ABNORMAL RESULTS

Once you have identified an abnormal result or received an email about an abnormal result, you should do the following:

Document the abnormal result under abnormal follow up note (#1 under documentation notes) and what your action was with the regard to the abnormality.

1. Some results require emergent return of the patient to the ER (ie severely elevated K+ level). Call patient with instructions and document your actions.
2. Other results may require soon return to walk in or to your clinic. Please ask a PCA to help you schedule follow-up, and document your actions.
3. Other results may require call of a script to the patients local pharmacy (ie. positive urine culture) or leaving a script with the triage nurse in walk-in clinic. Any DT can assist you with this. (Click here for prescriptions instructions).
4. If you are unable to reach your patient by phone, you may send a letter to the patients home if it is an non-urgent matter. (ie results of bone density). Print up lab, write note to patient about this, and mail it to the patient. (for instructions on how to mail, click here, follow “Mail prescriptions” )
5. If the matter is of a critical nature and the phone is not in service or the phone number on the computer is inaccurate, you should send a telegram ASAP and document this in the chart. The telegrams can be found in 4 West room 18. (located in black binder labeled telegrams in top of second cabinet from the left).

4W-18

Telegram Folder

ABNORMAL MAMMOGRAMS

Document the abnormal result under abnormal follow up note (#1 under documentation notes) and what your action was with the regard to the abnormality. Ask a DT with any questions.

Once you order the follow-up imaging study, radiology will send your patient a letter with the abnormal result and date for follow up study. It is good form to contact your patient about these findings and notify them personally that they are scheduled for a follow up study.

Abnormalities of mammogram reports fall into several categories.

1) Areas of calcification requiring additional spot compression views.
-You should order the appropriate diagnostic study (additional view/recall) for further evaluation.

2) Other abnormalities require 6 month follow up study.
– You should order diagnostic study with 6 month follow up.

3) Other abnormalities document nodularity and may require US for followup.
(note: not all patients with dense breasts require US follow up)

4) Other abnormalities require evaluation by breast specialist for biopsy. You should refer patient to breast clinic under referrals and you should call x4319 and speak with Elizabeth to get a date for the clinic appointment. (Your PCA can assist you with this.)