Manual Entry of Lab Results


(system) #1

gary-schiltz wrote on Saturday, April 25, 2015:

I want to verify that OpenEMR does not currently have a module/feature for manually entering lab results. Let me first describe what the clinic I volunteer at needs, including what I even mean by the term “lab results” so that we’re on the same page. Brief background: the clinic, Mindo Salud (http://mindosalud.com) is a small, rural clinic located in Ecuador, and sees on average about 10-20 patients per day. We have a small on-site lab with a few pieces of equipment that our own lab tech uses to perform a variety of lab tests. For tests that we can’t perform, our doctors write a prescription for the test and recommend one or more labs in Quito where they can get the tests performed (and presumably pick up the results to come back and discuss with the doctors in the clinic).

I am not a medical person myself, rather a (somewhat) retired software engineer who is volunteering to provide free IT services to the clinic. I installed OpenEMR there about a year ago, and we now have about 1000 patients in the system. However, lab results have, so far, been recorded completely manually on paper and stored in folders in the lab. Since I’m a geek and not a medical professional, I can only provide a layperson’s view of the tests that are performed, and describe the forms that results are currently recorded on. With that caveat out of the way, here are the names of the tests that I have forms for (my and Google Translate’s version in English, since the forms are in Spanish): Serology; Blood Chemistry; Hematology and Coagulation; Urine Analysis; Fecal Analysis. A few sample fields are, for example: hemotites per cubic mm (hematology), presence or absence of various types of protazoa and metazoa (fecal analysis), cholesterol and triglyceride readings (blood chemistry).

If there is not already a module for this, I might consider writing one. I’m going to do something, in any case, thought I haven’t done anything in PHP and haven’t dug into the OpenEMR code very much all. Anyway, as I said, for those who understand the system better than I do, please comment on whether or not OpenEMR has anything at least closely related to what I’ve outlined above. If not, then I’ll post a quick summary of what I’d like to do in the OpenEMR dev forum for advice on how to get started with OpenEMR development.


(system) #2

fsgl wrote on Saturday, April 25, 2015:

See this.

The module is a bit fastidious. Configuring Procedure Order must be executed exactly per article, otherwise it would fail.

Would suggest that you consult the physicians how they want each panel or group of tests organized before embarking on Procedure Order configuration.

Fortunately the medical terminology is very similar in Spanish & English as a result of the Latin-Greek etymologies. We should be able to get a sense of the tests in Spanish.


(system) #3

gary-schiltz wrote on Saturday, April 25, 2015:

Thanks! I’ll look through it in more detail, and post my questions to the dev list.


(system) #4

cverk wrote on Saturday, April 25, 2015:

For the limited in office lab tests we do, CLIA waived tests, I just made layout based forms to fill in the results. It is encounter based for that visit, but pretty simple and quick for staff to enter.


(system) #5

fsgl wrote on Sunday, April 26, 2015:

Our office orders a minimal amount of diagnostic studies. Essentially for pre-operative patients, it would be CBC, Lytes, U/A, Chest X-ray & EKG.

Reports from our local hospital are entered into Documents tab as .jpeg files.

The occasional Sed Rate & C-Reactive Protein are recorded in the clinical note after they have been discussed with the patient.

In a group practice the Procedures module offers the advantage of multiple patient search & the ability to sign off on the test.

Whether here in the U.S. or abroad; physicians, in a large practice, would prefer to have the ability for a quick search. More importantly an abnormal result is less likely to be overlooked thus preventing treatment delay.

So it’s worth the trouble of setting up Procedures.


(Sherwin Gaddis) #6

I need to resurrect this old topic.

There was a request come in to manually enter discrete results into the lab.
https://www.open-emr.org/wiki/index.php/Sample_Create_and_Use_Procedure_Orders_4.1-4.2#Discrete_Results_tier_for_the_Chemistry_procedure_order

These were the only instructions I could find in the Wiki and they are really old because the new looks nothing like this and new being 5.0.2.

This document is in the manual for 5.0.1 but the references don’t match 5.0.2. Pages have changed.
Is there any new documentation for this process.

I will have to test the demo 5.0.1 but both of my menu links for 5.0.2 go to the same Procedure review page.

image


(Sherwin Gaddis) #7

I figured out what I was doing incorrectly. I had not put any discrete results in the system for the procedure. That should be a big enough hint.


(Zbig01) #8

Sherwin

Do the help files under Procedures > Providers and Procedures > Configuration in the development demo, which will be soon the 5.0.2 release not provide a clear understanding of the process?