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Expectations for DONEING of Results Messages by Authorizing Provider (3.2.3)

Expectations for DONEING of Results Messages by Authorizing Provider (3.2.3) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record

3.2.3


UW HEALTH CLINICAL POLICY 1
Policy Title: Expectations for DONEING of Results Messages by Authorizing Provider
Policy Number: 3.2.3
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: November 16, 2015

I. PURPOSE

To describe actions expected from the authorizing provider before DONEING A RESULT MESSAGE in the
Health Link Inbasket.

II. DEFINITIONS

INBASKET is the clinical communication system built into Epic/Health Link.

Communications received via Inbasket are seen as MESSAGES. Messages types include
(a) CLINICAL MESSAGES w hich typically requiring action,
(b) DOCUMENTS AND ORDERS requiring completion or signature,
(c) NOTICES regarding patient status that do not require action

A RESULT MESSAGE is one type of clinical message. Result messages are the sole message type
addressed in this policy.

DONEING is the action of pressing the button, causing a particular message to attain DONE status
and disappear from the Inbasket. Once a result message has been DONED, a permanent audit trail of the
entry is created in the patient’s electronic record and serves as an attestation that actions w ere performed.

III. POLICY ELEMENTS

DONEING a result message from the Inbasket indicates that the provider has f inished taking the necessary
actions on the result, has specif ied the necessary actions and delegated them, or otherw ise know s that the
actions have been taken

IV. PROCEDURE

A. Inbasket Execution by Self
i. The provider has:
a. Review ed the information in the message (lab, radiology, ECG, etc.).
b. Considered the impact of that information.
c. Made a decision about w hat action is needed (if action is needed).
d. Executed or delegated the action needed.
e. Communicated the information to the patient (or delegated that communication).
f. Documented points 3, 4, and 5 above. In many cases, the documentation is a by -product
of actions taken in Health Link (such as orders, MyChart messages, and/or letters w ritten
to patients). Additional documentation is typically needed w hen information w as conveyed
by phone.
B. Inbasket Delegation to Another Clinician
i. The provider has:
a. Review ed the information in the message (lab, radiology, ECG, etc.).
b. Considered the impact of that information.
c. Made a decision about w hat action is needed (if action is needed).
d. Delegated that action to another clinician.
e. Communicated the information to the patient (or delegated that communication).
f. Insured that documentation is recorded for points 3, 4, and 5 above. In many cases, the
documentation is a by-product of actions taken in Health Link (such as orders, messages
to MyChart and/or letters w ritten to patients). Additional documentation is typically needed
w hen information w as conveyed by phone.
C. Attestation of Actions Performed
i. The provider clicks “Done” because they (or other clinical staff) have already acted “outside” of
Inbasket, (in a clinic, pre-operative or inpatient setting). The action includes communication w ith the
patient, taking relevant clinical action, and recording the appropriate documentation (by MyChart,


UW HEALTH CLINICAL POLICY 2
Policy Title: Expectations for DONEING of Results Messages by Authorizing Provider
Policy Number: 3.2.3

letter, or in an inpatient or clinic progress note).
D. For pre-operative tests and tests on inpatients that are posted during hospitalization
i. The attending physician may notify the patient OR may use clinical judgment to decide that specif ic
notif ication to the patient is not necessary (example: normal daily labs).
E. For tests on inpatients that are posted after hospital discharge
i. For patients w ith an external follow -up physician, the discharging UW Health attending physician
should:
a. Phone the patient and execute needed actions, or
b. Phone the follow -up physician regarding the result and any needed management
ii. For patients w ith a UW Health follow -up physician, the discharging UW Health attending physician
should:
a. Phone the patient and execute needed actions, or
b. Phone or send a message to the patient’s Primary Care Provider or follow -up physician
iii. The discharging UW Health physician may use clinical judgment to decide that specif ic notif ication
is not necessary (example: negative culture results)

V. COORDINATION

Author(s): Medical Director of Medical Informatics
Content Experts: Medical Director of Patient Safety; Associate Professor and Division Head of Hospital
Medicine
Senior Management Sponsor: Chief Ambulatory Medical Officer
Approval committees: Safety Committee; Quality Council; UW Health Clinical Policy Committee; Medical
Board
UW Health Clinical Policy Committee Approval: April 20, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REVIEW DETAILS
Version: Original
Next Revision Due: March 16, 2017