What do you do after getting lab results in at a LTC

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HI, I'm a new grad Lvn and just got a job at a snf/LTC and I'm so confused about the paper work i.e. labs, and MD orders. What do you do after getting in labs results in, please someone help me!!!!! and also can anyone give me the step by step order what to do on a.m.'s or p.m.' the nurses I work with seem not to care that I'm a new grad. Thank you

Specializes in critical care, ER,ICU, CVSURG, CCU.

some facilities have policy, but in general you fax and or call the physicianscoffice, i like faxing, as the conformation page is nice, chart that you have, csome facilities leave the labresults in a binder under a physician name, for follow up pending physian reply on abnormals, so follow up can be done. for serious results as +cultures, uti, pt/inr, electrolytes etc, i like put on the report book, so the 2-10 shift can follow thru, or if results come on evenings, the day shift can follow.....for serious critical values, i will fax the office, call the office and get the nurse, my line goes like this " i really need your help mrs "x" pt/inr, or ua c&s came back ( bad or whatever describes it) i faxed it to you would you please show it to dr and get back with me.....i document faxed results, talked with nurse susie, pendind dr response . :rolleyes:

amoLucia

7,735 Posts

Specializes in retired LTC.

Just make sure you ABSOLUTELY make contact with a real person after hours, on weekends and on holidays if there is an abnormal. Like a dropping H&H, abnormal electrolytes, PT/INRs, lab cultures with appropriate sensitivities, medication levels (digoxin, dilantin, etc), ABT drug peak & troughs, etc. Most especially if it's a CRITICAL lab value. And critical values should be reported ASAP so quick action can be taken. Doctors, nurses and facilities have been hung out to dry for delay in timely response.

And as PP replied, always document in the permanent record (ie nurses notes) your actions. Report your actions to the next responsible staff member also.

If you've called early enough, I sometimes will make a second phone call. Since you're a newbie, I would alert the nursing supervisor for other recommendations. Supervisor is another measure of safety/security and usually that kind of info will be relayed during supervisor-to-supervisor shift change report.

pinkiepinkPN

75 Posts

HI' date=' I'm a new grad Lvn and just got a job at a snf/LTC and I'm so confused about the paper work i.e. labs, and MD orders. What do you do after getting in labs results in, please someone help me!!!!! and also can anyone give me the step by step order what to do on a.m.'s or p.m.' the nurses I work with seem not to care that I'm a new grad. Thank you[/quote']

You really need to be asking your preceptors, nurse manager, or DON what the exact procedures are. Every place is different, and they all have different ways of filing, documenting, etc....but, generally when you get lab results in, you fax them to the patients doctor, and them wait for the doc's office to either call you or fax you with orders for appropriate treatment/prescription, which you then have to fax to the pharmacy to be filled and you have to enter the order into the computer and print out copies to put into the MAR and the pt chart.

Yeah, it's freaking insane...I know.

SunnyVet14

15 Posts

Has 14 years experience.

Usually the ordering physician automatically gets a copy of the labs, but it's best (as pinkiepink said) to ask someone in the know to be sure of the steps. Critical lab results have priority and most clinical settings have strict time guidelines for addressing them. As you get more exposure to the process, you'll know what to anticipate....like a low potassium (often seen in LTC because of some diuretics) will mean the patient needs assessment for hypokalemia and will most likely need a dose increase of oral KCL or started if not already taking.

If it is normal, you don't call MD, fax it, and put it in the chart. Write on the nursing note what you did. On the lab paper write date and time when you faxed it with NNO. If it is abnormal, you call the MD. If no one is answering the phone, you leave a message, fax it, and tell the next shift nurse. I work 11-7 shift so I don't call anyone. I might fax lab result if I am not busy.

Runninonempty

12 Posts

PT INR I call the doctor and write a note on his response for other labs I loom for abnormalities and if something is way off I call the doctor if I'm already calling the doctor for another reason I might just throw in "Mrs Jones lab results are in for you to review" if it's a normal lab

chrisrn24

905 Posts

Usually the ordering physician automatically gets a copy of the labs' date=' but it's best (as pinkiepink said) to ask someone in the know to be sure of the steps. Critical lab results have priority and most clinical settings have strict time guidelines for addressing them. As you get more exposure to the process, you'll know what to anticipate....like a low potassium (often seen in LTC because of some diuretics) will mean the patient needs assessment for hypokalemia and will most likely need a dose increase of oral KCL or started if not already taking.[/quote']

See at my work its rare the doc actually gets a copy of the labs! We usually call them!

OP these are questions you need to bring up with your preceptor.

x19amanda

31 Posts

well usually all the labs that were drawn that day should come at the same time, and i collect all necessary resident's charts so I have the proper information at hand if certain labs are effected by medications etc. I also have suggestions ready to go; such as increasing fluids, daily weights, increasing a certain med etc. i also look at the MD book to see if there is any messages that need to be communicated to the MD from throughout the day as well, so I can get it all done in one phone call. After getting orders for anything left in the md book and with labs, I write the order, put it in the MAR, house report, chart on teh computer, fax what I need to pharmacy, and call any HCP's for any ordered psych meds, tx's (incidents) etc. Im new as well, trust me you will get the hnang of it.

pinkiepieRN

6 Articles; 385 Posts

Specializes in adult psych, LTC/SNF, child psych. Has 8 years experience.

We call in all PT/INRs as well as anything abnormal on a CBC or BMP. We also call in "special" labs such as drug levels like Dig, Dilantin, Vanc, U/A C&S. Actually...I think the policy is to call in *all* labs, normal or not. But sometimes if it something like a CBC, BMP or C&S, you'll call the doc and they'll say, "I'm on my way in. Just flag it and I'll see it when I get there."