy, completeness, objectivity, and legibility are of utmost importance in the documentation process. Documentation of laboratory and diagnostic testing includes recording all pretest, intratest, and posttest care:
Document that the purpose, side effects, risks, and expected benefits, as well as alternative methods, have been explained to the patient and note who gave the explanation. Include information about medications, IV moderate sedation, start and end times, and patient responses. Describe allergic or adverse reactions. Record data regarding disposition of specimens as well as information about follow-up care and discharge instructions.
Document the patient’s reasons for refusing a test along with any other pertinent information about the situation and who was given this report.
Maintain records of laboratory and diagnostic test data. Frequently, these records are transferred onto compact record storage systems such as microfilm or computer disks. For example, when an individual tests positive for HIV, it is necessary to review donor records at blood donor centers to determine whether the individual ever donated blood. If the infected person donated blood, the recipients of those blood components must be contacted and informed of the situation. This process is called look back. Because many years may pass between donation and transfusion and the time the donor tests HIV positive, medical history records of blood donors must be stored indefinitely.
Documentation should reflect the time, day, month, and year, either by date/time stamp in the electronic health record or handwritten on paper documents. This information can assume great importance in the office or clinic setting when charts become very lengthy. Enter appropriate assessment data and note the patient’s concerns and questions that help to define the nursing diagnosis and focus for care planning. Document specific teaching and preparation of the patient before the procedure. Avoid generalizations.
When an interpreter is utilized, document the name and relationship to the patient or interpretation service used. Record that patient consent to give confidential test information through an interpreter was obtained before revealing the information. Record any deviations from basic witnessed consent policies (e.g., illiteracy, non–English-speaking client, sedation immediately before the request for consent signature, consent per telephone); include nurse measures employed to obtain appropriate consent for the procedure.
Keep a record of all printed and written instructions. Record medications, treatments, food and fluids, intake status, beginning and end of specimen collection and procedure times, outcomes, and the patient’s condition during all phases of diagnostic care. If the patient does not appear for testing, document this fact; include any follow-up discussion with the patient. Completely and clearly describe side effects, symptoms, adverse reactions, and complications along with interventions provided and the patient’s response to those interventions.
Document significant noncompliant behaviors such as refusal or inability to fast or to restrict or increase fluid or food intake, incomplete timed specimens, inadequate or improperly self-collected specimens, and missed or canceled test appointments. Place copies of letters sent in the patient’s chart.
Reporting includes patient notification regarding test outcomes in a timely fashion and documentation that the patient or family has been notified regarding test results. Document follow-up patient education and counseling, understanding of that teaching, and whether follow-up teaching is needed.
Report results to designated professionals. Report critical values immediately and document to whom results were reported, orders received, and urgent treatments initiated.
Report all communicable diseases to appropriate agencies.
Report and document situations that are mandatory by state statute (e.g., suspected elder abuse, child abuse as evidenced by x-rays).
Clinical Alert
New reporting requirements are based on a syndrome recognition surveillance system for disease outbreaks, reservoirs for bacteria, the highest illnesses, and risk of bioterrorism diseases (botulism [foodborne illnesses], anthrax, smallpox, hemorrhagic fever, Hantaan virus, Ebola virus, yellow fever, plague [bubonic and primary septicemia], and the coronavirus). This system recognizes that animals (zoonotic) may be the primary source of diseases. It also highlights collaboration by desiring input from primary providers, PAs, nurse practitioners, school nurses, emergency medical technicians, veterinarians, laboratory technologists, and animal control (severe illness wildlife).
Reporting of infectious diseases and outbreaks and toxins to state and federal governments is part of record-keeping. Chart 1.6 is an example of required disease reporting to the CDC. Check with your individual state or province for specific guidelines.