Home Forums Discussions Feedback and Recommendations Diagnosis on orders

When you print an order during a note, it lists everything in the note including the diagnosis. Unfortunately, if you print an order out of the note from a right click on the list of patients and save it to the chart, it only lists the test.

It does NOT list the diagnosis. This is problematic, because when a patient loses the order or the lab loses it or the fax doesn't go through, etc., when your nurse goes into the chart to do the order again, she/he doesn't know the diagnosis.

Bert:

I can't seem to reproduce your problem.

When I write an order during a note, it doesn't list anything except the ICD-9 diagnosis.

When I order by right-clicking on the list of patients, the order form still lists every ICD-9 diagnosis that is in the patient's Summary Sheet.

I'm not sure what I'm doing wrong. Maybe I'm misunderstanding you.

You are not looking at the actual recording. I don't mean the requistion. I mean the charting.

If you write a note in the chart for CBC with a diagnosis of fever, you will get Recommended to the patient: CBC and a diagnosis of fever (if you got rid of all the other diagnoses which I always do -- a topic for another day).

However, if a staff member or you writes an order by opening the patient chart WHEN you are not actually doing a progress note (with the ability to save) the order will be done as above, but there will be NO record of it anyway.

Therefore, one is supposed to right click on the patient list and choose Order from the drop down list. Your staff the chooses which doctor to send it to. After they print the order, a copy will show up in your message box so you can A) review it, and B) save it to the chart. Therein lies the problem.

WHEN YOU SAVE IT TO THE CHART, it will only show that they ordered a CBC. It will not show the diagnosis, hence if they later need to do it again, they will not know the diagnosis.

If this is not understandable, I will show you by remote desktop.

I just have my staff cut and paste the ICD codes up to the box where the tests are requested. That way after I sign off on the order and it becomes a message, the dx codes will be seen as well as the requested tests when the patient loses the paper.

cf,

That is a good workaround. We will try that. However, it is a step that shouldn't have to happen. This should be rather easy to fix.