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.
Toni Shortsleeve, LibreHealth Documentation Intern, July 16, 2018
Dr. Virginia Apgar is logged in to the LibreHealth EHR system.
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.
At the top of the page, Dr. Apgar will select New Encounter.
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.
This will open a new SOAP form.
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.
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.
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.
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.
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.
The Sending To field will drop down the menu list of your facility’s outside resources. We will send to Imaging Tech Labs.
The Order Date is today’s date. If you click on the Order Date text field, a calendar will let you choose the date.
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, this should remain blank.
Priority is the urgency as defined by your practice’s policies.
Leave the Status as the default Unassigned unless you are making an original procedural order.
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.
Procedure is another free-form text box. It is used for original procedural orders. We’ll leave it blank for this order.