LibreHealth EHR Provider Orders
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
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.
During the exams, the provider performs exams and other procedures which are recorded in the forms of the Encounter Summary.
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.
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.
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.
Initial Provider Order
On the Encounter Form, Dr. Apgar will choose the Administrative menu group.
The Ordering Provider has a drop-down menu that shows all of the users in the facility who are authorized to use this form.
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.
Procedure is another free-form text-box. It is used for original procedural orders. We’ll leave it blank for this order.
Diagnosis Codes lets you search the EHR installed code sets for an applicable diagnosis code.
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.
The Order Type has a menu list of the practice's order types. In this case we want to choose Imaging.
The Add Procedure button saves the current Order, and duplicates the set fields to add another procedure.
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.
The Save button is the usual method to finalize and commit the order to the Encounter Form. Click on the Save button.
You will see a new screen showing confirmation of the order. This completes the process of the Provider’s Order Form.
Now we’ll explore transcribing the Order Form.
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.
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
Marc is only interested in encounters at his facility that happened on Monday May 14.
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.
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.
Marc has opened Jessica’s Encounter Form to see the Procedure Order from Dr. Apgar.
This will open the Patient Transactions screen.
On this Referral Form will be the same information that is on the Provider Order Form.
Notice that we are not including Vitals.
Click on the text-box of Requested Service.
This will open a new Search screen.
Choose CPT4 Procedure/Service. In the Search for text-box enter x-ray.
Choose each code that was seen in the Plan section of the SOAP.
This will automatically fill in each CPT4 Code for each service requested.
Now that Marc has completed the Referral Form, he will Save the Referral Form.
And he will Cancel out of the Procedure Order.
The Patient Transactions screen shows what was requested.
Now Marc can E-Sign the Procedure Order to show that it has been transcribed.
Back to the Encounter Form you will see the Provider Order is locked and the order has been signed and dated.
The Referral Form can now be printed, and the referral can be submitted to the External Resource.
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.