Critical Tests and Critical Values/Results - Policy ADMIN 0199

Q: What is the purpose of this policy on critical tests and critical values/results?

It defines critical tests and critical results/values, identifies who reports to whom, and sets acceptable timing between result availability and reporting.

Q: Who receives and how quickly must critical results be communicated?

The generating area contacts the ordering LIP or designated on-call LIP; in specified units it contacts a responsible licensed caregiver. Critical values/results in Attachment B must be reported within one hour of final determination.

Q: When are subsequent critical values/results not required to be reported?

After the initial critical value/result is communicated, subsequent critical values/results do not need reporting unless a specific request is made by an LIP or the subsequent results worsen.

Oct 5, 2026

Upload by James

Policy defines which diagnostic procedures constitute critical tests and which findings qualify as critical values/results requiring urgent communication. It specifies the roles of the value/result generating area, the ordering licensed independent practitioner (LIP), designated on-call LIP, and responsible licensed caregivers for defined high-acuity units. It sets reporting time expectations, outlines when repeat notifications are not required, and requires documentation in the electronic medical record or manual downtime verification.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

I. Description

II. Rationale

III. Policy

A. Purpose

B. Definitions

C. Procedure

D. Documentation

ATTACHMENT A: Critical Tests

ATTACHMENT B: Critical Value/Result

| Administrative Manual | | | | --- | --- | --- | | | Policy Name | Critical Tests and Critical Values/Results | | | Policy Number | ADMIN 0199 | | | Date this Version Effective | December 2015 | | | Responsible for Content | Medical Staff Executive Committee | I. Description To assure the results of critical tests and critical values are reported in a timely manner. II. Rationale The UNC Health Care system recognizes the importance of effective and timely communication of critical tests and critical values/results in patient safety. It is the policy of UNCHCS to report the result of a critical test or critical value/result to a licensed independent practitioner (LIP), and in the case of critical tests/value results for patients located in Intensive Care Units, Burn Center, Dialysis, Labor and Delivery, PACU and BMTU, to a responsible licensed caregiver. Any test performed under the immediate supervision of a responsible physician (including but not limited to: cardiac stress testing, cardiac catheterization, TEE, or EEG for brain death) are not subject to this policy as the physician is immediately aware of values/results. III. Policy A. Purpose 1. To define critical tests and critical results/values. 2. To define by whom and to whom critical tests and results are reported. 3. To define the acceptable length of time between the availability and reporting of critical tests and critical values/results and diagnostic procedures. B. Definitions 1. Critical Tests Those tests that will always require rapid communication of the results, even if normal. (See Attachment A) 2. Critical Values/Results A critical value/result is defined as any value/result or interpretation where a delay in reporting may result in a serious adverse outcome for the patient. (See Attachment B) C. Procedure a. The value/result generating area (e.g. clinical laboratories, radiology, electrocardiographyetc. ) will contact the ordering LIP or if (s)he is not available a designated on-call LIP. In the case of critical value/results for patients located in Intensive Care Units, Burn Center, Dialysis, Labor and Delivery, PACU and BMTU, a responsible licensed caregiver will be contacted. b. All critical tests will be reported to the appropriate LIP or responsible licensed caregiver within the time specified in Attachment A. c. All critical values/results in Attachment B will be reported to the appropriate LIP or responsible licensed caregiver within one hour of the generating area determining the final value/result. d. Once the LIP or responsible licensed caregiver has been notified of the initial critical value/result, subsequent critical values/results do not need to be reported, unless specifically requested by an LIP or if the subsequent values/results worsen. e. All laboratory values/results are immediately available to the LIP in the electronic medical ADMIN 0199 Page 1 of 6 Critical Tests and Critical Values/Results record. D. Documentation 1. Each value/result generating area documents the results of critical tests and critical values in the electronic medical record. 2. In the event of a downtime procedure when the electronic system is not available, the responsible licensed caregiver receiving the result will: a. Write it down; b. Read back the complete result; c. Verify that the read back result is correct; d. Note verification in the progress note. 3. In case of emergency (such as a code or in the O. R.), repeating the result to the calleris acceptable. ADMIN 0199 Page 2 of 6 Critical Tests and Critical Values/Results ATTACHMENT A Critical Tests | Service | Test | Turnaround Time From Ordered to LIP | | --- | --- | --- | | Heart and
Vascular
Services | ECG for chest pain ordered as STAT in the ED | 10 minutes | | Radiology | CT Scan for s/s of stroke in ED or inpatient unit | < 45 minutes | | Radiology | CXR s/s of stroke in ED or inpatient unit | < 45 minutes | | Hear

FAQs

What is the purpose of this policy on critical tests and critical values/results?

It defines critical tests and critical results/values, identifies who reports to whom, and sets acceptable timing between result availability and reporting.

Who receives and how quickly must critical results be communicated?

The generating area contacts the ordering LIP or designated on-call LIP; in specified units it contacts a responsible licensed caregiver. Critical values/results in Attachment B must be reported within one hour of final determination.

When are subsequent critical values/results not required to be reported?

After the initial critical value/result is communicated, subsequent critical values/results do not need reporting unless a specific request is made by an LIP or the subsequent results worsen.

Oct 5, 2026

Upload by James