Lab results

Day-to-Day Users
1

bdwderm wrote on Tuesday, February 03, 2009:

Hi,

Just curious to see how others are recording pertinent lab results. I’ve been adding pathology results to the problems list or my note.

Any suggestions otherwise?

brent

2

ideaman911 wrote on Tuesday, February 03, 2009:

I presume you do know that you can scan them to a JPG and then save them as a document?  I am unaware of anything like the Vitals which can track the lab results, but there is nothing to stop you from creating a new label for any of the Vitals stuff you don’t need if there are a few key issues you need to follow.  The vitals will display the last few you enter, so for example it might make sense to track A1C, etc depending on your practice.  They are in …/forms/vitals/general_new.html

3

bdwderm wrote on Tuesday, February 03, 2009:

Thanks for the follow up; I will look into your suggestion. I am aware of the scanning option - we scan to a windows box just to save the doc - I don’t need to view them often so simply entering the data to OEMR would be fine!

Brent

4

bdwderm wrote on Tuesday, February 03, 2009:

Or I might modify immunizations to labs/pathology. We don’t do immunizations.

thanks again

5

drbowen wrote on Wednesday, February 04, 2009:

I record labs in a couple of different places.

If the labs are available at the time of the visit i type the pertinent ones into the office visit.   I mostly use form_dictation and type all my notes.  I use the classic:

S:

O:

A:

P:

organization.

If the patient is in for diabetes I will typically make an entry like:

Mrs. Jones is here for evaluation of her diabetes mellitus.  On her blood sugar meter her average blood sugar is 115.  Her A1c is 6.1%.

On read back the pertinent labs are in the S: section and are part of my interview with Mrs. Jones.

When we are calling a patient back about a set of laboratories we put a telephone entry into "Notes(more)".  Again we summarize the most most important highlights of the laboratories.  OpenEMR does not include the username when printing out the "Notes" section on the comprehensive report so I always sign my notes like the following:

I called Mrs. Jones about her laboratories.  Her glucose, renal function, electrolytes and liver panel were all normal.  Her total cholesterol is 230, triglycerides 445, HDL 21, and LDL is 167.  We discussed her diet in reference to her cholesterol panel which needs a lot of work.  Sam Bowen, MD

Sam Bowen, MD