OMS-SOP-003: Results communication and follow-up of missing results

Standard operating procedure (SOP) · OMS-SOP-003 · Version 0.1 · Draft for local review

Supports: 59.3

1. Purpose

To make sure that results of tests and investigations are communicated to patients and to the clinicians responsible for their care in time to act, and that any missing or delayed result is found and followed up (59.3).

2. Scope

Item	Coverage
Applies to	Outpatient clinicians, nurses, administrative staff and results teams
Results	Laboratory, imaging, pathology, genetic and specialist test results, and any result that requires action for the patient
Locations	Outpatient clinics, specialist services and the results team

3. Definitions

Term	Meaning in this SOP
Actionable result	A result that needs a change in treatment, a further test, a referral or a conversation with the patient
Communication time	The maximum time from result receipt to communication, set by result category in Section 6.1
Missing result	A test that was requested, that should have been completed by its expected date, and whose result has not been received or recorded
Result owner	The clinician named as responsible for acting on the result

4. Background

Delayed or missing results are a common source of harm in outpatient care. Results can be lost between the laboratory, the requesting clinician and the patient, and few people look for them. A named owner, a set communication time and a tracked list of expected results prevent most of these failures.

5. Responsibilities

Role	Responsibility
Requesting clinician	Names the result owner on the request, states the expected result date and what action will follow
Result owner	Reviews the result and acts on it within the set time, and records the communication
Results team or administrator	Tracks received results, flags results not yet acted on, and chases missing results
Nurse or clinician who speaks to the patient	Communicates the result, checks understanding and records the conversation
Service manager	Keeps the tracking list, the procedure and the audit in place

6. Procedure

6.1 Communication time by result category

Category	Maximum time from receipt to communication
Urgent or critical result	Same day, by a clinician, by telephone or in person
Actionable abnormal result	Within 5 working days
Normal result that the patient asked to receive	Within 10 working days, in writing or by the agreed method

6.2 Communication

1. Check the patient's identity before disclosing the result.
2. Explain the result in plain language, what it means, and the next step, and check the patient's understanding.
3. Give the patient the chance to ask questions, and the contact details for follow-up.
4. Record the communication: the date, the person who communicated, the method and the result given.

6.3 Tracking and missing results

1. Enter every expected result on the tracking list with the requesting clinician, the result owner and the expected date.
2. Review the list each working day for results received but not acted on, and results past their expected date.
3. Chase a missing result within one working day of its expected date, with the laboratory or the department concerned.
4. If the result cannot be found within five working days, inform the result owner and the patient, and arrange a repeat test where clinically needed.
5. Record every chase and its outcome on the tracking list.

7. Decision points

Situation	Action
Result is critical and the result owner cannot be reached	Inform the duty clinician at once, who must act on the result
Patient cannot be contacted by telephone	Write to the patient by the agreed method, record each attempt, and inform the result owner
Result is received after the patient has already been seen for another reason	Communicate it at the next contact, and not later than the set time
Patient asks not to receive a result	Record the request, check it is informed, and discuss it with the result owner

8. Escalation

• Result not communicated within the set time: the result owner's manager is informed the same day.
• Missing result unresolved after five working days: the service manager reviews the case and reports under INC-SOP-001 if harm is possible.
• Repeated delays for the same result type: the service manager reviews the pathway at the governance meeting.

9. Monitoring

The service manager audits the tracking list each month for the timeliness of communication and the number of results chased, and reports results to the governance meeting each quarter.

Measure	Target
Urgent results communicated the same day	100 percent
Actionable results communicated within 5 working days	At least 95 percent
Missing results chased within one working day of expected date	100 percent
Results on the tracking list unresolved for more than 30 days	0

10. Records

• Tracking list of expected results.
• Result communication record in the notes.
• Chase record for missing results.
• Incident reports for delayed or missed results.

11. Training

All clinicians and administrative staff who request, review or communicate results complete training on result categories, communication and the tracking list at induction and every two years.

12. Related documents

Code	Document
OMS-SOP-001	Specialist consultation: assessment, consent and clinician scope
OMS-REG-001	Outpatient recall and follow-up register
LBT-SOP-008	Laboratory report content and delivery
INC-SOP-001	Root cause analysis of serious incidents

13. Evidence

This SOP is based on the reference sources listed below and on the requirement of criterion 59.3 of the ASF standards. The communication times must be confirmed against the facility's results policy at each review.

E-learning for this document

• No course linked yet. Request a results management course from the academy (see the Standard 59 request list).

References

1. NHS England. Results management and missing results guidance. Current edition (check the current NHS England publication before use).
2. Facility results management policy and set communication times (to be inserted by the facility at adoption).

Change history

Version	Date	Change
0.1	2026-10-26	First draft for review. Not yet approved by the ASF Expert Committee.