Ordering Labs
Anyone can order a lab as long as it has the provider's name as the ordering physician. The following note types have direct access to the Clinical Order Sheet: Complete Assessment, Prescriber Progress Note, Nursing Note, Primary Care Note, and the Quick Note.
1. On the Complete Assessment, go to the last tab (Finish Initial) and click the button.
*All patients and providers seen in this article are fictional and on a test account.
On the Prescriber Progress Note, go to PN part 2 tab and click the button.
On the Nursing Progress Note, click the button.
From the Primary Care Note, click the button
From the Quick Note, click the button
2. On the Clinical Order Sheet screen, click the button.
3. Click the button to create the lab order.
4. Fill out the Add Test Requisition window.
a. From the dropdown menu, select the test you want to order.
b. When the test should be performed.
c. How many times the test is performed.
d. The patient's diagnosis for test.
e. Procedure code or International Laboratory Code Registry code.
f. Indicate if the test should be performed while fasting.
g. What type of test (Lab).
h. Start date/when to have test.
i. End date/when lab request expires.
j. The reason for the test.
k. Save the order.
5. Once the test requisition is ordered, it will show on the Lab Requisition Order Form. Continue adding as many New Orders as needed by following the same steps outlined above.
Nurses can mark Verbal Order and Read Back under VO and RB. The ordering video below (at the bottom of this article) demonstrates this.
6. Once the orders are all entered, finish the Lab Requisition Order Form as below.
a. Name on Order will populate automatically based on the note creator.
b. Location on Order will populate automatically based on your Working At location, and can be changed by clicking into the dropdown field and making a selection.
c. Signature Image allows you to Capture the ordering clinician's signature for the lab request.
d. Click into the field to select a Provider Account #.
e. The Patient's Name & Address, Date of Birth, Medical Record Number, Medicare Number and Insurance Information will populate automatically from Demographics, as will Diagnosis and the Ordering Clinician's NPI and Medical License Number, displayed just above the signature.
f. Include any instructions to the lab in the Instructions field. You can Create Custom Instructions Button to add your own customized instructions.
g. All Orders will be itemized here. Click Delete All Orders to clear the list. Nurses can indicate when an order is a Verbal Order (VO) and has been Read Back (RB).
h. Lab Req Protocols allow you to establish a pre-determined set of lab orders that can be populated into the requisition without having to add each new order individually. Labe Request Protocols can be created by group administrators in Group Level Settings and Directories.
i. Make a selection in the dropdown field to note who the results should be sent to (optional).
Once the requisition form is complete, you have numerous options for saving and printing the sheet:
7. If you want to print the order form, click the button.
8. Click the button to save as a PDF. These can be later seen or printed from the Documents tab on the Chart Face.
 
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