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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 dropdown list, Dr. Apgar will choose SOAP.

Orders-vapgar-soapdrop.jpg