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= LibreHealth EHR Provider Orders =
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= YES- we accept contributed documentation =
  
== Introduction ==
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-- from users who are proficient in a useful workflow and would like to make it available to the body of healthcare professionals that use LibreHealth EHR. Authors who publish documentation on this wiki receive full credit for it, and also help promote the uptake of LibreHealth EHR.
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.
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The Libre documentation project has already benefited greatly from the contributions of many interns who submitted much of the content of the 'To The Docs!' section up to this point. One especially helpful set of submissions is the translations into French of several of the Libre Features and Clinic Workflows. So if you have a special insight into a Libre workflow, or an expert health care vocabulary in a language besides English, read on to see how you can participate.
  
Provider’s Order may also be known as Procedures Orders.
 
  
Toni Shortsleeve, LibreHealth Documentation Intern, June 18, 2018
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In another document I've developed a [[LibreWikiStyleGuide| style guide]] containing some short notes on the rudimentary best practices one should observe when writing this style of documentation. Please at least be aware of them, though your docs will not be rejected if they differ from the recommendations!
  
== Initial Visit ==
 
  
Dr. Virginia Apgar is logged in to the LibreHealth EHR system.
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Thanks in advance! - Harley Tuck, LibreHealth EHR Wiki documentarian
  
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= How to contribute =
  
[[File:orders-vapgar.jpg]]
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# Contact me with your proposal for a document contribution: [mailto:htuck@mi-squared.com htuck@mi-squared.com]
 +
# Read through the Libre Docs Style Guide
 +
# Write your docs- yes, I'd be happy to consult with you on the content and the style
 +
# Send me the markup pages to an email I will tell you when we confer
 +
# I will publish your docs.
  
 
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I'm looking forward to working with you!
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.
 
 
 
 
 
[[File:orders-vapgar-new-patient.jpg]]
 
 
 
 
 
During the exams, the provider performs exams and other procedures which are recorded in the forms of the Encounter Summary.
 
 
 
[[File:orders-vapgar-encounter-summary.jpg]]
 
 
 
== SOAP Notes ==
 
 
 
At the top of the page, Dr. Apgar will select New Encounter.
 
 
 
 
 
[[File:orders-vapgar-new-encounter.jpg]]
 
 
 
 
 
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.
 
 
 
 
 
[[File:orders-vapgar-visit-forms.jpg]]
 
 
 
 
 
From the Visit Forms drop-down list, Dr. Apgar will choose SOAP.
 
 
 
 
 
[[File:orders-vapgar-soapdrop.jpg]]
 
 
 
 
 
This will open a new SOAP form.
 
 
 
 
 
[[File:orders-vapgar-soap.jpg]]
 
 
 
 
 
'''Subjective''' is the patient’s statement about the symptoms. Using 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.
 
 
 
 
 
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.
 
 
 
[[File:orders-vapgar-soap-note.jpg]]
 
 
 
 
 
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, choose e-Sign.
 
 
 
[[File:orders-vapgar-soap-esign.jpg]]
 
 
 
 
 
By entering her pass phrase and choosing the Sign button, Dr. Apgar will e-sign and lock the SOAP note so it can’t be modified.
 
 
 
[[File:orders-vapgar-soap-sign.jpg]]
 
 
 
 
 
 
 
== 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.
 
 
 
[[File:orders-vapgar-create-procedure.jpg]]
 

Latest revision as of 20:43, 19 July 2018

YES- we accept contributed documentation

-- from users who are proficient in a useful workflow and would like to make it available to the body of healthcare professionals that use LibreHealth EHR. Authors who publish documentation on this wiki receive full credit for it, and also help promote the uptake of LibreHealth EHR.


The Libre documentation project has already benefited greatly from the contributions of many interns who submitted much of the content of the 'To The Docs!' section up to this point. One especially helpful set of submissions is the translations into French of several of the Libre Features and Clinic Workflows. So if you have a special insight into a Libre workflow, or an expert health care vocabulary in a language besides English, read on to see how you can participate.


In another document I've developed a style guide containing some short notes on the rudimentary best practices one should observe when writing this style of documentation. Please at least be aware of them, though your docs will not be rejected if they differ from the recommendations!


Thanks in advance! - Harley Tuck, LibreHealth EHR Wiki documentarian

How to contribute

  1. Contact me with your proposal for a document contribution: htuck@mi-squared.com
  2. Read through the Libre Docs Style Guide
  3. Write your docs- yes, I'd be happy to consult with you on the content and the style
  4. Send me the markup pages to an email I will tell you when we confer
  5. I will publish your docs.

I'm looking forward to working with you!