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From the Visit Forms dropdown list, Dr. Apgar will choose SOAP.  
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[[File:orders-vapgar-soap-sign.jpg]]
 
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== Initial Provider Order ==
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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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[[File:orders-vapgar-create-procedure.jpg]]

Revision as of 22:22, 16 July 2018

LibreHealth EHR Provider Orders

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.

Toni Shortsleeve, LibreHealth Documentation Intern, June 18, 2018

Initial Visit

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


Orders-vapgar.jpg


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.


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.

Orders-vapgar-encounter-summary.jpg

SOAP Notes

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


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.


Orders-vapgar-visit-forms.jpg


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


Orders-vapgar-soapdrop.jpg


This will open a new SOAP form.


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.

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.

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.

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.

Orders-vapgar-create-procedure.jpg