Adding Lab Results Manually

overview & requirements lab results are typically sent to the emr electronically however, sometimes they arrive by email, fax, or hard copy (brought in by the patient) in such a case, the results need to be added manually—typically by the moa requirements some of the fields described here are available only from profile 9 0 11 onwards adding lab results manually lab results can be added manually via medical record/results work centre/manual trans work centre/unsigned trans adding the lab results via medical record/results on the main toolbar menu, click on medical record if you're not already in the patient context, search for and select the applicable patient when the medical record for the patient opens up, select the results view in the window toolbar menu, click on the add manual measures icon this opens the add new transactions window if the lab result you wish to add matches an existing template in the available items panel on the left, you can select a template to populate various fields otherwise, you can enter each field manually, one at a time because you want to add lab results, in the transaction panel on the right, set the transaction category to "pathology" this changes the selection of other fields that are available enter the following field values, as appropriate field description patient because you have already selected a patient , this field is already populated however, it can be changed this field indicates the patient to whom the results apply and is a mandatory field date (and time) this field defaults to the current date and time, but you can change it this is different to the recorded time of the transaction, which you cannot change, but which can be viewed in the manual transactions view category already set to "pathology" in a prior step, because you want to add lab results collection date (and time) the date (and time) when the specimen/reading was taken, if applicable order date (and time) the date (and time) when the provider ordered the lab test, if applicable prov the provider's name if left blank, the transaction will appear in the unmatched transactions list upon saving pos the place of service supplier the lab from which the result has come privacy used if you want only members of the selected role to be able to see the transaction copies to provider(s) that should receive a copy of the transaction in their unsigned transactions view, in addition to the provider selected in the prov field above accession num the accession number provided by the lab this number uniquely identifies the lab result code the test code, if provided by the lab description the test name, if provided by the lab notify provider with new version checked if you want a task to be created for the provider selected in the prov field the task contains a link to this transaction next, to add results, right click on the table of items from the context menu, select new item and then select the type of result result types include text this is used for a simple text result such as "inconclusive" multi text this is the same as text, but can be more than one paragraph quantity this is used for results that are compared to a precise number, e g , "10" quantity range this is used for a result which will be compared to an inclusive min max numerical range such as "5 15", or to a one sided numerical boundary, such as ">5", ">=5", "<15", or "<=15" quantity ratio this is used for a numerical ratio date/time this is used for date/time values boolean this is used for binary true/false or yes/no values image this type is not appropriate for manual transactions slice image this type is not appropriate for manual transactions once you have selected the item type, the term selector window opens the option dropdown is used along with the search window to search for lab test codes it defines the criteria for how the search finds the term specified options include is exactly searches based on the term being an exact match with the specified string of characters this is the default option starts with searches based on the term starting with the specified string of characters contains searches based on the term containing the specified string of characters has code searches based on loinc code / lab test code for the term select a term and concept pair from the lists in this window you must select one pair click ok next, enter the following field values for the selected result item, as appropriate field description date and time the date and time sent by the lab value the value sent by the lab reference range the meaning of the lab result is intended to be evaluated in reference to the range defined if the item type for the result is "quantity range", this reference range must be one of the following inclusive min max numerical range, such as "5 15" minimum (exclusive or inclusive) numerical range, such as ">5" or ">=5" maximum (exclusive or inclusive) numerical range, such as "<15" or "<=15" unit the unit of measure in which the item is recorded right click and select modify/item properties from the context menu for example, for weight one might select "kg" optionally, by double clicking directly into the warning field for the appropriate item, you can display a warning symbol to indicate that the value of the transaction is abnormal status optionally, you can specify an item status, choosing from one of the following final, corrected, preliminary, pending, deleted next, enter the following field values, as appropriate field description comment optionally, enter a relevant comment about this transaction as free text once saved, this appears inside the result, as a comment/note as well as in the item's properties annotation enter an annotation, if appropriate like other annotations, it displays in the patient's record, in the results view of the transaction, in red font, along with the date and time it was added, and its author acquired an indication of whether the transaction was obtained from a source outside your organisation (for example, a scan) signed an indication of whether the transaction is to be flagged as 'signed' if left unticked, the transaction appears in the relevant provider's unsigned transactions view until signed off click ok this saves the manually added lab result and it appears in work centre/manual trans adding the lab results via work centre/manual trans on the main toolbar menu, click on work centre select manual trans this opens up the list of manual transactions in the window toolbar menu, click on the new icon this opens the add new transactions window search for and select the applicable patient this field indicates the patient to whom the results apply and is a mandatory field the rest of the process is the same as when adding the lab results via medical record/results (as described above) adding the lab results via work centre/unsigned trans on the main toolbar menu, click on work centre select unsigned trans this opens up the list of unsigned transactions in the window toolbar menu, click on the add manual measures icon this opens the add new transactions window search for and select the applicable patient , this field indicates the patient to whom the results apply and is a mandatory field the rest of the process is the same as when adding the lab results via medical record/results (as described above) note if you select to flag the transaction as signed, it will be moved out of the unsigned trans list, but it will still be available in the manual trans list related articles the linked articles below contain more information on the following retopics changes to unsigned transactions and results ui docid\ m4jjyzjtuzpf2mr4u3ir4adding measure items docid\ vixsmt7sz0atyaccdhn9bvideo unsigned transactions walkthrough part 1 docid\ uxpw6jji86t7v8sghomyivideo unsigned transactions walkthrough part 2 docid\ cpl94ny53wupmupqqdb3o