Pathology, Radiology Orders Must Be Complete
BWH and Partners HealthCare recently completed an internal audit of the ambulatory area that showed a significant number of incomplete laboratory and Radiology requisitions/orders.
Effective Aug. 15, BWH implemented a hard stop policy for incomplete requisitions/orders received: No specimen collection will be performed when accompanied by a requisition that does not include 1) the signature of the ordering physician, nurse practitioner or physician assistant, 2) ICD-9 code(s) and 3) legible clinician code. Patients with an incomplete requisition/order will be sent back to the practice to obtain the required information.
All clinical laboratory requisitions require the following information:
• Clinician’s signature
• Legible clinician’s name and/or clinician ID code
• ICD-9 code(s)
• Patient’s full name
• Patient’s medical record number
• Date of birth or age
• Gender
• Date of service
• Specific tests/services requested
• Date of specimen collection and when relevant, collection time
• Initials or ID code of the person who collects the sample(s)
• Location
A similar hard stop will be implemented for Radiology and non-invasive cardiology (echocardiography, vascular lab, cardiac stress lab) test ordering in September.
BWH, DFCI and Faulkner Radiology will require an electronic provider signature and a diagnosis in Percipio before the requested examination will be performed. The provider must enter the request in Percipio directly or electronically sign requests entered by her/his support staff.
The exception to this policy is when the requested examination is a clinical emergency and the requesting provider is not immediately available. In these exceptional circumstances, the provider must sign the request within 24 hours of the exam completion.
Unless indicated as optional, all information requested on a requisition/electronic order form is required. Other data relevant to a particular test or service will be specified on the requisition/electronic order form unique for that service. Any missing or illegible information will constitute an incomplete requisition. Unsigned requests will be monitored and reported to clinical chiefs.
In order to minimize the impact on patient service, the practice must ensure that all requisitions/orders are completed according to the above specifications before the patient leaves the practice. This also includes samples that are collected in the practice. Each practice is required to put systems in place to ensure full compliance with these requirements.