Home Forums Discussions Feedback and Recommendations saving orders

one thing that prevents me from going paperless is that (as far as I know) the order is not saved in a way that you can access (if it isn't part of the progress note). Haven't you ever had a patient lose a lab order (or a referral) and want another copy?
And in between visits, you might see abnormal test results and create an order for additional studies, but there is no record that you have done so, right?

I like the idea of summarizing contacts with the patient by using the subject line to give a brief summary and then having these contacts listed under Past Encounters. The problem is that only 1) messages 2) addendum/procedures and 3)encounters or progress notes are included in this listing. I could try and make everything into a message but it would require re-stating the "orders" or re-stating the letter sent to the patient instructing him/her to take some action.
This is a little like the "to do" list that was mentioned in another string. One purpose is to have the staff make sure these things were done. And the other is documentation. I'm not paperless now because I can't imagine how I would document the following: labs received and reviewed, TSH is abnl, pt notified of need for dose change and f/u labs. That's not a rare one. How do others handle this sort of thing?

Orders done using the ORDERS button outside a progress note will save it -- it sends it to your e-mail and you have to save it. Try it and you will see it in your history. The only issue is that it does not save the diagnosis list associated with it. I think we all need to use the SUGGEST IMPROVEMENT BUTTON and ask them to save all orders in previous records with diagnoses listed on it. It makes it hard to redo orders unless I as the provider does it - when you re-order something it will put all diagnoses which is the problem list.

One other tip is that in my area as most of my pt. go to one place for lab and x-ray is that I fax the order to them and print it for the pt. A pain, but seems to help. Obviously this will not work for city with 10 different x-ray places, lots of labs, etc.

I get my labs electronically and when I sign it I type a letter to pt (using a template) or just a quick note in the comments section. Otherwise I usually just send an e-mail to my front desk for them to call pt. with order for something and then the e-mail is saved. You can also use the messaging to start e-mail and type everything you want and then instead of sending, just save to chart.

I would load the program on a laptop and open a few fake pt - experiment with them and see what works best. I am just grateful that I don't have telephone notes, sticky notes or handwritten notes to look at and write on.

Thanks Quann for your question and thanks Steven for your suggestion-this has been a problem-looking forward to trying it.

Quann,

Depending on the number of orders, there is an interetsing workaround, but it takes some getting used to, and you may not like the overall format of your note.

You can leave the Chief Complaint blank. Do the note as usual, give it a diagnosis and use the order window as normal. Then, write your diagnosis in the chief complaint with any orders you did beside it. You can even cut and paste the orders on the chief complaint line. Now when you save the note, the visit history will show the actual diagnosis instead of "Patient complaints of joint pain, etc." which I find not to be helpful. The line will say: "Bronchitis: CXR, CBC, etc.

Of course, even though there is no limit to how many labs you list, it could get tedious. And, your printed note would start with Bronchitis: CXR, CBC, etc. Many of us in the past have argued that the diagnosis should populate the visit history as it would be much more helpful to see three Otitis Medias and two Pneumonias.

As to keeping track of your labs and what you did, I still think that importing an Excel sheet that you have customized to your practice is the way to go.

Just some thoughts. Probably not very practical.

so you're creating a new progress note, leaving the physical exam blank? I've actually used that approach when I've gotten the hospital discharge summmary and wanted to update the meds and the diagnoses and the treatment plan, and it certainly makes that rather lengthy post hospital office visit go more smoothly...

No, actually, you leave the Chief complaint blank. Because what you write in the chief complaint is what populates the visit history.

This is one I get dinged on by insurance reviewers - many of the residency practices keep a separate copy of orders pending, and they check off when the results are received. That way, once a week or once a month they can check for things missing. This is too much work for my practice, but might be a perfect job for a computer - at least once all the lab interfaces are working.

I am going to send this to AC as a suggestion:

The Orders should not “die” when the chart is signed. The orders need, “magic buttons” to allow them to be assigned a time frame and a responsible person. This would be a feature to be selected or not by the user in the preferences. If turned on, when you use the “Orders” button you will have two more spots to click. The first is to assign the project to someone, (the MA or the Doctor, or even the office manager) but not a big drop down box, three simple clicks, 1-Dr. 2- MA, 3- Other and you get the whole box. The second box is time frame with 4 boxes to click for 1- Stat, 2- this week, 3- in one month, 4- other.
When the order is completed, the worker creates some document, (imported item for your sig, or an addendum) and sends it to you for signature. If it is not completed on time the SOFTWARE sends it to you to notify you that the order has not been completed.
This is inspired from a forum thread and especially the comment by:
Kevin Miller, MD
Paradise Family Healthcare
Venice, Florida

It completely solves the problems for audits by insurance plans and does so with very little extra work for the Doctor and a huge boost in the accountability of the system. This is a BIG "Outcome Oriented Medical Record" step. I really like this.

Tracking orders is a big hassle. My wife (my office manager) uses a tickler file. She or our receptionist make a copy of the order and then place it in a folder which is reviewed on a schedule. It works well for radiology as both the main radiology group in town and the hospitals fax over a note for when the patient is scheduled. Not as good for labs as I usually just place the carbonless duplicate in the paper chart and don't give it to the front office staff.(I'm still transitioning to the electronic office).

One trick I've started experimenting with is to create a medical assistant named FOLLOWUP. As I'm doing the patient's orders I create a reminder and time it about a week after I anticipate the test to be done. My plan is to use this in place of the paper tickler and designate someone to chase everything down. (As we are now scanning results in, this task shouldn't be too time consuming.) In the reminder field I type in just the basics (i.e. CT Chest results-R pulm nodule follow up). Unfortunately I set this up just a month ago and went on vacation for 2 weeks so I haven't really gotten it going yet. However with the reminder function you can save a copy of the reminder to the chart and also cc yourself, which are 2 good ways of documenting that you did the follow up.

With regards to the suggestion to use the Chief complaint line for the diagnosis, my understanding of medical coding is the CC line is one of the most important. As silly as it seems to me, failure to have a chief complaint can be a reason to deny payment (I learned this from my old business manager when I worked for a group practice).

I agree having a way to track the orders directly from the time it is typed would be the most ideal.

This is another feature that is contained in FAP. Since ALL of our incoming information, labs, x-rays, MRIs, consults, records come into one inbox and all of these are automatically in FAP, I only have to look at once place.

Now, say I have a patient, John Smith, and I orders a CBC, CMP, LDH, C3, C4 and TPO antibodies, these are going to come in day one, day 3 and day 10. So, as the labs come in, I have a hard time keeping track of all the results. But, you can type Smith, John and up pops his name. You then copy and paste all his labs into the comment section, hit enter and he pops up into the Watch Window. Now, anytime a file with his name comes in, his name lights up. You can look at the lab, do what you need to, then open the window and delete what has come in or type any notes. When his TPO come back 1,000, you simple right click on the lab, and choose to send to Follow-up. Now it is in one follow-up window for you to perform an action step at the end of the day.

We need to do that phone session because we are not using this important second half because of how we went live a month after starting and my febble mind lost half of what you showed me. Let's talk to do a sit down soon...

Paul,

I am here all day. May need to go to Circuit City or Best Buy to get some Power Supplies (Go Al). Just pick a time.

What is FAP? Thanks.

Bert,
You're up my man...

Actually besides Bert's reply I have a thread about. 2nd day with file assist pro. Check it out and you'll get a feel for it....