Interpretation, Formulation, and Issuing of Test Results

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Table of Contents

Introduction
Standard Reporting Systems and Recommendations
Interpretation of Results and the Process of Issuing the Final Report
The Potential for Misinterpretation
A Sample Report
References

Introduction

Interpretation of test results is not less important than specimen collection and analysis. Laboratory specialists need to be particularly attentive when interpreting the results since any errors in this process may cause harmful outcomes for patients. Lab technologists at Al-Rahba adhere to all regulations concerning the formulation of reports and their interpretations.

Standard Reporting Systems and Recommendations

A commonly established way of reporting results is to release the test outcomes from the Center System through the Hospital Information System upon verification by the technologist who did the test, senior technologist, or head of the section.

Standard reporting in the Laboratory Information System PathNet incorporates the following procedures:

for hematology and chemistry sections, a technologist should choose the option “Accession Result Entry” in PathNet. Then, the patient accession number should be entered. When the Center shows the results on the screen, the technologist should confirm them by choosing the “verify” option on the bottom right part of the screen. For the tests performed manually, it is necessary to input the results into the system prior to verifying them (1).
for the blood bank section, it is necessary to choose “BB Result Entry” in PathNet and follow the same steps.

There may also occur a need to report the results by telephone. Only panic values are reported with the help of this method. According to the Panic Value Notification policy, it is necessary to report panic values to the ward nurse or requesting physician.

Interpretation of Results and the Process of Issuing the Final Report

Interpretation is a permanent part of patients’ medical records. Upon verification in the LIS, all patient results are forwarded to the HIS Powerchart, in which the results form is viewed by the physician. In order to preserve confidentiality, results are not given to patients or their family members. Instead, they are relayed through the physician, and a patient can ask for a hard copy through medical records.

Appropriate interpretation presupposes entering the results of manual and blood bank tests into a logbook. This duty should be fulfilled before the shift ends. The technologist should sign the laboratory’s copy of the results and mention the time and date of completing the test. Such reports are kept in a file for a period of nearly two years.

Interpretation of results excludes giving any medical advice to patients or their family members by technical staff. When a patient or family member asks for interpretation, only a hematologist or laboratory COS may offer some comments or suggestions (2). However, these specialists need to consult the physician prior to providing any interpretation for patients or family members.

All lab reports for manually filled inquiries should be available at the reception. They can only be given to authorized staff members (clinic porter, ward porter, nurse, physician, or Medical Records Department clerk) after acquiring their signatures. The reports that will be sent to the physician have to be signed by the technologist who did the test and, if possible, the head of the section or senior technologist within normal working hours (8 a.m. – 4 p.m.). After normal hours (4 p.m. – 8 a.m.), on Fridays and Saturdays, and Public holidays, the technologist responsible for performing the test has to issue a report and verify it.

The final report has to contain the following elements:

the patient’s name and other identifiers of the specimen;
the name of the clinician that ordered the test;
the tests that were performed, their results, and units of measurement;
the date and time when the specimen was collected;
the condition of unsatisfactory specimens;
reference values for the tests;
the time and date of reporting the results;
the identity of the lab specialist who performed the test (3).

The Potential for Misinterpretation

If some of the requirements and policies concerning the test results are not followed, there is a possibility of misinterpretation of results. In the blood bank section, the most common misinterpretation is associated with hemolysis laboratory tests (4). Such a situation occurs when an emergency blood transfusion is needed, and there is no time to perform the screen and blood type of a patient. In such cases, universal donor group blood is transfused to a person. If no antibody screen is performed, there is a potential risk for a deferred reaction to hemolytic transfusion in case if the patient has been all immunized to “minor RBC antigens” (4). As a result of such misinterpretation, a patient may develop worsening anemia. This and other misinterpretation issues may produce a harmful impact on patients, and it is crucial to do everything possible to avoid them.

A Sample Report

CBC (Complete Blood Count)

Date of performing the test: Time:

Patient:
Clinician:
Lab specialist:
Unsatisfactory specimen (tick or cross):

Date of reporting the results: Time:

Component	Standard range	Obtained result	Units
RBC count	3.50 – 5.50	3.60	MIL/UL
WBS count	4.5 – 11.0	14.0	K/UL
Hematocrit	36.0 – 48.0	39.0	%
Hemoglobin	12.0 – 15.0	19.0	G/DL
MCH	25.0 – 35.0	25.8	PG
MCV	79.0 – 101.0	80.0	FL
MCHC	31.0 – 37.0	35.0	%
RDW-CV	11.0 – 16.0	11.5	FL
Platelet count	150 – 420	400	K/UL
MPV	7-10	8	FL

Annotation: all but two components checked by the CBC test are within the norms. Increased WBS count may signify inflammation of infection. Increased hemoglobin may signify pulmonary fibrosis or congenital heart disease.

Signature: ________________

References

College of American Pathologists. All common checklist: CAP accreditation program. Northfield: College of American Pathologists; 2015.
Joint Commission International Accreditation Standards for Hospitals. 6th ed. Oak Brook: Joint Commission International; 2017.
Health Authority of Abu Dhabi. HAAD clinical laboratory standards. Abu-Dhabi: HAAD; 2011.
Laposata M. Clinical diagnostic tests: how to avoid errors in ordering tests and interpreting results. New York: Demos Medical Publishing; 2016.

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