Procedure configuration & order process

This is an example on how to configure and use the Procedure module on a local or web based install,

with no official connection with a Laboratory push and pull information system.

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Please note that the following resources for an older version of OpenEMR are very helpful as well

• http://www.open-emr.org/wiki/index.php/Sample_Create_and_Use_Procedure_Orders_4.1-4.2
• https://www.youtube.com/watch?v=UEk4QZ1Pl3k (How to submit a lab procedure order)
• https://www.youtube.com/watch?v=W0mjP2j7EI0 (Basic lab training)

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You have to complete three preliminary steps before using this module.

• Define the Laboratory service Location(s) within the Clinic or external. GOTO: Administration => Addr Book => Add new => Type: Lab service

• Check and adjust default settings related to Procedures. Administration => Lists => Look for Procedures and:

• Body Sites
• Boolean results
• Lateralities
• Report Statuses
• Result Abnormal
• Result Statuses
• Routes
• Specimen types
• Type
• Units

Adjust these to your local needs

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Create a list of groups for Procedures. Most Procedures have certain common origin. Blood arterial Blood venous, Urine, Fecal etc. Radiology, Ultra Sound, Culture samples, Neurology, Cardiology, Pulmonary, Pathology etc. (Use your own local application forms for lab-tests as an example)

More information on this configuration can be found in the file: Process Guide on Lab Configuration.

• Next step is to configure your laboratory Test structure in three levels:

• Test Group: Group level
• Test Order: Procedure Order level
• Test Results: Discrete results level

Good practice is to start with a three level Excell table with all Groups, Order types, Results, etc.

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Example of three level Of Cervical Cytology

• Group (top level): Gynecology Laboratory Services

• Procedure Type: Group

• Procedure Name: Gyn Lab Services
• Description: Short info of test procedure
• Sequence: Numeric value to sort order of tests (0 = is top of group)

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• Order (second level): Cervical Cytology
• Type: Procedure Order
• Name: Cervical Cytology
• Description: Short explanation
• Sequence (0 = is top of sort order of tests)
• Order from: Location where tests will be performed. (See steps of Define Laboratory Locations otherwise this field can not be used)
• Discrete Results (third level): Discrete results details (In four groups)
• Fill Identifying Code
• Fill Standard Code
• Next three fields are optional and do not have to be filled in certain tests.
• Result level (third level): Discrete Result

In order for a test to appear on the "pending review" tab, the tests ordered must be correctly configured - otherwise it fails silently.

• a. each 'procedure order' must have a 'discrete result' under it.
• b. Once an order is placed, click save and transmit. These orders do not have to go to any external lab for it to appear under 'pending review' in version 4-1-2. Even a referral can be 'transmitted'.
• c. Once under 'pending review' one can update its status, add results manually.

Advice: Working with the result document (eg an EGD report) saved under documents - but once reviewed, will be updating under 'pending review', so you know for future it was reviewed and you don't have to keep going back to the primary documents.

• d. once it is signed off under 'pending review' the status automatically appears under 'patient results' and updates the 'procedure order' for that specific encounter. Very nice feature!

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In order to generate a requisition form, go to the relevant patient's page, click "reports" and you'll see the procedures.

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NB: Some tasks, especially recurring or that which could be encapsulated in a rule, are best handled using clinical rules.