In this section, you will view the steps needed to document Screening Test results for the patient.
|Note: Many practices will customize their templates to reflect age appropriate routine screening tests (hearing, vision, urine, Hgb) as Standing orders so that the clinical staff can complete these tasks prior to the provider seeing the patient.|
- If you are already in a note (Encounter or Well Visit), then click on the Assess/lan tab to see if there are preset Standing orders.
If you are in the Tracking View, then look at the Checklist column, click on the checkbox, and proceed.
- Double-click on the words 'In House Diag Tests:' this will open the Diagnostic Test Requisition Form.
- In the below example, there is an order for a hearing and vision screen.
Well Visit Note Editor: Assess/Plan tab
- Confirm that you will be performing both tests
- Notice that the hearing and vision tests are preselected and the boxes are pre-checked.
- if you will not be performing one of the tests ordered, then Uncheck the box in the task column
Diagnostic Test Requisition Form
- Click Save after you have confirmed your order - this will open the Diag Test window with the Requisition highlighted and the Orders/Results in the window below.
Diag Tests Tab
- Select a pre-formatted Result from the drop-down fields - OR - type in a Result in the result field
Diag Tests tab: Orders/Results Window
Practices can edit what is flagged as abnormal in the Diagnostic Result Templates.
This can be changed at the time the provider reviews the results.
Diag Tests Tab
- Click the Green Check button to save and this will change the requisition status to Received.
- Click on the X in the upper right hand corner of the diagnostic test window to close.
|NOTE: the next time you enter the Diag Test tab or when the provider enters it to review the results the Abnormal results are 'floated' to the top for ease of view.|
Diag Tests Tab: Orders/Results Window