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This lesson describes how to create a Lab Order and manually enter results for the Order.

Add a new Lab Order during a patient Encounter

Add a new Lab Order during a patient Encounter;Lab Orders for a patient can only be as part of the patient Encounter.  
            Lab Orders can also be added through the Orders tab in the patient's Treatment Plan (see lesson "Treatment Plans - Lab Orders".  
            NOTE: Lab Orders added using these methods are visible on the Patient screen.
            
            Using the Orders tab in the Encounter:
            1. Click the "Orders" tab.
            2. Click the "new" icon to add a new Order.
            
            **The "Orders" tab will only be available if designated by the Encounter Type.  

Lab Orders for a patient can only be as part of the patient Encounter.  

Lab Orders can also be added through the Orders tab in the patient’s Treatment Plan (see lesson “Treatment Plans – Lab Orders“.  

NOTE: Lab Orders added using these methods are visible on the Patient screen.

Using the Orders tab in the Encounter:

1. Click the “Orders” tab.

2. Click the “new” icon to add a new Order.

**The “Orders” tab will only be available if designated by the Encounter Type.  

Update the Lab Order

Update the Lab Order;1. Type - Select "Laboratory" from the Order Type drop-down.
            2. Update all applicable fields:
            Order Date - This will populate automatically with the current date/time.
            Ordered By - select the Ordering clinician.
            Order Expires - This will populate automatically, one year from the Order Date.  Modify as needed.
            SNOMED - if desired, locate the appropriate SNOMED code.
            Code - In cases where Labs are electronically transmitted this may be required.
            Description - this will auto-populate after the lab test is selected.
            Problem - This will auto-populate if the Order is added via the Treatment Plan.  If desired, select one if not auto-populated.
            Diagnosis - If desired, attach a diagnosis code to the order (this may be required by some labs with electronic transmissions)
            Relevant Clinic Findings - If desired, enter any relevant clinical findings to attach to the order.
            Placer Order Number - If desired, may be used to for barcode scanning.  (This may be required, or auto-filled by some labs)
            Laboratory* - Select the Lab to process the order.
            Test* - Select the Test for the Order.
            **Lab Tests in the Test drop-down are specific to the laboratory selected. Laboratories an Lab Tests are maintained under Clinic > Maintenance > Laboratory
            Taken By – select the staff member performing the test, or collecting the specimen.
            Transmitted Electronically – check to flag orders that have been transmitted electronically (i.e. via eRx or Lab process).
            On-Site – this can be used to flag tests that are completed on-site.
            Completed – this can be used to indicate an order is Completed.
            3. In the Specimen information section, select the Specimen Type, Specimen Quality and Specimen Collection Date.
            (Specimen Reject Reason, Specimen Condition and Specimen Action Code may be populated from the Laboratory when electronically receiving results.)
            4. If desired, use the Notes tab to add additonal information about the Lab order and the Instructions tab to indicate related instructions.
            5. Click Save to Save the Order.
            6. If needed, use the Show In Report button to print a Lab Order with the order details. 
            7. If known, add Results by clicking the Results tab, then click the New icon.
            
            ‘ src=”https://docs.pattrac.info/wp-content/uploads/2020/01/fF0cI_2.jpg”></p>
<p>1. <strong>Type</strong> – Select “Laboratory” from the Order Type drop-down.</p>
<p>2. <u style="text-decoration: underline !important;">Update all applicable fields:</u></p>
<p><strong>Order Date</strong> – This will populate automatically with the current date/time.</p>
<p><strong>Ordered By</strong> – select the Ordering clinician.</p>
<p><strong>Order Expires</strong> – This will populate automatically, one year from the Order Date.  Modify as needed.</p>
<p><strong>SNOMED</strong> – if desired, locate the appropriate SNOMED code.</p>
<p><strong>Code</strong> – In cases where Labs are electronically transmitted this may be required.</p>
<p><strong>Description</strong> – this will auto-populate after the lab test is selected.</p>
<p><strong>Problem</strong> – This will auto-populate if the Order is added via the Treatment Plan.  If desired, select one if not auto-populated.</p>
<p><strong>Diagnosis</strong> – If desired, attach a diagnosis code to the order (this may be required by some labs with electronic transmissions)</p>
<p><strong>Relevant Clinic Findings</strong> – If desired, enter any relevant clinical findings to attach to the order.</p>
<p><strong>Placer Order Number</strong> – If desired, may be used to for barcode scanning.  (This may be required, or auto-filled by some labs)</p>
<p><strong>Laboratory*</strong> – Select the Lab to process the order.</p>
<p><strong>Test*</strong> – Select the Test for the Order.</p>
<p><em>**Lab Tests in the Test drop-down are specific to the laboratory selected. Laboratories an Lab Tests are maintained under Clinic > Maintenance > Laboratory</em></p>
<p><strong>Taken By</strong> – select the staff member performing the test, or collecting the specimen.</p>
<p><strong>Transmitted Electronically</strong> – check to flag orders that have been transmitted electronically (i.e. via eRx or Lab process).</p>
<p><strong>On-Site</strong> – this can be used to flag tests that are completed on-site.</p>
<p><strong>Completed</strong> – this can be used to indicate an order is Completed.</p>
<p>3. In the Specimen information section, select the <strong>Specimen Type</strong>, <strong>Specimen Quality</strong> and <strong>Specimen Collection Date</strong>.</p>
<p><em>(</em><em><strong>Specimen Reject Reason</strong></em><em>, </em><em><strong>Specimen Condition</strong></em><em> and </em><em><strong>Specimen Action Code</strong></em><em> may be populated from the Laboratory when electronically receiving results.)</em></p>
<p>4. If desired, use the <strong>Notes</strong> tab to add additonal information about the Lab order and the <strong>Instructions</strong> tab to indicate related instructions.</p>
<p>5. Click <strong>Save</strong> to Save the Order.</p>
<p>6. If needed, use the <strong>Show In Report</strong> button to print a Lab Order with the order details. </p>
<p>7. If known, add Results by clicking the Results tab, then click the<strong> New</strong> icon.</p>
<h3>Add the Lab Results</h3>
<p><img decoding="async" width="959" title="" style="max-width: 100%;" alt="Add the Lab Results;In many cases Lab Results can be recieved electronically and automatically populated against the Lab Orders for multiple patients depending on the Lab. 
            This step describes how to manually populate Lab Result for an order. This may be neccesary for lab tests and specimens analyzed within the agency. 
            **NOTE: Lab Results are visible within the main patient chart in the Labs tab. They are not admission or Clinic specific. (Only viewable by staff with appropriate access)
            
            1. Patient - this will populate automatically with the current patient information. 
            2. Update applicable fields:
            Description - If desired, enter a description for the result. (This may populate with electronically received results)
            Result - Enter the Result
            Unit - If applicable, enter a quantitative unit fro the test.  (This may populate with electronically received results and will vary by lab.) 
            Reference Range - if applicable, enter the ranges in which “normal” values are expected to fall. (This may populate with electronically received results)
            Abnormal - If applicable, select the Abnormal value. (This may populate with electronically received results)
            Status - Enter the status of the Result.
            LOINC - This code may populate with electronically received results
            Code - This code may populate with electronically received results
            Result Received - Select the Results Received date.
            Observation Date - Select the Observation Date.
            Analysis Date - Select the Analysis Date.
            Document - if desired attach a scanned lab slip.  Electronically received results will attach a document from the lab.
            Reference - if desired, enter a Reference value. (This may populate with electronically received results)
            3. Laboratory, Address and Test Requested will auto-populate based on the Order information.
            3. Click Save and Close to exit the Results screen.  
            
            
            " src="https://docs.pattrac.info/wp-content/uploads/2020/01/fF0cI_3.jpg"></p>
<p><strong>In many cases Lab Results can be recieved electronically and automatically populated against the Lab Orders for multiple patients depending on the Lab. </strong></p>
<p><strong>This step describes how to manually populate Lab Result for an order. This may be neccesary for lab tests and specimens analyzed within the agency. </strong></p>
<p><strong>**NOTE: Lab Results are visible within the main patient chart in the Labs tab. They are not admission or Clinic specific. (Only viewable by staff with appropriate access)</strong></p>
<p>1. <strong>Patient</strong> – this will populate automatically with the current patient information. </p>
<p>2. <em>Update applicable fields</em>:</p>
<p><strong>Description</strong> – If desired, enter a description for the result. (This may populate with electronically received results)</p>
<p><strong>Result</strong> – Enter the Result</p>
<p><strong>Unit</strong> – If applicable, enter a quantitative unit fro the test.  (This may populate with electronically received results and will vary by lab.) </p>
<p><strong>Reference Range</strong> – if applicable, enter the ranges in which “normal” values are expected to fall. (This may populate with electronically received results)</p>
<p><strong>Abnormal</strong> – If applicable, select the Abnormal value. (This may populate with electronically received results)</p>
<p><strong>Status</strong> – Enter the status of the Result.</p>
<p><strong>LOINC</strong> – This code may populate with electronically received results</p>
<p><strong>Code</strong> – This code may populate with electronically received results</p>
<p><strong>Result Received</strong> – Select the Results Received date.</p>
<p><strong>Observation Date</strong> – Select the Observation Date.</p>
<p><strong>Analysis Date</strong> – Select the Analysis Date.</p>
<p><strong>Document</strong> – if desired attach a scanned lab slip.  Electronically received results will attach a document from the lab.</p>
<p><strong>Reference</strong> – if desired, enter a Reference value. (This may populate with electronically received results)</p>
<p>3. <strong>Laboratory</strong>, <strong>Address</strong> and <strong>Test Requested</strong> will auto-populate based on the Order information.</p>
<p>3. Click <strong>Save and Close</strong> to exit the Results screen.  </p>
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