A lab result note records your review of a test result: what it showed, what it means for this patient, what you did about it, and how the patient was told. Copy the free template, see a critical potassium phoned by the lab and a mildly raised ALT on routine bloodwork, and check how to document a critical value read-back.
Blank lab result note template
FreeLAB RESULT NOTE Patient: [Name] Date of birth: [Date] Reviewed: [Date and time] Reviewed by: [Name, credentials] Ordered by: [Clinician, if not the reviewer] How it arrived: [Results inbox, phoned by the lab as critical, faxed or scanned outside report, or radiology call] RESULT Test and specimen: [Test name, sample type, date and time collected, lab or imaging site] Value: [Result with units, the lab's reference range, and its flag] Trend: [Earlier values with dates, or no earlier result] Related results: [Other results that change how this one reads] Sample quality: [Lab comments such as hemolysis or delayed processing, or none] CRITICAL VALUE CALL Called by: [Caller's name, role, and lab or department; delete this section if not phoned] Time received: [Date and time] Read-back: [Patient name and second identifier, test, value, and units read back; caller confirmed] Clinician notified: [Name and time, if someone else took the call] CLINICAL MEANING Context: [Diagnoses, current medicines, recent changes, and symptoms asked about] Interpretation: [What the result means for this patient; true or likely spurious, and why] Urgency: [Normal, abnormal non-urgent, abnormal needing action, or critical] ACTION Decision: [No action, repeat test, medicine change, referral, imaging, or same-day assessment] Done now: [ECG, exam, or other test, with findings, or none needed] Medicine changes: [Name, dose, and change: held, stopped, reduced, or started, or none] Next test or referral: [What, when, and how urgent] PATIENT COMMUNICATION Told by: [Name and role] How and when: [Phone, visit, portal message, or letter, with date and time] Identity checked: [Two identifiers, before giving results by phone] Explained: [Result, meaning, plan, and the symptoms that need urgent care] Understanding: [What the patient repeated back, their questions, and their agreement] Attempts: [Each failed attempt with date, time, and method, or reached first time] TRACKING Pending: [Repeat test, referral, or report, with its due date] Owner: [Who checks it comes back, and the backup] Reminder: [Task or recall set, and its date] Closed when: [The result or event that closes the loop] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice; lab call taken by the ordering physician, ECG and repeat sample the same afternoon
Serum potassium 6.1 mmol/L, flagged critical; reference range 3.5 to 5.1, lab critical limit 6.0. Drawn Tuesday, November 3, 2026, at 8:40 a.m. for routine monitoring. Earlier potassium 5.0 on August 4, 2026, and 4.7 in May. Creatinine 1.6 mg/dL, 141 µmol/L, up from 1.3 mg/dL, 115 µmol/L, in August; eGFR 45, down from 58. Sodium 137. Lab comment: sample not hemolyzed.
Phoned by the medical laboratory technologist on duty, who gave her name, at 2:05 p.m. on November 3. Taken by the ordering physician. Wrote it down, then read back the patient’s full name, date of birth, test, value, and units; the technologist confirmed all five.
74-year-old man with heart failure with reduced ejection fraction, LVEF 35%, and chronic kidney disease. Takes lisinopril 20 mg daily, spironolactone 25 mg daily, furosemide 40 mg daily, and bisoprolol 5 mg daily. Asked by phone: no palpitations, chest pain, muscle weakness, or fainting. Started ibuprofen 400 mg three times a day for knee pain 10 days ago. Interpretation: true hyperkalemia, moderate, from spironolactone and lisinopril with a drop in kidney function that ibuprofen most likely caused. Sample not hemolyzed, so a false high is unlikely. Urgency: critical.
Seen in clinic at 3:30 p.m. ECG: sinus rhythm, rate 68, no peaked T waves, PR and QRS normal. Repeat potassium and creatinine drawn at 3:40 p.m. and sent urgently. Spironolactone held from today. Ibuprofen stopped; acetaminophen for knee pain. Lisinopril, furosemide, and bisoprolol continued at the same doses. Told to avoid salt substitutes and potassium supplements. Repeat result at 6:10 p.m.: potassium 5.8 mmol/L, creatinine 1.6 mg/dL. No ECG changes, no symptoms, and potassium below 6.5, so emergency transfer not needed.
Phoned by the physician at 2:15 p.m.; identity checked by name and date of birth. Told his potassium is high, that it can affect the heart’s rhythm, and asked to come in at 3:30 for an ECG and a repeat test; he agreed. At the visit he repeated the plan: “Stop the spironolactone and the ibuprofen, keep the rest, blood test Friday.” Told to call 911 or go to the nearest emergency department for palpitations, chest pain, fainting, or new muscle weakness. Phoned again at 6:20 p.m. with the repeat result, his daughter on speaker with his permission.
Repeat potassium and creatinine on Friday, November 6, 2026; requisition given. Results task set for the ordering physician, due November 6, with the practice nurse as backup. Copy of this note sent to his heart failure clinic nurse, who will advise on restarting spironolactone at a lower dose. Closed when potassium is below 5.5 and the spironolactone plan is agreed.
Primary care; results inbox review two days after a yearly check-up, letter sent by portal
ALT 68 U/L, flagged high; lab upper limit 40. AST 41 U/L, upper limit 35. Alkaline phosphatase, bilirubin, and albumin in range. Platelets 265, in range. Drawn Monday, October 26, 2026, at her yearly check-up; reviewed Wednesday, October 28. Earlier ALT 38 in September 2025 and 31 in 2023. HbA1c 5.9%.
51-year-old woman, BMI 32, prediabetes. On atorvastatin 20 mg daily since May 2026. From the check-up note: about 7 drinks a week, mostly wine at weekends, and a daily turmeric supplement since the summer. No abdominal pain, jaundice, or itching. Hepatitis C antibody negative in 2024; no hepatitis B test on file. FIB-4 0.96, calculated from her age, AST, ALT, and platelets: low risk of advanced fibrosis. Interpretation: ALT under 2 times the upper limit with normal liver function. Possible causes are steatotic liver disease linked to weight and prediabetes, the supplement, and alcohol. Atorvastatin is less likely, and an ALT under 3 times the upper limit is no reason to stop it. Urgency: abnormal, non-urgent.
Repeat ALT and AST in 3 months, with hepatitis B tests added. No change to atorvastatin. Asked to stop the turmeric supplement. Advised to cut down on alcohol and offered a visit to talk about weight and prediabetes. If ALT is still raised on the repeat, order a liver ultrasound and review at a visit.
Abnormal results letter sent through the patient portal on Thursday, October 29, 2026, the route she chose at her check-up. It gives the result in plain words, says it isn’t urgent, and sets out the supplement, alcohol, and repeat test steps. Portal shows the letter opened on October 30. She replied asking whether to keep taking the statin; answered by portal message the same day: yes, keep taking it. She wrote back that she has stopped the turmeric.
Requisition for ALT, AST, and hepatitis B tests in the portal, due late January 2027. Recall set for Monday, January 25, 2027, owned by the practice nurse; if the tests aren’t done by February 8, the nurse phones her. Closed when the repeat is reviewed: in range, filed with a normal results letter; still raised, ultrasound and a visit.
The result as the lab or radiologist reported it, with what another clinician needs to judge it without opening the report.
Avoid: Copying the whole panel into the note. Name the results that matter, and say the rest were in range.
When the lab or radiology phones a result, the record of the call itself: who called, when, and proof the result was heard correctly.
Avoid: “Lab called.” Without the time and the read-back, no one can show the result was heard correctly and acted on in time.
What the result means for this patient, and how urgent it is. The same number can be routine in one patient and an emergency in another.
Avoid: Restating the flag, such as “potassium high.” Say why it is high, and what that means for this patient today.
What you decided, written so that someone else could carry it out.
Avoid: “Will monitor.” Name the test, the date, and the result that would change the plan.
How the patient learned the result and the plan, and what they took away.
Avoid: “Patient notified.” Say who told them, how, when, and what they understood.
What is still open, who owns it, and when it closes, so a repeat test or referral isn’t lost.
Avoid: Relying on memory, or on the patient to come back. Set a dated task in your system.
“Reviewed” alone doesn’t show you saw the problem. Write what the result means and what you decided, even when the decision is no action.
“K 6.1” tells the next reader little. Add the units, the range, and the last value: a creatinine that rose from 1.3 to 1.6 mg/dL says more than either number.
“Five point one” and “six point one” sound alike on a busy line. Write the result down, read it back, and record that the caller confirmed it.
Hemolysis, a long delay before processing, or a tight tourniquet can push a potassium up falsely, but only a repeat sample shows it. Repeat it before you file it.
Say who told the patient, how, when, what was explained, and what they understood. If you couldn’t reach them, list each attempt.
A repeat ordered but not tracked becomes a lost result. Give it a due date, and name the person who checks that it came back.
Vero Scribe writes the lab result note in your template from your dictation, or from the call or visit with the patient, with their consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The test, the date it was collected, the value with units and the reference range, and earlier values; what it means for this patient and how urgent it is; what you decided; how and when the patient was told and what they understood; and what is still pending, with a due date and an owner.
Record who called, from which lab, and when. Write down the result, read back the patient’s name and a second identifier, the test, the value, and the units, and note that the caller confirmed them. Then record when the responsible clinician was told, what was done, and when the patient was reached. Your organization sets who may take these calls and how quickly a clinician must be told.
The note is for the chart and the care team: your reasoning, the decision, and the tracking. The letter goes to the patient, in plain words. One result often needs both: the note records that the letter was sent, and the letter carries the plan to the patient.
A short one. Record that you reviewed it, that no action is needed, and how the patient will hear. When a normal result rules out something you were worried about, add a sentence saying so.
Record each attempt with the date, time, number, and whether you left a message, and try the other contacts on file. For an urgent result, follow your organization’s escalation steps. If you still can’t reach them, send an unable to reach patient letter with a date to call by, and keep the tracking item open.
Whoever acts on the result. A covering clinician who takes a critical call writes the note, makes the decision, and sends it to the ordering clinician as a task, so the follow-up doesn’t fall between the two.
Yes. Put the report’s impression and the radiologist’s recommendation under Result. A critical imaging finding phoned by radiology is documented the same way as a critical lab value, with the call, the read-back, and the times.
Yes. Copy it, or download it as a Word or text file. No account needed.
Yes. Paste this template into Vero and dictate the result, your reasoning, and the plan, or let it listen to the call or visit with the patient’s consent. Vero drafts each section; you review and edit it, then copy it into your record or export it to Word or PDF.
The SOAP note reordered: assessment and plan on top, with the history and findings below to back them.
For clinical phone calls and nurse triage: the caller, red flags, advice, disposition, and who calls back.
The chart note for a refill or renewal between visits: last fill, monitoring due, safety checks, the decision, and who approved it.
The record of a team or family care conference: attendance, consent, each discipline’s update, decisions, and actions with owners and dates.
For bedside and clinic procedures: indication, consent, time-out, technique, findings, specimens, complications, and aftercare.
Keep results, repeat tests, and callbacks from slipping.
Visit notes, results, and letters, drafted for your review.
Tell the patient what the result means and what to do by when.
When calls about a result haven’t reached the patient.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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