12.70 Review of Test Results and Notification to Patients ‐ Transplant Program
Category: UWHC Departmental Policy
Policy Number: 12.70
Effective Date: June 26, 2013
Section: Clinic Specific (Ambulatory)
To establish a process for the health care provider or their designee to review results and notify patients of
diagnostic test results.
A. Diagnostic results done in the ambulatory setting are directed to the transplant nurse coordinator
(Coordinator) for review.
B. “Abnormal” laboratory results are defined by laboratory ranges or clinical relevance (generally established
“delta changes” or patient specific thresholds or best practice alerts).
C. Diagnostic results are triaged by Coordinators per established protocols/guidelines and reviewed with the
ordering provider when indicated.
D. Due to frequency and volume of lab results, patients are instructed how to obtain results of laboratory
tests. For example, by contacting their local lab, or when drawn at UWHC by calling the transplant office
or checking MyChart.
A. All laboratory test results ordered by the transplant provider performed in the ambulatory setting will be
reported to the active Coordinator assigned to that patient. Including:
1. Patients having laboratory tests at local communities that are ordered by transplant physicians
and faxed to UWHC.
2. Tests drawn as part of the transplant program visit or transplant evaluation visit.
B. Best Practice Alert (BPA) trigger will be released to the Coordinator’s in-basket for below defined aberrant
Test Name Applicable Organ Aberrant Lab Trigger
alanine aminotransferase (ALT) Liver transplant recipients
based upon most recent previous ALTresult
>= 25 increase
Alphafetoprotein ALL organ recipients > 8.5
based upon most recent previous amylase
>= 50 increase
Carbohydrate Antigen 19-9 ALL organ recipients > 37
Carcinoembryonic Antigen ALL organ recipients > 3.0
CMV Quant by PCR All organ recipients All results
Creatinine ALL organ recipients
based upon most recent previous creatinine
< 3 then >= 0.3 increase
3- 4.9 then >= 0.5 increase
> 5 then >= 1.0 increase
EBV Quant by PCR All organ recipients all results
(GGT) Liver transplant recipients
based upon most recent previous GGT result
Potassium ALL organ recipients < 3.0 or >/= 6.0
Prostate Specific Antigen ALL males > 4.0
C. Laboratory values drawn outside of UWHC will be recorded in HealthLink by the nursing staff or
Department Assistant (DA) who is assigned to that clinic, according to UWHC Administrative Policy 7.98 -
Entering Test Results Into UW HealthLink (EPIC).
D. The Coordinator will triage laboratory values according to established transplant protocols/guidelines and
contact the physician as needed.
E. Patients will be notified of results of laboratory tests according to the following:
1. Transplant program visits: Patients will be given a copy of all available laboratory results drawn
in accordance with the clinic visit during the clinic check out.
2. Patients are encouraged to sign up for MyChart to obtain results of tests.
3. Patients are instructed to contact their local lab or the transplant office, or view MyChart for
results of standing lab orders and record values in their record book.
4. Coordinators or designated office staff will notify patient of clinically relevant abnormal labs,
particularly aberrant laboratory results as defined by above parameters or those out of a patient’s
defined threshold and provide necessary instructions for care of follow-up.
a. Documentation of notification will be made in the patient's electronic medical record by
the person notifying the patient.
b. Communication with patients outside of the clinical setting will be done according to
Ambulatory Policy 8.20 – Telehealth Standards in Ambulatory Clinics.
F. Abnormal laboratory values designated as "critical" by Laboratory Medicine Policy #5.3 will be
communicated to the Coordinator, DA, or clinic staff immediately by the laboratory staff in accordance
with UWHC Administrative Policy 8.07 – Critical Results and Critical Tests/Procedures, Communication of.
The DA will communicate critical values that come in immediately to the coordinator via page or direct
1. The Coordinator/DA may also be called by outside laboratories regarding critical labs.
2. After hours, hospital paging will page the Coordinator on call with any critical laboratory results.
3. The coordinator will verify:
a. That the patient with critical lab value is a UWHC transplant patient.
b. That the critical lab value is a lab test ordered by a UWHC transplant provider; if not,
refer call to ordering provider.
c. Methods of verification include: Laboratory staff, UWHC electronic medical record, and
4. Coordinator will then:
a. Contact patient.
b. Investigate correction action as indicated.
c. Contact appropriate physician when indicated.
d. Take corrective action as indicated in guidelines.
e. Document the problem/intervention and any appropriate medication changes in the
electronic medical record using the critical labs doc flow sheet.
f. If after hours, communicate problem/intervention to patient’s Coordinator on the next
G. Diagnostic Procedures
1. All results of diagnostic procedures ordered by transplant providers performed in the ambulatory
setting will go to the active Coordinator assigned to that patient.
2. Abnormal testing results designated as “critical” per Policy 8.07 Appendix B will be reported to
the ordering physician.
3. Transplant biopsies: Results may be provided to the patient during the biopsy visit by the
physician, clinic staff, Coordinator, or physician designee. Non-urgent biopsy results will be
provided to the patient via a phone call from the Coordinator, along with any instructions for care
or follow-up as directed by the physician in a timely manner, unless prior arrangements have
4. Abnormal diagnostic test results will be reviewed with the ordering physician in order to establish
a plan of care for the patient.
5. Coordinators will notify patients of all abnormal diagnostic test results ordered by transplant
physicians and provide necessary instructions for care of follow-up during the clinic visit or by
6. Patients will be notified of normal diagnostic procedure results performed at UWHC and ordered
by transplant physicians via telephone or written communication in accordance with Ambulatory
Transplant - Solid Organ Policy 3.31 - Patient Clinic Visit Check-Out Process - Abdominal
OPO Policy 8.07 - Lab Inspection of Sterile Supplies
Ambulatory Policy 8.20 – Telehealth Standards in Ambulatory Clinics Outside of the Clinical Setting
Laboratory Medicine Policy #5.3
UWHC Administrative Policy 8.07 - Critical Results and Critical Tests/Procedures, Communication of
UWHC Administrative Policy 7.98 - Entering Test Results Into UW HealthLink (EPIC)
V. REVIEWED AND APPROVED BY
Ambulatory Policy and Procedure Committee
Manager, Liver Transplant
Deborah D. Tinker, MSN RN CENP, Director, Ambulatory Nursing