Clinical Results Overview
If you haven't already done so, please read Visits Overview, Patient Check-Out Overview, Visit Activities Overview, Medical Activity Codes and Results, and Immunizations and Surveillance Overview before continuing!
Summary
There are two steps to completing activities on a visit. The first, discussed Visit Activities Overview, is simply entering all the activities that have been performed and marking them as complete. Or, if an activity was scheduled but not performed, indicating that it was cancelled or refused. Once this step is completed, then the activities that were performed will be available for billing.
The second step in completing activities on a visit is entering clinical results where needed. For most activities, all you need to know is that they were done and marking them complete is all it takes. For some activities, additional information is needed. Here are some examples:
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For TB skin test and Hep B vaccinations you need to indicate the step taken on this visit so that the program can calculate the date for the next step. This allows you to identify patients who are due or overdue for an activity so that they can be contacted. It lets employers determine whether all employees are in compliance with certain medical requirements.
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For vaccinations, you might want to enter the dose, lot, lot expiration date, and manufacturer.
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For titers, the final result, positive or negative, needs to be entered.
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You might have some lab activities that you have set up to receive the numerical results of the lab test. A lab results panel, a specialized version of a medical activity template, can be created for recording the results of sets of lab tests. Results for all lab tests can be received via lab interface. They can be received by the lab results panel even if the related activities were not placed on the panel when it was set up.
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For audiograms, spirograms, and vision tests you can enter the details results.
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Drug screen panels can be set up to allow you to enter all the information required to produce DOT reports.
How Do I Enter Results?
The basic process for entering clinical results involves going from the [Enter Visit] window to the list of charges for the visit, opening each one that requires the entry of results, clicking the RESULTS tab, and entering the Result Code User-definable code that indicates the status of a particular medical activity. For example, a result code of 1 may indicate the first dose of a multi-dose immunzation, or it may indicate a PPD was placed but not yet read. . If this is an activity such as audiogram that requires detailed results, a special screen will pop-up for you to enter the details. Read Enter Clinical Results to learn the exact procedure.
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If your clinics licenses the Net Health Employee Health and Occupational Medicine , clinical results can also be entered on the RESULTS tab or the PROCEDURES tab. |
What Do You Want To Do?
Enter Results:
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Enter Clinical Results
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Charting Notes Overview and Entry
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Enter Diagnostic (ICD-9 Code)
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Document Lab Results
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Lab Results Panels
Special Entry Activities:
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Enter Audiometry Results
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Enter Details Drug Screen Results
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Enter Spirometry Results
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Enter Vision Testing Results
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Enter Vital Signs