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How to Enter Lab data?

bijanzz wrote on Friday, November 08, 2013:

Dear Friends
We are evaluating possibility of implementing OpenEMR in our Research Center. We have some question that can’t find it’s answers.
Most Important: How can we enter Patients’ Laboratory data? (Ex: CBC, LFT, TFT, Urine Analysis …)?
We couldn’t find any specific section for lab data, and we don’t want to enter lab data in Separate forms such as SOAP or other custom forms.
I appreciate any Help.

Bijan Alipour M.D
TUMS

fsgl wrote on Friday, November 08, 2013:

See this Wiki article.

bijanzz wrote on Saturday, November 09, 2013:

Thanks, But as I understood, this is for Ordering a Lab procedure, which we don’t need. What we need is just a way to enter lab data, not Ordering.

bijanzz wrote on Saturday, November 09, 2013:

Thanks, But as I understood, this is for Ordering a Lab procedure, which we don’t need. What we need is just a way to enter lab data, not Ordering

1 Like

fsgl wrote on Saturday, November 09, 2013:

The Procedure module can be used to record results without ordering.

Other alternatives:

  1. Electronic Procedure Orders module (4.1.2) can be used only for results. Go to an encounter for a patient, click the Administrative tab, choose Procedure Order and record result. See attachment.
  2. Contributed form #33.
  3. Create a new Issue for Lab Results.
  4. Create a new field in Demographics or History for Lab Results.
  5. Your own customization.

blankev wrote on Saturday, November 09, 2013:

If I understand your answer, you want to enter the results of your lab tests.

This might be the solution:

Procedures => make GROUP.

In you specific group make your °: Discrete results for all tests. This can be made with specifics for female male, certain age groups etc and will create a flag if it is out of normal range.

Where you put the results of the tests is not predefined. You have to make it once for you clinic or situation. Than you can enter your test results.

Good luck

mdsupport wrote on Saturday, November 09, 2013:

Since you are looking at entering data manually, looks like these are in-house tests. This package does not come with any predefined templates. But you can set it to record the tests as follows:

  1. If you have 100s of tests and corresponding results, there is a batch import facility to set up configuration.
  2. For simple tests, use procedures -> configuration to setup group, test and test specific results (See temp1-3)
  3. When patient/subject is seen, create encounter/visit.
  4. Create order from encounter menu Administrative -> procedure order. You can record order for multiple tests or enter multiple orders for single test or a combination.
  5. When you get the results, select the patient and use procedures -> pending review which will show the test along with the rows for recording results defined in step 2.
  6. Although the colors are confusing, you will be able to manually enter the values and set the statuses.
  7. When the ordering physician sets the status as reviewed, the order will move from procedures -> pending review to procedures -> patient results.
  8. You will also see the order and results in the encounter overview (temp4).

fsgl wrote on Saturday, November 09, 2013:

A variation of Pimm’s suggestion, in 4.1.1:

  1. Encounter/Administrative tab/Procedure Order.
  2. Click Order Type.
  3. Add Top Level.
  4. Choose Discrete Result from Procedure Type.

ahmadnajjar wrote on Wednesday, June 11, 2014:

Hello fsgl

the last solution is not applicable for OpenEMR V.4.1.2? Am I right?? if yes! can you please inform me how can i add patient results in the system without adding patient orders

thank you

fsgl wrote on Wednesday, June 11, 2014:

The Procedures module is the same in 4.1.2.

See Paul’s post about adding results.

There’s an example for Henry Tudor in the 2103 Demo with the 6/11/14 encounter.

When “Save & Transmit” is clicked, an error “Transmit failed: Procedure order, ordering provider or lab is missing”.

MDS should be able to point out what is missing in the configuration and how to correct the error.

Once an procedure order has been successfully saved & transmitted, you will be able to enter the results from Pending Review.

This is one of the more difficult modules to set up. I’ll add the missing step to the Wiki, once I know.

cmswest wrote on Wednesday, June 11, 2014:

afaik you have to add a procedure order and a Procedures->Provider

take another look at 2103 Demo

fsgl wrote on Wednesday, June 11, 2014:

O.K., saved & transmitted; pending results opened. Results can be manually added but cannot save.

cmswest wrote on Thursday, June 12, 2014:

made change in acl rule, good to go

fsgl wrote on Thursday, June 12, 2014:

Thank you, Stephen.

Forgot I was logged in as administrator. Had I logged in as physician, there would have been no issue. Making mistakes is good for the Wiki article.


Seha,

Have a look in the 2103 Demo, by navigating from either one of the above links. It will give you a good sense how to configure the module.

Because this is a recurring question, I’ll do a Wiki article with pictures and post the link to it when done. Did’t remember how to set it up even with the 4 articles and 2 threads. Definitely deserves another pictorial tutorial.

fsgl wrote on Friday, June 13, 2014:

Guide with plenty of pictures.

bradymiller wrote on Saturday, June 14, 2014:

Thanks for the excellent guide!!
-brady

fsgl wrote on Saturday, June 14, 2014:

It was getting embarassing each time this “how to” question came up that I would forget. Rather than rediscovering the answer anew, it was simpler to put it in the Wiki.

Thank you for your indefatigable efforts.

ahmadnajjar wrote on Sunday, June 15, 2014:

Hello fsgl

thank you for your guide, but i have tow concerns:
1- Why should i do two groups (Chemistry and Electrolytes), and i think after adding the second group you edited it to procedure order? can i add electrolytes direct as an order in the system, and the same for other orders (K, Na) because you changed them from orders to results as i guess

2- the duplication of patient’s results still exist! is that related to configuration or maybe it is a system bug?

thank you again

fsgl wrote on Sunday, June 15, 2014:

Hi Admad,

You’re most welcome.

This module is not the easiest to set. Unless a practice uses it everyday, it’s easy to forget the configuration steps.

The developers designed it such that 3 levels of configuration are necessary. The top level is the Group, Chemistry, Hematology, Serology, CT’s, etc. Most physicans order a cluster of tests most often rather than 1 study at a time, so a user will need the second tier, Electrolytes. The third tier will configure the individual tests of Electrolytes. It is confusing regarding the nomenclature. Ideally the first tier should Category and not use Group for first and second tiers.

For Henry Tudor’s encounter of 6/14/14, the Electrolytes have been ordered. You should be able to view them in Pending Review. Once you login as Physician, enter the Reported date, Status, results and click the “Sign Results” that means that the Physician has reviewed and signed off on the results. Then all of that data will move to Patient Results.

When a search is done for Electrolytes, one gets a panel of 4 tests. If that is not your preference, the single study can be set up like BUN in the 2103 Demo. Bear in mind that it’s really a 3 level configuration still, but Chemistry had been previously configured. For example if you wanted Hematology, then Complete Blood Count is level 2 and Hematocrit/Hemoglobin would be the third tier.

I don’t understand the question of duplication.

ahmadnajjar wrote on Sunday, June 15, 2014:

Hello fsgl

Thank you for your reply, but I need to clarify my points in my previous post:
1- In the guide you the first step was creating the top level of the and it was “Chemistry Group”

  • It is clear and I don’t have any issue with this point.
    2- Then you created a new group (see picture #5 in the guide) and you named it as “Electrolytes”, after than you edited the group to be as a procedure order in the system (see picture #6 in the guide).
  • My question here: why did you create the group (Electrolytes Group) and then edited it to procedure (Electrolytes procedure order), I think we can create the procedure order directly without creating the group and then edit it.
    3- After that you created the Na + K as a procedure orders and edited them as a discrete results (See pictures 7,9,11, and 12)
  • Again, I’ll repeat my question why did you create the orders (Na, and K) and then edited them to discrete results (Nam, and K results), I think we can create the discrete results directly without creating orders and then edit it to results.
    Regarding the duplication in the lab results, please see the attached picture:
    I have configured the system the same as you mentioned in the guide, but the results appear dual time! I don’t know why if it is a system bug or something I should do in the configuration.

Sorry for the long reply, but I need to make everything clear for you.
Thank you and appreciate your help
Seha