The Importance of Tracking and Following in the Medical Practice

Allegations of a failure to diagnosis and/or a delay in diagnosis are the leading causes of medical malpractice claims. Many of these failures and delays in diagnosis are directly related to the failure to receive and review diagnostic testing.

Having a good tracking system in place is important to ensure the receipt and review of all outstanding orders. Many patients believe that no news is good news and that if it was important or if anything was wrong, they would receive a call from the office. Waiting for a patient to follow-up on their own test results is not a best practice. A system to track clinical labs, diagnostic imaging, surgical procedures and referrals to other physicians is essential to patient safety.

Many practices are utilizing computerized physician order entry (CPOE) as a component of the electronic medical record (EHR). While CPOE has afforded physician practices safety related benefits, caution must be used to ensure the proper tracking of these elements. Whether utilizing a system of paper records or an EHR, the following components should be incorporated into the workflow:

1. Test results are received.
2. Results are reviewed in a timely manner.
3. The patient is notified of the results, normal or abnormal.
4. The medical record is documented to show the results were received, the patient was notified with the results, and the discussion surrounding the need for follow-up if necessary.

It is not uncommon to encounter challenging issues when implementing a CPOE workflow, and in addition to a solid implementation and strong training, a post implementation audit should be considered. Just as you would check a written log book periodically, you should also be looking at the data in your EHR to ensure that the workflow is correct.