Normal, Repeat, Critical Values and Reporting
Normal Range/Reference Range
A range which usually includes 2 Standard Deviations of a normal population pool or 95.5% of normal people. It should be noted that 4.5% of Normal people will have results just above or below the "Normal ranges" published.
Automatic Repeat Ranges
Results that fall outside of these ranges will be automatically repeated (unless a prior result done recently is in the same abnormal range). The patient identification, clerical, etc. will also be checked and test rerun.
A range of abnormal test results which are potentially life threatening and require the immediate attention of a physician. Values beyond the published ranges would be automatically called to the attention of the Supervisor or charge technologist. Any questions as to interpretation will be given to a pathologist. The physician in charge of the case will be notified directly of these abnormal results if appropriate.
The repeat and alarm values have been adopted by the Laboratory Management and reviewed by the Medical Staff. When a repeat value is obtained, the procedure must be repeated using the original specimen unless the value is on a patient known to be abnormal from recent testing, or the value correlates with other related abnormal findings on the patient. When a value is repeated and confirmed, this should be indicated as a comment on the result in the LIS. When a value is excepted from repeat because the results are found to be consistent with previous testing, this should be indicated in the LIS as a comment indicating that the result was verified.
Critical Values on in-house patients are telephoned to the patient unit. Alarm values and Stat results on out-patients are to be telephoned to the ordering physician.
The majority of reporting from the laboratory is via electronic distribution into various electronic medical record systems. Inpatient reports are distributed exclusively via interfaces from the Laboratory Information System to the electronic inpatient record. As each orderable item is completed and verified in the LIS, reports are released immediately for real-time updating of the electronic record. Results are permanently archived into both the LIS and the electronic medical record.
Results completed at other CMHC facilities, including Bridgton and Rumford Hospitals, are linked via a common community medical record number. This serves to display all results for a given patient under one concise view that is independent of the laboratory/facility that performed the testing.
Clinical Pathology Printed Reports
Outpatient Interim - This report format prints only new information on the charting run. Once results have been printed on the interim report, they are not reprinted on any other chart. Most Outpatient reports that are sent to physician’s offices are in an interim format. This report becomes the permanent chartable report.
Outpatient Cumulative - This report format cumulates all results on the encounter. As testing is performed and verified over several days, a new cumulative summary will be generated, including results that were reported earlier. The final cumulative summary will include all of the results for that encounter. When combined with a pending test section, this report allows for a more condensed chartable report.
Consulting Copy - This report is generated in an interim format and is used to generate additional copies of outpatient results to other providers who may be identified as consulting physicians.
Anatomic Pathology Printed Reports
Reports are issued on an accession level. That is, they are not cumulative but encompass only the results for one sample (or accession) in any given report. For this reason, they are added to any prior reports that have been charted.
This report includes results of samples submitted for biopsy or surgical pathology. It may also include cytology reports of fluids that are processed as a cell block.
A/P Addendum Report
This report is a follow-up to an anatomic pathology report, which may be generated when there is additional information on a sample. It is usually generated as a result of consultations that are performed at outside reference laboratories.
A/P Preliminary Report
This report is generated as an interim report when it is necessary to issue a report before the standard anatomic pathology report can be completed. It is always followed by standard anatomic pathology report.
This includes cytopathology reports including fluid cytology and PAP smears.
Miscellaneous Printed Charts
This report is triggered whenever a result is entered after discharge. It will be distributed to the physician’s office.
Selected for certain physician’s offices as requested by the office practice. This report will print an interim view of lab results for any physician that has requested copies of inpatient results
Outpatient Printed Report Distribution
Remote Report Distribution
Reports are distributed via the Laboratory Information System to printers in client’s offices when the volume of reports is significant. These reports are sent via an automated fax on a schedule determined by the client.
Network Report Delivery
Client offices which are located within the medical center network are set up to receive reports directly on plain paper laser network printers.
Offices and locations which are not set up for either Remote Report Distribution or Network reporting, receive reports via either mail or courier.
Disease Control Reporting
Copies of some test results are submitted to the Maine Center for Disease Control and Prevention as required by law. Typically this includes sexually transmitted diseases and diseases of unusual significance. Patient demographics, including name and address are submitted to Disease Control.
Additional information may be found at the Maine Center for Disease Control and Prevention website.
Print Chart Layout
The chart report description is found at the upper right corner of the report form. It describes the type of chart that is generated, which will facilitate placing the report in the correct section of the medical record.
The report Header and Footer identify general information about the patient or chart. These sections of the report are delineated with a horizontal line to separate it from the clinical data section which is in the body of the report.
The body of the report is the middle section which contains the clinical data in the report.
Page numbers are found in the upper right corner of the report. They allow staff to easily determine that all pages are present and in the correct sequence.
End of chart message
The end of chart message is found in the footer of the last page of the report. It designates the final page in a multiple chart report, and helps staff to confirm that all pages are present.
The report date is located in the header of the report. It reflects the date that the report was created. It does not necessarily reflect the specimen date. This date is helpful when organizing reports in the medical record.