Home Forums Discussions Problems 13 Steps to Sign-Off Labs - Too Cumbersome!!

We are using V 4.0.73.

When our doctor signs off on a lab, it takes her 13 steps to get a note in the chart, and comments on the lab (First has to go to send message/reminder to send a message to herself with her evaluation/comments on the lab, then copy/paste what she wrote there to the comment box on the sign-off window, click send, complete the sign-off and then find the message in her inbox and click save to chart).

Plus, she can't view the lab while writing her comment so she has to hand scribble the pertinent values she wants to make note of in the comment.

She also cannot look at the chart at the same time she is looking at the lab so she can't see the patient's history, why the lab was ordered, or what medications she was on when the lab was done.

Has any of this been improved with Version 5?

How do others sign-off on labs while making comments??

Thanks,

S.K.

I have my staff put all labs/reports (which come in as PDFs) in a folder on the server called "reports to review". When I get a chance, I review each, enter my comments on it with a red comment box (I use Adobe Standard that came with my scanner), highlight and copy that message, and paste it to a message in AC to my nurse. I save the file, and move it to a folder "to import", from which my receptionist gets it to import into the chart. In fact, I have all things needing sign-off to first be viewed by me from the "to review" folder, then moved to the "to import" folder. This makes it easy to do a mass sign-off of the imported items, as I've already looked at them. I always hated having the inbox cluttered with the sign-off items to review, and this solved the problem.

My nurse saves the AC message to the chart when the patient is notified, and stamps the PDF file with "notified" stamp;
This way, the labs and comments are easily viewed (can view the PDFs in their native program while working on the AC chart), and the message is also permanently saved to the chart.

We use cutePDF and print to pdf, naming each file
John Doe - bloodwork
then we save to a folder on the server called INCOMING FAXES.

The doctor checks this folder throughout the day, and using a program called PDF annotator actually draws his comments on the lab using a colored pen tool. We have tablet computers, but you could use the same program and type if you use laptops or desktops. It's a lot cheaper than adobe professional. (there are several good annotator programs available).

The downside: the comments are not searchable
it takes several steps for the staff

The upside: it's super fast for the doctor.
it's easy to see what's been addressed since the colors show up in the AC viewer window.

He reads, makes medical decisions, and hits save. Then he drags to someone's folder, usually the nurse's. She calls the patient with the results and makes a notation on the lab, then saves and drags to the "to import to patient chart" folder.

The receptionist imports the file when we have down times during the day.

It sounds more complicated than it is. The only problems happen when someone drags to the wrong folder, but a quick file search takes care of that in a jiffy.

If someone would like to see a screenshot, just PM me.

Chris,

So you do not use the lab interfaces which import the labs electronically right into the chart (and into your inbox for review)? You just have the labs fax or send the labs to you in PDF form?

That would solve the issue of not being able to view the lab and the chart at the same time...

How do you keep track of lab data over time for the patient? (ex: flow sheet). Our doctor would note the pertinent lab values in her message (which she then saves to the chart) when signing off labs. She then has to compile this data each time she wants to look at a trend (or on electronic labs, she can click the "track data" button to show a graph of a particular value).

Thanks for your thoughts!

S.K.