LAB 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]