Tests & Procedures Section - Applying/Adding, Completing, Resulting
While working in an encounter, you may see the Tests & Procedures section found in the Objective section. This section is a reinvention of our “Due List”. The Tests & Procedures section displays items that are “due” so when a patient comes in, and the staff is working in an encounter, the clinician has visibility of those “items” that the patient is due for here in this section. Note: These same items are also visible from the separate chart tab named Due List.
If the patient is due for any tests or procedures, they are listed in the summary of this Tests & Procedures section.
To see details of those pending tests or procedures on a patient’s “due list” shown here in this section, simply click on the title bar of that section Tests & Procedures to expand the contents.
The section expands to show details of the order name, the due date, status, what Health Surveillance panel it may be a part of, who ordered/triggered it, when it was ordered/triggered, etc.
Applying Items to the Encounter
When the Tests & Procedures section is expanded to show details, it will allow you to apply any pending Tests & Procedures (due list items) to perform, complete & result within the encounter visit.
These items/procedures/tests are “pending” and need done to the patient/employee if they have the status of “pending”. If the order item has a due date, it will also display. This will help you see what is due and if you want to go ahead and do those items on the patient today during the visit, or wait until a future visit closer to the due date. Note: any questionnaire that a patient/employee is completing via the patient/employee portal and has started (in progress status) will not display here in the due list since it’s ‘in progress’.
To apply any of these pending items or any other pending procedure items to be performed in today’s encounter, one can quickly do that when the Tests & Procedures section is collapsed. Select the specific order items to perform on the patient during today’s visit by clicking on the plus icon or pending due list item itself. The system will automatically insert that test/procedure into the encounter as its own section and puts in ‘In Progress’ status.
If you have the Tests & Procedures section expanded, you can still apply any of these pending items or any other pending procedure items to be performed in today’s encounter. Select by checkmarking the specific item(s) to perform on the patient during today’s visit. After checkmarking the specific items, you need to click Add to Exam button.
You can select all order items in mass (if you wish) by checkmarking the box in the column title.
Once you’ve applied the specific pending items or other pending procedures, to today’s encounter visit it will refresh the encounter and embed those procedures into today’s encounter as individual ‘sections’ right after the Tests & Procedures section.
The Tests & Procedures section will collapse and under that section, you will then see individual title sections named the specific order items/procedure items you marked to be added to this exam to be performed and resulted on the patient/employee today during today’s visit. It also automatically inserts the order items as “in progress” status.
You may also notice that since those procedures are now applied to the encounter as their own section, you can jump to them also using the jump section encounter tabs.
You have just successfully indicated (by selecting and applying) pending due list order items to be performed today on the patient’s encounter visit.
Performing, Completing, and Resulting
Now it’s time to perform those tests/procedures that we indicated we would perform today. Any procedures (that we marked to perform today by clicking that add to exam button on the selected pending order/due list items) will be automatically applied to the encounter with their own section titles named and shown under the Tests & Procedures section.
To complete and key in a result to a procedure or test and result it within the encounter, simply click the specific procedure’s title bar in the encounter.
Once you click on the one you performed, it will expand the section to allow you to complete and type in the results. Note: these are order items that can be programmed to open specific layouts and entry fields. Please contact your MIE Implementer if you need specific order items to expand to open specific data entry fields or device interface links or injectible data fields. Each procedure item can be set to it’s own unique data entry layout fields to capture the data needed for resulting. When uploading a PFT or Audio test on a dynamic encounter the results will show up immediately instead of after the section is closed. PFT and Audio procedures will be marked as completed when a test is uploaded on an encounter.
If the pending due list item is a ‘required’ item by a Health Surveillance Panel for this patient, when the test/procedure is expanded to perform, one will see the pass/fail criteria option checkboxes by default. Note: The pass/fail criteria data collection options can still be configured on order item layouts that are not ‘required’ by the health surveillance panel. This is not on by default (is only on for ‘required’ panel items), so contact your MIE Implementer.
Here is a screenshot example of where we clicked to expand to open the Urine Dip procedure item to key in the results of the urine dip lab test and where we mark the order item as complete. The layout this Urine Dip procedure item is linked to also allows for connection to a device where we could import results electronically also if desired.
Once you’ve entered in the data entry fields (or free text result) to result the specific Test & Procedure on the patient/employee, please click the  Completed checkbox. This will mark the order/procedure as “completed” and removes it from status of “pending” and/or “In Progress”.
To go on to another section or procedure in the encounter to work on, simply click the title bar of that section to collapse that procedure you just completed and resulted, or click the NEXT button at the bottom of that procedure section you completed and resulted. This will collapse the procedure you were working in and will advance you to the next procedure to do and result/complete, or you can jump to any other encounter section to work in. Your work is also saved.
Here is a screenshot of a procedure order item that does not have a unique data entry layout programmed to it. If a procedure order item does not have any layout tied to it, you will always have the default status checkboxes to be able to mark it complete, and ability to free type a result in a free text field. When done, click the NEXT button just like all other in house procedure items you are performing. Your work is saved.
Once you’ve clicked “next” out of that section, it will collapse and show you a summary of the results for that procedure. Also, your work is always saved and it will automatically remove that test/procedure from the pending due list (tests & procedures) section because you marked it complete.
Adding Additional Items to the Encounter Via a Picklist
Within the Tests & Procedures section, you will see an icon next to ‘Add tests & procedures’. You will see this icon if this section is collapsed or expanded.
When you click that icon, it opens the default order picklist set named In House Testing. This is a picklist configured to display choices of all the procedures your practice can do in-house and result. This can encompass various orders/items/procedures. If you needed to add an additional test or procedure to do on the patient during today’s encounter visit (that’s not already shown on their pending “due list” here in the Tests & Procedures section) this is where you go to add something to their record to be done. This is essentially In-House ordering and/or resulting.
Contact your MIE Implementer to have the In House Testing picklist configured to what your practice performs in-house and results.
A different default order picklist set that opens up when you click Add Tests and Procedures can be setup based upon the encounter location. It doesn’t have to always default to open up the In House Testing picklist. Contact your MIE Implementer for help. All you need to do is create separate order picklists with the order items you want for a particular location. The name of the picklist must END in the specific location code (location code is found in Location Manager tab) e.g. Labs NORTH In these examples, the encounter location is “North Location Office” which is location code NORTH. I then created a picklist named In House Testing NORTH and set up the order items that the North office can perform in house. Then when they click Add Tests and Procedures, as long as the encounter visit location matches, that will be the default order picklist that opens for them. Same in another example, it doesn’t have to be named In House Testing, I instead did same scenario but instead created an order picklist named Labs NORTH and when they click Add Tests and Procedures it would open to that default picklist instead if the encounter location matched that location code in the order picklist name.
Once you click on Add Tests and Procedures, and the order set picklist pops up, checkmark which testing items you need added to the patient’s chart to be performed during today’s encounter visit. When done selecting, click the Add Procedures button at the top or bottom of this screen to apply the selected tests to the patient’s chart to be done.
Any procedures/tests/items you checkmarked to add to the patient’s visit, will be applied to the encounter visit and automatically inserted as in progress status. Checkmarking any procedures/tests/items in that In House Testing picklist signifies you will be performing them at today’s visit or ordering them to result them in-house.
Once those are selected by the above steps, the section will refresh, the items you selected from the In-House Testing picklist will be applied to today’s encounter visit you are in. The order items you selected are now shown in the encounter in their own sections. They are also automatically inserted as in progress.
To work these procedures and result them, please see previous steps (page 4) of this help document on how to perform, complete & result tests & procedures.
Adding Additional Items to the Encounter Via Autocomplete
Within the Tests & Procedures section you can order additional items to be performed at today’s visit via an auto-complete field instead of the In-House Testing picklist of preconfigured selections. You can access the auto-complete when in collapsed mode by clicking the ‘More…' in the list.
That then expands the Tests & Procedures section and displays the auto-complete field for your use.
Begin typing in the Order auto-complete field. After the order item(s) are found using the auto-complete, you click the ‘Add to Exam’ button.
The tests/procedure items (applied to an encounter and marked as completed & resulted) via the above methods can store as their own document upon the encounter’s archive & close. For example: completing and resulting an audiometry test/procedure in a dynamic encounter can be programmed to save as its own specific document in the patient’s chart by itself as example: Audiogram. It is still part of the whole encounter and encounter stored document itself, but that specific order/test/procedure item and results can store as its own document also upon encounter archive & close. This is set in the test/procedure order item itself in the WebChart database utilizing the document type field for the system.
Other dynamic encounter sections themselves can store as their own document upon the encounter’s archive & close also. Each dynamic section is a layout and the layout can be set to a specific document type to store as. The section would still be part of the entire stored encounter document, but upon archive & close, the section would store as its own document in the chart if a document type is set on the section layout. Contact your MIE Implementer for any programming needed.