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How to Document Lab Results

Lab Interface 

If your county has a lab interface, lab orders placed in SmartCare can automatically be sent to the lab. 

  1. 1. Lab orders have been set up as Quick Orders. This means they can be entered without having to go through the entire How to Create a New Order for a Client  process.   

  1. Note: Orders set up as Quick Orders cannot be added to Order Sets.  

  1. 2. Before completing a lab order you should ensure you have a client record open. See General Client Search section.  

  1. 3. Click the Search icon. 

  1. 4. In the Search bar enter the lab order name. 

  1. Quick Orders can be accessed directly through Search and have an “O” to the left of the order name.  

  1. For my example I am using CBC 

  1. 5. Select the lab order from the list, this will open the Quick Order document.  

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  1. 6. The selected order will populate to the Order field. 

  1. 7. You may select the Clinic/Location from the dropdown as needed.   

  1. 8. Select diagnosis from the dropdown 

  1. a. If you need to add a diagnosis click the Add Diagnosis button and search for diagnosis within the pop-up window.  

  1. i. This will add the diagnosis to the order, not the client’s record.  

  1. 9. Frequency will default to Once.  

  1. a. Future Functionality: if order has other frequency options (e.g. weekly) select the option from the dropdown. You must enter a Start and End date; see step 12 and 12.a below. The order will automatically generate new lab orders based on the frequency.  

  1. 10 Labs will display the Lab this order will be sent to. If you have multiple interfaces to different labs, ensure this has the correct option.   

  1. 11. Select the Ordering Physician from the dropdown 

  1. 12. Start date and time will default to the current time. Make changes if needed.  

  1. a. Future Functionality: End date and time are required if frequency is more than onceSee step 9.a above for details.  

  1. 13. Select Program from the dropdown; this is a multi-select field.  

  1. 14. Clicking the Send to Lab button will send the order to the lab. However, this is not regularly used as labs get sent to the lab once the document is signed, step 18 below.  

  1. 15. Click Add Order to add the order to the list.  

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  1. 16. You can add additional lab orders by entering the name in the order field. This field is a typable-search field, as you type options will appear.  

  1. a. Select the correct order.  

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  1. 17. Repeat steps 7-15.  

  1. 18. Sign the Order using the steps found under How to Sign a Document. As soon as the document is signed, the order will be sent to the pharmacy.  

  1. a. When documenting an order on behalf of a Prescriber, the Prescriber must be added as a co-signer and must complete their co-signature. For more information, see How to Co-sign a Document. 

  1. 19. Order will have a status of Sent to Lab. 

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Non-Interface Lab Results 

Lab results received from a lab that does not have an interface are scanned into the client’s documentation using the Scan/Upload feature. 

  1. 1. Click the Search icon. 

  1. 2. Type “Scan” into the search bar. 

  1. 3. Click to select Scanning (My Office). The Scanning list page will open. 

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  1. 4. Select the icon for the type of document import you wish to perform. 

  1. a. Scan and Batch Scan use scanning hardware to convert paper documents into electronic images and import them into SmartCare. 

  1. b. Upload and Batch Upload take existing electronic files and import them into SmartCare. 

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  1. 5. If you selected Scan, the Scan page will open.  

  1. a. Your scanning hardware will initialize. Follow organizational workflows to operate your scanning hardware. 

  1. b. An image will display in the center pane when a file has been successfully scanned. 

  1. c. Select a record option from the dropdown. 

  1. d. Click the ‘…’ button to perform a client search using the steps found under How to Search for a Client. This step will be skipped, and a client will be pre-selected, if you opened Scanning (My Office) with an active client. In this case, select the ‘…’ button to change active clients. 

  1. e. Select a record type from the dropdown. This will be set to “Labs” or one of the Lab Results options for lab results. 

  1. f. Set an effective date. 

  1. g. Type a Description into the text field. 

  1. h. Click Save. 

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  1. 6. If you selected Upload, the Upload pop-up will open.  

  1. a. Click Select. 

  1. b. Select your desired file from your computer file browser. 

  1. c. Click Upload. An image will display in the center pane. 

  1. d. Select a record option from the dropdown. 

  1. e. Click the ‘…’ button to perform a client search using the steps found under How to Search for a Client. This step will be skipped, and a client will be pre-selected, if you opened Scanning (My Office) with an active client. In this cases, select the ‘…’ button to change active clients. 

  1. f. Select a record type from the dropdown. This will be set to “Labs” or one of the Lab Results options for lab results. 

  1. g. Set an effective date. 

  1. h. Type a Description into the text field. 

  1. i. Click Save. 

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  1. 7. NOTE: Before selecting Batch Scan, you will need to print one or more Scan Separators from the Scan Separator (My Office) page. One Separator should be placed between two documents to signal to the system that they should be treated as separate. If you selected Batch Scan, the Batch Scan page will open. 

  1. a. Your scanning hardware will initialize. Follow organizational workflows to operate your scanning hardware. Ensure a Scan Separator is placed between each set of documents. 

  1. b. On the left, you will see multiple documents listed. Select the radio button beside one to display it. 

  1. c. Click the Client button to perform a client search using the steps found under General Client Search. 

  1. d. Select a record type from the dropdown. This will be set to “Labs” or one of the Lab Result options for lab results. 

  1. e. Set an effective date. 

  1. f. Type a Description into the text field. 

  1. g. Repeat Steps 7b-7e for each document scanned. 

  1. h. Click Save. 

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  1. 8. If you selected Batch Upload, the Batch Upload window will open. 

  1. a. Click Select. 

  1. b. Select your desired files from your computer file browser. The Batch Upload function supports multiple selections. 

  1. c. Click Upload. 

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  1. d. On the left, you will see multiple documents listed. Select the radio button beside one to display it. 

  1. e. Click the Client button to perform a client search using the steps found under General Client Search. 

  1. f. Select a record type from the dropdown. This will be set to “Labs” or one of the Lab Result options for lab results. 

  1. g. Set an effective date. 

  1. h. Type a Description into the text field. 

  1. i. Repeat Steps 8d-8h for each document scanned. 

  1. j. Click Save. 

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  1. 9. After Saving your associated documents, Search for the Documents (Client) screen and select it. 

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  1. 10. Review the documents scanned/uploaded here. If necessary, click the Add hyperlink in the Associated Documents column to upload new documents that should be associated with the selected document.  

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Interface Lab Results 

When there is a bidirectional lab interface, results will automatically come into the system.  

  1. 1. When results are sent from the lab the order will have Results Obtained Status in the Order list pages; Orders(My Office)  and Client Orders (Client). 

 

  1. 2. Additionally,  results will appear in the Lab Results widget. This widget is available in the Dashboard.  

  1. 3. Enter the ordering physician’s name. This is a typable-search field, as you type the name options will appear.  

  1. The field will default to your name but will only show results based on the ordering physician name. You can only have one name at a time.  

  1. The widget will display any lab orders for the ordering physician with Results Obtained status.  

  1. 4. Click the Order Name hyperlink to review the results.   

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  1. 5. You will be in the Lab Results Review screen.  

  1. 6. Results will appear in the Lab Results Review section.  

  1. 7. Clicking the View PDF button will display the PDF within the same section. 

  1. a. Button will change to View Results.  

  1. b. Not all results will have a PDF, this is dependent on the interface.  

  1. 8. View Flowsheet hyperlink will open the flow sheet associated with this lab.  

  1. See step 16 below for details.  

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  1. 9. Click the expand icon next to Review to view additional fields.  

 

  1. 10. Select between Normal, Abnormal, and Not Specified radio buttons 

  1. 11. Select Results Review Comments to select a standard comment.  

  1. 12. Enter comments into the textbox, if needed.  

  1. 13. Enter a user’s name into the Assigned to field if you would like to assign these results to someone.  

  1. a. Assigned orders can be seen and tracked in Orders (My Office).  

  1. b. Enter Assigned to Comments if the order was assigned to someone.  

  1. 14. Select Nurse Reviewed button 

  1. a. This button is only active when the individual is not set up as a prescriber.  

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  1. 15. This review information can be seen and tracked in the The Lab Results and Review List. 

  1. a. This list page is for this specific client.  

 

  1. All lab results will also populate into a flow sheet automatically.