Document lab and imaging orders in a Chart Note
I would prefer when I enter lab or imaging orders, they should go into current chart note. Consider adding an "orders and medication" section in the Plan section.
Hello everyone – As of 2/16/2017, we have introduced a new section in the encounter note: your practice can now submit, track, and review lab and imaging orders directly within a chart note, allowing you to see a more holistic view of your patient visits with fewer clicks.
You can read more about how to add or create a lab or imaging order here:
Dr Douglas Haas commented
This is very important. Surprised not more votes. Cumbersome to do two more clicks to see lab and imaging orders. Should show up in encounter like med refills do in the plan section.
When ever the encounter gets signed off and a Superbill gets generated there is a need to show proof of medical necessity of upcoding. Ordering additional labs or medical imaging is showing proof of medical necessity if this auto-generated as an auto-post in the SOAP note.
Please consider having the labs generated on PF also be auto-posted and having the attached lab order also be attached to the encounter in the SOAP note
Dr Carla Lambert commented
I agree. When we send the lab order to the lab there is a check box to assign the lab order to a specific encounter date. This should make it very easy to link it into the encounter, just as the medications and diagnoses are added in. Please consider doing this so we can cut down on some of the repetitious typing.
Agree. We need to add labs and imaging RESULTS to our lab notes for better assessments. This is especially true when we are sending referral notes.
Dr Danielle Saad commented
The order note should have an assesment section that is connected to the diagnosis entered for the patient so that we can easily include the needed ICD 10 codes with orders.
Dr Debra Coplon commented
You can document an imaging order in the screening assessment section-one way to keep track that it was ordered.
Dr Angus Matheson commented
I imagine this like the eRx - when ordered, it is a line in the plan. Now to see what was ordered, need to go to a seperate place in the chart to see what was ordered on a particular day - in fact go to 2 places one for labs and one for imaging. It would be great if the note automatically showed what was ordered that day.
Dr Mary Ackerley commented
It would be so much easier to be able to click on a lab value and have it added to the current chart note. I often compare lab values and now have to go back and forth between labs to type each in the note ( and flowsheets does not seem to work for the specialized labs I order)
Ms Heidi Friedman commented
I agree. Right now the provider has to specifically document the results in the encounter. If the lab results or imaging order could be added or attached to the encounter it would be a lot better. I also think that there should be an option to attach signed documents to specific encounters that they correspond to, for example, physical therapy notes from an outside facility, and in general anything that is reviewed with the patient should be attached to the encounter so it's all in the note for the visit rather than having to click around and hunt for it.
Mary Stanley commented
Lab/imaging/tests should populate under appropriate diagnosis on the encounter visit for which it is ordered. It is time consuming to type this information in when it could be part of the programs design to automatically assign it to the right area. I find there is already more typing being done that streamlining the encounter in this area would be very helpful.
Is it possible to attach lab results into the Objective section of the SOAP encounter?
Julie Edwards/ BGSG commented
We have been putting as an addendum to the encounter note. It works and is attached in the office note. As a scheduler, I can not get my orders in before the provider finishes the office encounter. This is how our providers have decided they want the orders attached.
Keely Godwin, MD commented
This is really important. If I'm ordering an xray as part of a treatment plan, it should be treated like a medication that is also ordered in that same visit and should be included in the plan for that visit. I don't understand why it's not included in specific chart notes, since often imaging or lab is done as a response to an acute complaint.
Ms Katie Montague commented
I would also like lab results from that encounter to go under objective and immunizations/tb tests.