Background
Diagnostic results may return after an Urgent Care visit. Establishing a clear process for follow up or late arriving diagnostic study results will ensure that you close the loop regarding care provided during the visit. Follow up requires three components:
- Review of results
- Follow Up phone calls to patient or PMD, as required
- Documentation of follow up plan
Review of Results
It is important to have policy that outlines:
- how results will arrive and be logged into your system (paper, electronic)
- who is responsible for results review (ordering provider, provider of the day)
- which results are actionable
Follow up Phone Call
When necessary, telephone contact should be initiated for follow up of positive results or negative results requiring notification. You may contact either the family or the PMD (in some cases, both) to ensure proper follow up
Documentation
Templates can help ensure consistent follow up practices for certain results. The templates also form the basis of your follow up note and can streamline documentation.
The following templates exist as guidelines to ED follow up care
- General
- Radiology/EKG
- Lyme
- Sexually transmitted infections (STI)
- Blood/CSF Culture
- Throat Culture
- Urine Culture
- Wound Culture
General
I have reviewed the patient’s chart and elicited the following information:
Discharge diagnosis:
Treatment initiated at discharge:
| Treatment appropriate for above results | YES NO N/A |
| PCP/Parent notification of results required | YES NO |
RADIOLOGY EKG
I have reviewed the patient’s chart and elicited the following information:
| Initial study interpretation | |
| Final study interpretation | |
| Recommendations |
| No specific follow-up is necessary | |
| Appropriate follow-up arrangements have been made at the time of visit | |
| I have left a message with the patient’s family | |
| I have left a message for the referring or primary physician | |
| I was informed and called the PCP or referring doctor. S/he will follow-up with the patient | |
| I have been unable to reach the patient/family, referring doctor, or PCP. I will continue to attempt to contact |
STI
| POSITIVE CHLAMYDIA and/or GHONORRHEA Prelim (untreated) |
I have reviewed the patient chart. The patient was not treated at time of discharge and requires notification and treatment |
|
| POSITIVE CHLAMYDIA and/or GHONORRHEA Prelim (treated) |
I have reviewed the patient chart. The patient was treated at time of discharge with AzithromycinSupraxCeftriaxoneDoxycycline I plan to contact the patient to notify of results and to insure follow up. |
|
| POSITIVE CHLAMYDIA and/or GHONORRHEA Final result |
I have reviewed the patient chart. This is a final result. Please see notes dated ____ for treatment/contact during initial preliminary result |
Sexually transmitted infections are reportable to the DPH. The Infection Control nurses will notify the DPH about positive results within a few days. You may notify DPH sooner if you are unable to confidentially contact the patient.
| MADPH Department of STD Prevention (DSTDP) |
(617) 983-6940 is available to assist with confidential notification of patients and sexual partners of patients infected with STDs and/or HIV |
Lyme
| POSITIVE LYME ELISA | I have reviewed the patient chart. Will await Western Blot testing to determine presence of Lyme antibody and to further direct care of this patient. |
| POSITIVE LYME WESTERN BLOT (treated) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge for a presumptive diagnosis of Lyme ________. I plan to contact the family or PCP to continue antibiotic treatment. |
|
| POSITIVE LYME WESTERN BLOT (untreated) |
I have reviewed the patient chart. The patient was not treated with antibiotics at the time of discharge. I plan to contact the family or PCP to initiate antibiotic treatment. |
| POSITIVE LYME PCR (treated) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge for a presumptive diagnosis of Lyme ________. I plan to contact the family or PCP to continue antibiotic treatment. | |
| POSITIVE LYME PCR (untreated) |
I have reviewed the patient chart. The patient was not treated with antibiotics at the time of discharge. I plan to contact the family or PCP to initiate antibiotic treatment. |
| NEGATIVE LYME ELISA OR WESTERN BLOT: Low suspicion/Untreated |
I have reviewed the patient chart. There was a low suspicion for Lyme disease and the patient was not treated with antibiotics at the time of visit. No further ED follow up needed. | |
| NEGATIVE LYME ELISA OR WESTERN BLOT: Arthritis (treated) |
I have reviewed the patient chart. The patient was treated with antibiotics at the time of discharge for a presumptive diagnosis of Lyme arthritis. Since the antibody testing is negative this likely does not represent Lyme disease. Further antibiotic use determined by clinical condition at follow-up. I have contacted the family or PCP. |
|
| NEGATIVE LYME ELISA OR WESTERN BLOT: Non-Arthritis (treated) |
I have reviewed the patient chart. The patient was treated with antibiotics at the time of discharge for a presumptive diagnosis of Lyme ______. Although the antibody testing is negative this may still represent Lyme disease. Further antibiotic use determined by clinical condition at follow-up. I have contacted the family or PCP. |
| NEGATIVE LYME PCR | I have reviewed the patient chart. Although the antibody testing is negative this may still represent Lyme disease. Further antibiotic use determined by clinical condition at follow-up. I have contacted the family or PCP. |
CULTURES
Blood/CSF Culture
| POSITIVE BLOOD/CSF CULTURE Prelim result preliminary gram stain, no sensitivities |
I have reviewed the patient chart. I have contacted the family AND PCP to recommend prompt reevaluation in the Emergency Department. |
| POSITIVE BLOOD/CSF CULTURE Updated results Further speciation, with or without sensitivities |
I have reviewed the patient chart. The patient has been appropriately managed at the time of notification about the prelim culture OR I have called the patient back to the ED for reevaluation. I have contacted the family AND PCP. |
| NEGATIVE BLOOD/CSF CULTURE Prelim result |
I have reviewed the patient chart. The patient was / was not treated with antibiotics at the time of discharge. Will continue to monitor results. |
|
| NEGATIVE BLOOD/CSF CULTURE Final result |
I have reviewed the patient chart. No further follow up needed. |
For positive blood cultures, if unable to contact the family:
- Contact PCP to verify contact information
- attempt to have local police department reach family directly at home address
Throat Culture
| POSITIVE THROAT CULTURE Prelim result, question of Beta hemolysis |
I have reviewed the patient chart. Will await ID and sensitivities before directing further care. |
|
| POSITIVE THROAT CULTURE Final result, untreated |
I have reviewed the patient chart. The patient was not treated with antibiotics. Plan to contact the patient to direct further care. |
|
| POSITIVE THROAT CULTURE Final result, treated |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge for scarlet fever or pharyngitis. No further follow up needed. OR The patient was treated for another condition and I plan to contact the family to advise them of the results. |
| NEGATIVE THROAT CULTURE | I have reviewed the patient chart. The patient was / was not treated with antibioticat the time of discharge. No further follow up needed. |
Urine Culture
| POSITIVE URINE CULTURE (Prelim result, no sensitivities) |
I have reviewed the patient chart. Will await ID and sensitivities before directing further care. |
|
| POSITIVE URINE CULTURE (Treated and does not require specific follow up) |
I have reviewed the patient chart. The patient was diagnosed with UTI and treated with ______________ at the time of discharge, has a prior history of UTI and/or age> 2 years. No further follow up needed. |
|
| POSITIVE URINE CULTURE (Untreated and/ or requires specific follow up) |
I have reviewed the patient chart. The patient was not treated at time of discharge OR The patient was treated at the time of discharge but this is a first UTI in a child under 2 years old who will require further management OR The patient was treated at the time of discharge, but the organism is resistant. |
| NEGATIVE URINE CULTURE <50 - 100,000 colonies or mixed flora (treated or requires specific follow up) |
I have reviewed the patient chart. The patient was not treated at time of discharge but is at risk for UTI OR The patient was treated / symptomatic at the time of the visit. |
|
| NEGATIVE URINE CULTURE (<50 - 100,000 colonies or mixed flora) |
I have reviewed the patient chart. The patient was not treated with antibiotics and is not at high risk for UTI. No further follow up needed. |
Wound Culture
| POSITIVE WOUND CULTURE (Prelim result, no sensitivities) |
I have reviewed the patient chart. The patient was treated with _____ at time of visit. Will await ID and sensitivities before directing further care. |
| POSITIVE WOUND CULTURE (I&D only) |
I have reviewed the patient chart. The patient was treated with I&D only. Plan to contact the patient to direct further care. |
| POSITIVE WOUND CULTURE: MRSA (Treated and Sensitive) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge to which it is susceptible. I plan to contact the family to advise them of the MRSA. |
|
| POSITIVE WOUND CULTURE: MRSA (Treated but Resistant) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge, but the organism is not susceptible. I plan to contact the family or PCP for further antibiotic treatment. |
| POSITIVE WOUND CULTURE: MSSA or other pathogen (Treated and Sensitive) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge. No further follow up needed. |
|
| POSITIVE WOUND CULTURE: MSSA or other pathogen (Treated but Resistant) |
I have reviewed the patient chart. The patient was treated with ______________ at the time of discharge, but the organism is not susceptible. I plan to contact the family or PCP for further antibiotic treatment. |
| NEGATIVE WOUND CULTURE | I have reviewed the patient chart. The patient was / was not treated with antibiotics at the time of discharge. No further follow up needed. |
Documentation of Follow Up Phone Calls
Documentation of telephone calls is important as it constitutes continued contact related to the initial ED visit.
Common reasons for follow up phone calls in our setting:
Parent initiated:
- Diagnostic study results follow up
- Clarification surrounding mediations
- Clarification surrounding discharge/follow up plan
PMD or Pharmacy initiated:
- Diagnostic study results follow up
- Clarification surrounding mediations
- Clarification surrounding discharge/follow up plan
UC Provider initiated:
- Clinical follow up
- Diagnostic study results follow up
Key components of Telephone Contact Documentation
“If you didn’t document it, you didn’t do it.”
It is important to document phone conversations that impact clinical care and patient outcome
- Date /Time (automatically populated in PowerChart)
- Name of caller
- Relationship to patient
(helpful to obtain phone number in case of calls being disconnected) - Summary of phone conversation
- Note whether you reviewed the chart
- “I reviewed the medical record and lab results, patient diagnosed with UTI and treated with Suprax”
- or “I reviewed the chart, but the note was incomplete”
- or “see details of prior Follow Up Note from 6/1/13”
- Always document the patient’s condition and treatments provided
- “patient is still febrile, mom gave Tylenol 10 minutes ago”
- When relaying information from the caller use direct quotes as much as possible
- mother states child “has fever to 103, is lethargic and has a rash all over”
- Be specific about recommendations
- “I recommended immediate eval in the ED. Mother agrees to bring child to ED”
- “I am unable to evaluate the rash over the phone, I recommend follow up with your PMD today”
- Follow up with PMD today, return to ED if…, etc.
- Note whether you reviewed the chart
- Always assess how the child is doing
- Remember to be understanding of the stress families may be under with a sick child or an uncertain diagnosis
- Families may be frustrated with pending lab results, uncertain diagnosis, scheduling follow up
- If the family has concerns about the overall visit, provider, nursing, etc, they should be directed to your Patient Relations representative
- When faced with a parent who may be escalating, who may be rude — and you are concerned that this level of escalation may impact the ability to seek care for the child
- it is important to document the state of mind of the parent by describing their behavior:
- “mother is yelling”
- “Had to ask mother to explain situation multiple times”
- Avoid terms like “parent was demanding”, “parent was distraught” best to describe the behavior objectively
- it is important to document the state of mind of the parent by describing their behavior:
In addition to the above scenarios, we also discussed:
- Telephone discussion with consultants. Each consulting service varies on their willingness to discuss patients over the phone, some may require consults. Be specific if you discussed by phone, but did not consult.
- School notes: If parents are asking for specific time frames not outlined in the note:
- Contact ED provider who saw patient
- Refer back to PMD