How a note is read
What to write when a lab result is unclear
Keep unclear results clear in the chart: what the lab reported, what you assessed, who responded, and what is still pending.
7 min read built on 12 full opinions updated 2026-09-12
Written by a med-surg RN, ten years, day shift. Why there is no name on it
An unclear lab result can mean the test is still in progress, the finding is indeterminate, or you need clarification. Keep those distinctions in your note. Write what the lab reported, the report’s status, what you found in your assessment, and what happened next.
The short version
- Identify the finding and its source. Include the test, relevant specimen details, result and units, and when you received or reviewed it.
- Keep the laboratory’s qualifiers. Preliminary, equivocal, pending, final, and corrected mean different things. Don’t turn a screening finding into a confirmed diagnosis.
- Document your assessment separately. Write what the patient reported and what you observed at that time. A general statement that the patient looks fine is not enough.
- Be specific about communication and precautions. Name whom you contacted, when, what you told them, and how they responded. Record the precautions you actually put in place under an order or protocol.
- Show what remains open. Note what still needs clarification or testing and who will follow up or receive the handoff. Don’t wait for a final report to escalate a critical result or a concerning change in condition.
What goes wrong
The mistake is treating several different facts as one conclusion.
A preliminary culture becomes a confirmed infection. A hemolysis warning becomes proof that the result is wrong. You send a message to a clinician, then chart as though the clinician reviewed it.
Those are different events. Each shortcut leaves out something the next reader needs:
- The finding is what the laboratory reported.
- The status tells you whether the report is preliminary, final, corrected, or otherwise qualified.
- Your assessment describes the patient at a specific time.
- The clarification and actions show what you checked, what you communicated, and what was ordered or completed.
And final does not mean conclusive. A screening component can be marked final even when the finding is equivocal and reflex testing is still pending.
Keep the uncertainty visible. Keep needed care moving, too. Follow the urgent-notification and escalation process that applies while you work on clarification.
It is not hypothetical
Mapes v. State of Louisiana, Louisiana Court of Appeal, Fourth Circuit, 2022.
The opinion describes a critically low platelet count that the laboratory communicated to a nurse. The facility’s protocol required the nurse to notify the physician verbally, too. The record gave no indication that this happened.
The appellate court reversed summary judgment for the hospital and sent the case back for further proceedings. That was not a final determination that the communication failure caused the patient’s death.
This case is about critical-result notification, not how to label a preliminary result. The distinction that matters here is receiving a result and communicating it onward. Chart them separately. One does not stand in for the other.
What to write instead
These are fictional wording examples, not patient records or standing orders. Use only findings, conversations, orders, and actions that actually occurred.
UTI confirmed. Culture positive.
0905: Preliminary urine culture from specimen collected yesterday at 0600 reports >100,000 CFU/mL gram-negative rods. Identification and susceptibilities pending. Patient reports burning with urination; temperature 37.1°C, HR 84. Dr. Lee notified by phone at 0910 of preliminary finding, pending testing, and assessment; no new orders received. 1500: Pending culture review included in handoff to J. Patel, RN.
Potassium high because sample hemolyzed. Will redraw.
1010: M. Green, MLS, called potassium result of 6.2 mmol/L, flagged critical, with a hemolysis comment. Result read back and confirmed. Patient denies palpitations; HR 88, BP 126/74. Dr. Lee notified by phone at 1012 of result, specimen comment, and assessment. Repeat potassium and ECG ordered. Repeat specimen collected at 1020; ECG obtained at 1023. Repeat potassium pending.
Lyme test positive. Patient informed.
1100: Lyme antibody screening result reported as equivocal; screening component marked final. M. Green, MLS, confirmed at 1108 that reflex testing remains pending. Patient reports continued fatigue; temperature 37.0°C. NP Chen notified by phone at 1115 of finding, test status, and assessment; NP plans to review the reflex result when available. Explained to patient that the screening finding is equivocal and additional testing remains pending.
C. diff positive. Patient isolated.
1400: Three unformed stools since 1100. C. difficile test pending; no result available. NP Chen notified by phone at 1403 of stool frequency and pending test. Contact enteric precautions initiated at 1405 under facility protocol for suspected infectious diarrhea. Explained that precautions are being used while testing is pending, not because infection has been confirmed.
Here’s what these notes keep clear:
- The laboratory finding comes from the laboratory.
- The finding and the report’s status are not the same thing.
- The bedside assessment includes what was actually assessed.
- An order is separate from a completed action.
- Precautions are explained, not treated as proof of a diagnosis.
When you need clarification, chart the question and the answer. Say whether you asked about specimen quality, a missing qualifier, conflicting reports, or additional testing. Still waiting for an answer? Chart that the response is pending. Don’t make the note read as though the question is settled.
If a clinician has not responded, say so. Record the contact attempt, time, information sent, and any escalation you actually carried out. Sending a message is not the same as getting acknowledgment of a result.
If the report changes later, add a time-stamped update. Identify the corrected report, what it replaces, and any repeat notification or change in care. Leave the earlier entry intact. Don’t rewrite it to suggest you already knew the corrected information.
You can use this sequence:
Finding and source → reported status or limitation → patient assessment → clarification and notification → completed precautions or actions → pending follow-up.
Use the relevant EHR fields and add narrative where needed. You don’t have to fit all of this into one paragraph.
Words that do the damage
| Word or phrase | Why it causes trouble | Better replacement |
|---|---|---|
| Confirmed infection | May turn a preliminary or screening finding into a diagnosis. | Name the test, reported finding, and status. Attribute a clinician’s diagnosis separately. |
| Negative so far | Can make an unfinished test sound like a final negative result. | Preserve the laboratory’s preliminary finding and identify what remains pending. |
| Probably contaminated | Presents a suspicion as the explanation for the result. | Identify the specimen comment and who was asked to clarify it. |
| Lab error | Claims an error has been established when it may only be suspected. | Describe the discrepancy and the laboratory’s actual response. |
| Provider aware | Does not show whether a message was sent, received, or discussed. | Name, time, communication method, information conveyed, and response—or response pending. |
| Patient stable | Gives little information about what was assessed. | Document relevant symptoms, observations, and measurements at that time. |
| Isolated for confirmed disease | Can confuse a precaution with diagnostic confirmation. | Name the precautions, their order or protocol basis, and the current test status. |
What the guidance says
- If the patient tells you about a symptom, identify it as patient-reported. Don’t chart it as something you observed. (Montgomery College, CareerStaff)
- Check carried-forward text. Old findings should not read like your current assessment. (TextExpander, Host Healthcare)
If you remember one thing
Keep the lab’s finding, the report’s status, your assessment, and your actions separate. If follow-up is still pending, make that clear.
Read the decisions yourself
Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.
- Jovany Jampher Paredes v. State
- State v. Severinson
- Alan William Null v. the State of Texas
- Estate of Guillotte ex rel. Jordan v. Delta Health Group, Inc.
- Linell Redden, Individually and as Representative of the Estate of Robert Jones Redden, Sabre Marie Redden And Sean Michael Redden v. Denton County
- Redden v. Denton County
- Petras v. 3G Operating Co.
- Mindi Mapes and Donald Mapes, III, Individually and on Behalf of the Patient, Donald R. Mapes v. State of Louisiana, Through the Board of Supervisors of Louisiana State University Agricultural and Mechanical College on Behalf of Louisiana State University Health Care Services Division; Univeristy Medical Center Management Corporation
- Guerri v. Fiengo
- People v. Torres
- People v. Torres
- Lloyd Standley v. State
All the decisions behind this guide, in one page — searchable by court, year, or what happened.
What people say on the floor
Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.
I think it’s so situational. Some patient and families who have been dealing with a known disease process I was familiar with as a nurse—it would be a disservice to make them wait to ask the doctor every time.
r/nursing on Reddit: Is it within our scope to explain lab results? redditThat's funny, it was designed for paper charting. I haven't used it much since moving to an EMR. ... Yah makes total sense. Where I work nursing monitors lab values but generally only document them by exception if abnormal, they are not recorded during routine assessment of labs.
Why do nurses use this format when writing lab values? Is it some kind of memory trick? : redditIt's also ironic when the patient has some kind of complex wounds and people are writing "two RN skin check completed with so and so", but then don't write what they saw, or any further details. It screams JCAHO/insurance reimbursement. Overall, I think people over document but i
r/nursing on Reddit: What are your documentation do’s and dont’s ? redditWhen I went up to them afterwards, they told me it wasn't within our scope of practice to tell patients lab values. Although they said it in a nice way, I was still quite annoyed. I felt that interrupting my conversation with the patient was somewhat undermining my competence as a nurse.
r/nursing on Reddit: Is it within my scope of practice to disclose lab test results? reddit
What everyone else says
Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.
- Documentation of Health Assessment Findings – Health Assessment Guide for Nurses pressbooks.montgomerycollege.edu
- Nursing Notes Examples: Templates & How-To Guide | SimpleNursing simplenursing.com
- 7.2 Documenting and Reporting Data – Nursing Assistant wtcs.pressbooks.pub
- Documentation and Reporting in Nursing - Nurseslabs nurseslabs.com
- Proper Documentation for Pathology and Laboratory Reports - AAPC Knowledge Center aapc.com
- Documentation of Health Assessment findings – Guide to Health Assessment for Nurses pressbooks.pub
- Common Nursing Documentation Errors (and How to Avoid Them) textexpander.com
- Nurse Charting 101: Your Guide to Patient Documentation berxi.com