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Guidelines for Reporting Results: The Role of the Primary Care Nurse

Primary care nurses play a crucial role in healthcare by assisting in the delivery of patient care. One aspect of their responsibilities includes the disclosure of laboratory or diagnostic imaging (DI) results to patients. However, it is essential for nurses to navigate this process with caution and adhere to regulations. In this blog, we will outline important considerations for primary care nurses when disclosing results. In theory, all primary care nurses could report results to patients. But that doesn’t always mean they are the best provider to do so. So it turns the question from “Can I?” to "Should I?”.


When deciding whether it is appropriate to disclose laboratory or DI results to patients, primary care nurses should consider two key components: Competence and appropriateness. If the result falls within their level of experience or expertise then they would be considered competent to relay the result. If the primary care nurse has been involved in the patient's care and can adequately counsel the patient about the next steps in the care plan then they would be considered appropriate to disclose the result. In situations where further interpretation of the result is required, the result indicates increased severity in the patient's condition, or the nurse is unsure of the implications of the result for the patient's care, it is most appropriate for the ordering provider to relay the result. This allows for clarification of the patient's condition and the development of an appropriate plan of care.


To ensure proper documentation, nurses should include details of their interactions with both the ordering provider and the patient/caregiver. The documentation should capture the conversation, direction, or order from the ordering provider, as well as any discussions with the patient or caregiver. Nurses should adhere to the CRNA Documentation Standards (December 2022, effective March 2023) and CLPNA Documentation Guidelines (updated May 2023) to maintain accurate and comprehensive records.


Guiding Questions for Nurses

  • Do I have direction/provider order from the ordering provider to relay this result?

  • Have I been involved in the care planning that involves this result?

  • Am I able to competently explain the result and answer questions according to the result in the context of the care plan?

  • Do I have access to the ordering provider to clarify patient questions or concerns that may arise when relaying the result?

  • Is it more appropriate for the patient to discuss the result directly with the ordering provider?

  • Does my employer have a policy to guide my practice when relaying results?


References:

RNs: Practice Guide - Diagnostic Tests and the Role of the RN. This guide provides valuable insights into the responsibilities of RNs when disclosing laboratory or DI results. It can be found on the CRNA College Connect website under Learning and Development > More Practice Information > Diagnostic Tests and the Role of the RN.


LPNs: Standards of Practice for Licensed Practical Nurses in Canada. Sections 1.8, 1.9, 2.1, 2.4, 2.6, 2.10, and 3.4 of these standards outline LPNs' roles and responsibilities when communicating lab or diagnostic test results. Nurses can access this document for comprehensive guidance.

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