Procedures Module Configuration for Manual Result Entry

From OpenEMR Project Wiki

Preface

The goal of this guide is to provide a set of step-by-step instructions for setting up the Procedures Module to enter diagnostic results by hand. Doing so brings this data into the Encounter Form and closer to the clinical note.

Configuration necessitates meticulous attention to detail and order of execution. Once properly configured, deployment is relatively simple by comparison.

It is possible to upload a scanned image of results into Documents/Medical Record, but that will place the data at a further distance from the clinical note.

To transmit orders and receive results from an external laboratory facility, refer to Laboratory Exchange User Documentation.

Facility

Despite the fact that no orders will be transmitted to an external facility; it is necessary, however, to manufacture a fictitious Lab Service in order to configure this module. The fictional facility must be entered in the Address Book first.

"Our Own Lab" will the Lab Service for the purpose of this exercise.

From the Menu on the left side bar, go to Procedures/Providers and add "Our Own Lab".

Lab.png


Configuration

The module can be set up for a panel of tests or for a single study. A panel will require a 4 tier process while it is only 3 for a single test.

Panel

Click the Configuration link and the "Add Top Level" button to begin. This button must be clicked each time a new panel or new single study is added to the list.

1panel.png


The first tier, or level, of the configuration, will be the naming of the Group. Maintain the Sequence to keep the list in the desired order.

Lab2.png


To begin the second tier of configuration, click the "Add" link. It may be necessary to scroll to the far right to see that link in the image below. Use "Edit" to modify configuration. To delete a setting, click "Edit" and go to the desired dialog box to delete the entry. Lab3.png


The second tier involves naming the Group as "Electrolytes" and assigning an Identifying Code to it. The choice of numerals or letters is at the discretion of the practice.

Lab6.png
Lab7.png


Be certain that there is a "Yes" under the Order column and an Identifying Code as well. If these items are missing, it is a warning that the configuration had been faulty. The entries must be deleted and the process begun anew.

Click the "Add" link associated with "Electrolytes" to begin setting up Sodium. Scroll to the right if the image of the link is not visible. Lab8.png


The third tier will configure the first test of the panel, namely Sodium. Fields left empty are optional.

Lab9.png


Because mEq/L was missing; it had to be added in Administation/Lists/Procedure Units. Remember to make the addition Active before saving it.

1meq.png


It is helpful to have the range of values for a particular test in Discrete Result; but Recommendation is optional. Click "Add" link on the same line as Sodium to configure the fourth tier, Discrete Result.

1val.png


Lab11.png


A similar process is used to add the other tests of the panel. Again click the "Add" link associated with "Electrolytes" to begin. Scroll if need be. Pay close attention to Sequence; otherwise the tests will appear in alphabetical order; not Na, K, Cl, CO2 as physicians are accustomed.

Lab12.png
Lab13.png
Lab14.png


A full panel should look like the following. 2val.png

Single Study

Click "Add Top Level". A single test requires the naming of the Group and of the test.

Lab16.png
Lab17.png


Check that "Yes" and the code are present. Click the "Add" link to configure the third tier, Discrete Result. 3val.png


Lab18.png


Procedure Order

Create an encounter. From Administrative, choose "Procedure Order".

1po.png


Click in the designated area to search for the diagnostic study.

2po.png


Click the link to select the study.

Lab22.png


Click "Save and Transmit".

3po.png

Pending Review

To bring up the studies for result entry, login as Physician. Other staff, including Administrator, will not have the ability to perform this task. Generally this privilege should be reserved for the Physician. The Front Desk should not be permitted to sign off on diagnostic studies. In unusual situations wherein the Physician wears two hats and has the responsibility of the Administrator as well, this can be changed in Administration/ACL by granting the Access Control Object, "Sign Lab Results", to the Administrator.

Signlab.png


Lab24.png


Add the Reported date, assign a Status and enter the results before clicking the "Sign Results" button. Lab25.png

Patient Results

After signing the results, the data will appear in Patient Results. Lab26.png


Electronic Reports

This can be used to look up studies for a particular day or period of time. It is an excellent tool to prevent a study from being forgotten. In a busy practice it is not unusal to overlook an ordered study; only to discover later, to the horror of the practice, that in addition to the abnormal result; that the timely processing of that result could have saved the patient from a delay in diagnosis and treatment. Lab27.png


Postscript

Configuration of the Procedures Module is a bit of a workout. Like all other aspects of OpenEMR, the more a physician masters; the greater his confidence and the deeper his appreciation of the magnum opus of the developers of this Project and all other Open Source projects as well.

Always frolick along the way.