Labs 3 - Manual Laboratories with Structured Data

Select the Labs icon in the toolbar of MacPractice and select a patient with the Patient Selector. Clicking the green plus will activate the bottom portion of the Order within the patient’s chart. An Order is broken into three parts: the Order Details, the Order Assignment and status, and the Order Notes.

Start by entering in all of the Order Details by selecting the Laboratory Order type from the first drop down box. You will notice that a new drop down will appear, automatically selecting Other Labs. Enter in the Provider and the Office for this laboratory order. These will pull the patient’s information by default. Select the correct Incident within MacPractice. The Incident Menu can be used to help organize your labs. Ask your manager about the workflow in your office. Enter in a Short Description for the Laboratory Order within MacPractice. Be sure to give this Order a useful name as the Short Description will be available on the patient’s Clinical Summary. A Long Description can be added to help organize the Order within the patient’s chart.

Navigate to the Tests tab within the Order and click the green plus to enter in the codes for the tests that were ordered. These codes have been provided by CMS and cannot be changed within the database.

Once all of the Order Details have been entered, move to the Order Assignment and Status. Assign the order to a user in the office. This user should be the user that will be receiving the results from the Lab. The status will default to Pending Results this status should not be changed until the results have been entered into MacPractice. The Scheduled Date can be used for one of two purposes; you can record the date that the patient should be seen in the lab, or you can record the date that the results should be made available. This date is only used for tracking purposes within MacPractice. Use the Edit menu or the keyboard shortcut command S to save this order.

Once this record has been saved, it is recommended to scan the paper order form, or save the electronic form as a PDF into MacPractice. This can be completed by navigating to the Attachment tab within the Order. Click the green plus to select an existing Attachment within MacPractice or to select a document from your computer.

When the results have been made available to the office, navigate to the patient’s orders. The test results can be entered within the Test tab by selecting the Order and clicking the green plus in the Results section. These results can be used as filters within Clinical Reports. The attachment results can be saved within the Order under the Attachment tab.

Assign the Order to a clinician to be reviewed and change the status to Results Available. The Assigned User will see a blue notification on the Labs icon within the toolbar. This notification will change based on the patient that is selected. Deselect the patient from the Patient Selector to see all Laboratory Results that are available for your practice.

Select the Order to see the patient’s results. Use the Notes field to add any notes for the lab. Change the Unreviewed selection to mark the laboratory as Normal or Abnormal. You can use the checkboxes to mark if the Order has received a Preliminary Review and a Final Review. Once complete, check the Locked box to prevent unintentional changes. Sign the Order to place your digital signature on the Order. Note that the user will be required to enter their password to sign the Order. This will lock the Order Details section from any additional changes.
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