Genetic Test Ordering & Coordination Note

Date/Time Created: [Timestamp]

Last Updated: [Timestamp or N/A]

Author/Role: [Name, credentials, role]

Ordering Clinician of Record: [Name, credentials]

Patient: [Full name] | [MRN] | [DOB]

Encounter Context: [clinic visit / phone / telehealth / inpatient consult / other]

Order Summary

• Test Ordered: [Exact test name as listed by laboratory]
• Laboratory: [Lab name] ([in-network / out-of-network / unknown])
• Test Type: [germline / somatic / tumor-normal] | [diagnostic / predictive / screening] | [singleton / duo / trio / other]
• Specimen: [Specimen type]; Status: [scheduled / collected / shipped / received / not collected]; Collection date: [Date or unknown]
• PA Status: [approved / pending / denied / not required / unknown]; [Authorization number if approved]
• Expected TAT: [Published TAT timeframe] (Source: [source and date verified])
• Current Order State: [draft / awaiting consent / PA in progress / ready to collect / collected / shipped / in lab processing / results available / canceled]

Indication

(Provide 2–5 concise bullets supporting medical necessity and guiding lab interpretation.)

• [Clinical question being addressed]
• [Key phenotype features relevant to interpretation]
• [Pertinent family history summary] (State "Family history unavailable" if unknown rather than leaving blank.)
• [Prior related testing and outcomes]
• [Known familial variant details if applicable: gene, variant, affected relative, report availability]

Consent & Pre-test Counseling

• Counseling provided by: [Name, role] on [Date]
• Decision-maker: [patient / guardian]; Interpreter: [yes / no]; [Language if used]
• Consent status: [obtained / pending / declined]; Method: [signed / verbal / electronic]; If pending or declined: [Reason and next steps]
• Key topics addressed: [purpose] | [possible result types] | [test limitations] | [secondary findings preference] | [family implications] | [expected TAT] | [disclosure method]

(If consent is pending, do not mark order as sent. If patient declines, document declination and plan.)

Specimen & Coverage Tracking

Specimen Requirements: [Type, volume, tube/container, handling constraints per lab instructions]

Collection Plan: [Location]; [Scheduled or completed date]; Kit ID: [Kit identifier or N/A]

Shipping: [Method/carrier]; Ship date: [Date]; Tracking: [Number]; Lab receipt confirmed: [Date or pending]

Coverage:

• Payer/Plan: [Payer and plan]; In-network: [in-network / out-of-network / unknown] (Verification: [method])
• PA Requirement: [required / not required / unknown] (Basis: [policy or verification details])
• PA Submission: [Date]; [Method]; Documents sent: [List]; Reference: [Number or unknown]
• PA Outcome: [approved with auth number / denied with reason and appeal plan / pending]
• Patient Cost: Estimate discussed: [yes / no]; Expected responsibility: [Amount or unknown]; Financial assistance: [yes / no / N/A]

(Label unknown statuses explicitly; do not infer approval from submission.)

Results Plan & Tasks

Results Routing: Recipients: [Ordering clinician, genetic counselor, referring provider, others]; Destination: [EHR interface / fax / lab portal]; Patient portal: [per policy] | Patient preference: [if discussed]

Disclosure Plan: Method: [visit / telehealth / phone / secure message]; Responsible: [Name, role]; Scheduled: [Date or scheduling plan]; Urgent findings plan: [Contact method]

Post-Result Framework:

• Positive: [Confirmatory steps, management pathway, cascade testing plan]
• VUS: [Reclassification monitoring, family studies if indicated]
• Negative: [Residual risk counseling, alternative testing as applicable]

Open Tasks:

• [Task] — Owner: [Name, role]; Due: [Date]; Status: [not started / in progress / done]
• [Task] — Owner: [Name, role]; Due: [Date]; Status: [not started / in progress / done]
• [Task] — Owner: [Name, role]; Due: [Date]; Status: [not started / in progress / done]

Associated Documents

• [Requisition] — [Date] — [attached / location]
• [Consent form] — [Date] — [attached / location]
• [PA approval or denial] — [Date] — [attached / location]
• [Letter of medical necessity] — [Date] — [attached / location]
• [Pedigree] — [Date] — [attached / location]
• [Prior test reports] — [Date] — [attached / location]
• [Pathology report] — [Date] — [attached / location]

(If documents exist but are not attached, note where they can be found.)

Signature: [Name, credentials] — [Date/Time]

Addenda / Updates

(Append dated updates to preserve audit trail; do not overwrite prior content.)

• Date/Time: [Timestamp] | Author: [Name, role]
• Update summary: [Description of changes or new information]
• Order state after update: [draft / awaiting consent / PA in progress / ready to collect / collected / shipped / in lab processing / results available / canceled]