LibreHealth EHR Provider Orders

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Introduction

The purpose of this document is to show you how to use the Provider's Orders Form in a patient encounter and how to transcribe that provider’s order.

This workflow is how providers record their orders to the clinical staff for performing particular patient care activities such as sending a referral to another provider or sending a patient out to a lab.

We will follow from the provider’s initial appointment to the provider’s notes and orders. We will then follow the process of transcribing and sending those orders.

Provider’s Order may also be known as Procedures Orders.

Note: Patient and staff names or any data you may see are completely fictional.

Toni Shortsleeve, LibreHealth Documentation Intern, July 23, 2018

Initial Visit

Dr. Virginia Apgar is logged in to the LibreHealth EHR system.

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Dr. Apgar sees on the Calendar and on the Flow Board that she has an appointment with a new patient, Jessica Johnson.

Jessica was recommended by her mother Jenny Johnson, who is also a patient of Dr. Apgar.

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During the exams, the provider performs exams and other procedures which are recorded in the forms of the Encounter Summary.

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SOAP

At the top of the page, Dr. Apgar will select New Encounter.

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An Encounter must be chosen before the next step.

From the main menu she will click on the Patient/Client menu group. From the Patient/Client drop-down menu, she will choose Visit Forms.

From the Visit Forms drop-down list, Dr. Apgar will choose SOAP.

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This will open a new SOAP form.

Subjective is the patient’s statement about the symptoms. This uses the patient’s own words.

Objective is the provider’s observations during the encounter.

Assessment is the provider’s statement of what the problem is.

Plan is what the provider wants to do for this situation.

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In this case, Dr. Apgar is sending the patient to have images taken on the hand, wrist and fingers - and return in one week as follow-up visit.

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After the SOAP is filled in, Dr. Apgar will click on the Save Form button.

This SOAP Note must be e-signed to make it legally valid in the United States.

On the SOAP tab of the Encounter screen, Dr. Apgar will choose e-Sign.

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By entering her pass phrase and choosing the Sign button, Dr. Apgar will e-sign the SOAP note.

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Initial Provider Order

On the Encounter Form, Dr. Apgar will choose the Administrative menu group.

From that drop-down menu, she will choose Procedure Order.

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This will open the Procedure Order form.

The Ordering Provider has a drop-down menu that shows all of the users in the facility who are authorized to use this form.

This defaults to the logged in staff member if they are a provider.

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The Sending To field will drop down the menu list of your facility’s outside resources. We will send to Imaging Tech Labs.

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The Order Date is today’s date. If you click on the Order Date text field, a calendar will let you choose the date.

Orders-vapgar-procedures-orderdate.jpg

The Internal Time Collected field reports the time and date that specimens are collected locally and will be sent in with the referral.

If a specimen was collected, click on text box and use the date picker to confirm the date and time the specimen was collected.

If no specimen is being sent, it should remain blank.

Orders-vapgar-procedures-internal.jpg

Priority is the urgency as defined by your practice’s policies.

Leave the Status as the default Unassigned unless you know you are making a Procedure Order of the type configured in the menu item, ‘Procedures/ Configuration’.

Orders-vapgar-procedures-priority.jpg

The Clinical History is a free-form text-box where you can type in the provider’s clinical observations that are being evaluated by the ordered procedure.

Orders-vapgar-procedures-clinical.jpg

Procedure is another free-form text-box. It is used for original procedural orders. We’ll leave it blank for this order.

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Diagnosis Codes lets you search the EHR installed code sets for an applicable diagnosis code.

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When you click on the Diagnosis Codes text box, you will be taken to a search screen.

We want the ICD10 Diagnosis Code for a right wrist sprain.

It is Unspecified because we really don’t where the pain is coming from.

This is the first encounter as we haven’t seen it previously.

Click on the code of your choice.

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This will fill-in the Diagnosis Codes text box.

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The Order Type has a menu list of the practice's order types. In this case we want to choose Imaging.

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The Add Procedure button saves the current Order, and duplicates the set fields to add another procedure.

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The Save and Transmit button saves and transmits the referral form under two conditions:

1) If the policy of the practice says it doesn’t need to be transcribed

2)If a transmission interface has already been set up with that referral source

Both conditions must be met.

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The Save button is the usual method to finalize and commit the order to the Encounter Form. Click on the Save button.

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You will see a new screen showing confirmation of the order. This completes the process of the Provider’s Order Form.

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Now we’ll explore transcribing the Order Form.

Transcriptions

In the United States clinical practice, Provider Orders are typically processed by transcription staff.

They make any appointments that are ordered and they fill out the forms to be sent off.

They then verify in a legally identifiable way that the order has been carried out or transcribed.

In LibreHealth EHR, transcription is indicated by the transcriber e-signing the provider’s order form. However, some User Groups do not have permission to e-sign forms.

If the transcriptionist belongs to one of those groups, such as the Front Desk, the EHR Administrator can add the MIPS Reporter Access Control to a trusted staff’s permissions through the User Profile Access Control list.

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Marc White is the South West Practice transcriptionist and is logged in on his station computer.

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Marc learns that a patient has an order that needs to be transcribed.

One of the ways that Marc could learn about that is from a report in LibreHealth EHR that lists all of the clinical encounter forms that have not been e-signed. This report will include the Procedure Order form waiting to be transcribed.

To access this from the main menu:

1) Choose the Reports group

2) Choose the Visits sub-menu group from the Reports drop-down list

3) Choose Encounters from the Visits drop-down list

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Marc is only interested in encounters at his facility that happened on Monday May 14.

On Facility, South West Practice is chosen from the drop-down list.

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The Provider remains as the default All.



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The From date was chosen as the May 14 date.

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Notice the To date is for tomorrow, May 15. This is so that everything from today will be included.

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Check both check-boxes Details and Not Esigned.

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Choose the Submit Button. You will see a Print button appear. You may choose to Print to the printer that has been assigned to the computer station, or keep it on your computer at this station.

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This Encounter Report can be run as part of a daily audit or whenever it is needed, since it doesn’t change any of the information.

Marc is only interested in Procedure Orders that are not e-signed.

Looking in the Form column, Marc has seen that Jessica Johnson was seen on May 14 and the Procedure Order has not been signed.

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First Marc needs to look up the patient in the Patient Finder.

Notice there are three patients with the last name of Johnson. Jenny and her twin daughters, Jessica and Sarah, are patients at the South West Practice. Be cautious when choosing the actual patient from the Patient Finder. Make certain that both the full name and the birth date of the patient are correct.

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Marc has opened Jessica’s Encounter Form to see the Procedure Order from Dr. Apgar.

By clicking on Edit at the Procedure Form, he opens the actual Order.

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There has not been a referral created yet.

Marc will return to the Patient Summary and choose Transactions.

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This will open the Patient Transactions screen.

By clicking Add, a new Referral form will open.

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Referral Form

On this Referral Form will be the same information that is on the Provider Order Form.

Referral Transaction: 'Referral Date' = Procedure Order: 'Order Date'

Trans-refDate.jpg Trans-ordDate.jpg

Referral Transaction: 'Refer' = Procedure Order: 'Ordering Provider'

Trans-refBy.jpgTrans-ordBy.jpg

Referral Transaction: 'Refer To' = Procedure Order: 'Sending To'
Choose Yes, this is an External Referral.

Trans-refTo.jpgTrans-senTo.jpg

Referral Transaction: 'Reason' = Procedure Order: 'Clinical History'

Trans-reason.jpgTrans-clinHis.jpg

Referral Transaction: 'Referrer Diagnosis' = Procedure Order: 'Diagnosis Code'

Trans-refDiog.jpgTran-provDiag.jpg

Referral Transaction: 'Risk Level' = Procedure Order: 'Priority'

Trans-risk.jpgTrans-priority.jpg


Notice that we are not including Vitals.

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Click on the text-box of Requested Service.

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This will open a new Search screen.

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Choose CPT4 Procedure/Service. In the Search for text-box enter x-ray.

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Choose each code that was seen in the Plan section of the SOAP.

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This will automatically fill in each CPT4 Code for each service requested.

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Now that Marc has completed the Referral Form, he will Save the Referral Form.

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And he will Cancel out of the Procedure Order.

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The Patient Transactions screen shows what was requested.

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Now Marc can E-Sign the Procedure Order to show that it has been transcribed.

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Back to the Encounter Form you will see the Provider Order is locked and the order has been signed and dated.

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The Referral Form can now be printed, and the referral can be submitted to the External Resource.

Refer.jpg

Summary

We have followed Dr. Apgar as she met with the patient, used the Patient Encounter Summary, created a SOAP Note, and placed a Procedure Order.

We then followed Marc White as he transcribed the Procedure Order and created a Referral.

We hope this document is helpful as you follow the workflow required for Provider’s Orders.