lasan13 wrote on Sunday, January 11, 2015:
Hi
in some patient encounters patient come with a lab report. So we want to enter the result of that investigation results in to that encounter. how this can be handle by in open emr.
fsgl wrote on Sunday, January 11, 2015:
Two methods:
mdsupport wrote on Sunday, January 11, 2015:
If patient comes with results in HL7 format, it is better to import using built in functionality. Otherwise many of lab results are too complex to enter. Manual data entry also increases chances of typing errors.
Attaching results to an encounter in most cases could be misleading. If a patient comes in with labs done 3 months ago, the date of the report is more relevant than date of encounter. Upload the scanned image to documents - easier if it is pdf - and put correct date. You can also make your observations in the attached note saying the information was presented during encounter on xx/xx/xx.
If you find several patients coming in with results from same lab, establish a link with the lab for electronic results.
fsgl wrote on Sunday, January 11, 2015:
At the present time, Documents will not accept .pdf files for copying into a clinical note without considerable customization.
Most practices will attach a lab/imaging result ordered on the day of the encounter (visit), not from several months back. Test results, usually performed at the local hospital, are clearly dated & time-stamped.
Results, not signed off by the physician in a timely fashion & left unnoticed for months on end, can become grounds for malpractice resulting from a delay/failure to diagnose. Our mutual liability company constantly reminds us to be diligent & avoid this pitfall.
mdsupport wrote on Monday, January 12, 2015:
fsgl, Documents accept all files. Depending on the mime type of the workstations, the bottom frame will even display the files if appropriate viewer is installed. Not sure about other browsers but Firefox has a pdf viewer from Mozilla Labs. So if you check demo, Phil has a document from past. If we select it, the bottom half conveniently shows the pdf file.
All our practices choose to maintain all clinically date relevant documents by test date. That saves everyone having to look up the document every time to find the date specimen was taken.
When we order labs, most of our lab service providers will directly make a copy available to us for timely review and action. If a patient brings in results, it is more likely than not that lab was ordered by another physician. We consider these external labs by referencing them in encounter notes but we have no obligation to sign off since we did not initiate the clock. In many cases old results trigger another round of testing in our practices.
Muditha, if you plan to copy data using encounter date for the results, consider the picture you will be presenting in future referrals or patient reports. Although the data provided by patient says :
order date: Jan 1, 2014
Specimen date : Jan 1, 2014
Collection date: Jan 2, 2014
Test date: Jan 2, 2014
Result date: Jan 4, 2014
If patient brings this test result during encounter on Jan 1, 2015, unless you keep overriding the dates you could make it appear as if patient has same reading a year later. This will provide a skewed chronological timeline when reports are sent in HL7 format to other providers.
As a side note, insurances will most likely deny payments if your records make it appear that you repeated the labs on same day…
fsgl wrote on Monday, January 12, 2015:
Link above does not have content. No .pdf files in Documents for Phil Belford in 2102 Demo.
Work patterns in a group practice setting are not necessarily applicable to solo practices.
What works in the U.S. may be irrelevant in Sri Lanka, where the clinic may have in-house testing & where patients are generally self-pay.
mdsupport wrote on Monday, January 12, 2015:
Content was probably lost as the demo refreshed. Regardless, if you have pdf viewer support in your browser you can upload and view pdf files.
Agreed that work patterns for groups, indeed for every professional are different as seen by the need for ‘Personalization’ option in all systems. But the key question that every user of information needs to consider is how would they likely recall the information several weeks/months later.
If you are likely to ask “What were this patient’s Creatinine levels six months ago?” then you may be better off using specimen/test date.
If you are likely to ask “What was in this patient’s lab report when she was seen four months ago?”, use the encounter date.
Suum cuique.
Best to all.
fsgl wrote on Monday, January 12, 2015:
NULLI TACUISSE NOCET TUTUM SILENTII PREMIUM
cverk wrote on Tuesday, January 13, 2015:
What has worked for me depends if the document is electronic such as a fax routed to my desktop or on paper. On paper I will initial having reviewed it, scan it, label it by identifier and date reviewed such as “labcorp 01122015” and upload it under documents. Sometimes I have written notes on them for patients before scanning and send the original to the patient. If electronic I add an electronic signature , label it the same and import it. If patients bring in records that I want to scan and keep a copy of I will label them “outside records 01122015”. That way information is worked in to the record in the chronological order that I review and assess them instead of when they may have been produced on the outside. I figure that even if I order something like a lab, I don’t have a chance to act upon it until those results arrive and I review them. So that is the date I label and upload them with. The idea of the record is to document your thought process based on the information you have available at the time you are creating the note.
lasan13 wrote on Tuesday, January 13, 2015:
Dear fshl and Md Support
Thank you very much for your advises and interesting discussion. Your points are very well taken specially the “Data” mentioned by MD support.
Actually I’m a Medical Doctor. As fshl mentioned our GP Practice is bit different from the US System. Most of our GPs are still not using a EMR. I think main reasons are their lack of confidence of using computers/ IT and lack of human resources.
So What I want is to create simple system for our GPs with essential data elements.
ok let back to the discussion…
“Procedures Module Configuration for Manual Result Entry” mentioned by fsgl is what I’m looking for. Although lab result import functions and upload functions are there I think this is the best way to start in our setup. I’ll try with this and let you know if i have any more problems.
Just one more question…
IS THIS HIGHLIGHT THE ABNORMAL RESULT WHICH GOES OUT OF THE NORMAL REFERENCE RANGE?
Thanks again
fsgl wrote on Tuesday, January 13, 2015:
After setting the range of normal values for each test, the physician will have to decide if the result is normal or not. The module will not do it automatically for the physician.
fsgl wrote on Tuesday, January 13, 2015:
For future reference, this will give a sense how electronic results retrieval works.