Rad is an abbreviation of Radiology. The Rad Order can be placed for a patient on a selected Radiology.
Add New:
Click the button to make a new Order on the toolbar to make a new Order.
When user adds an order, the current patient and encounter details are
selected for the new order and information like Patient Name, Provider Name, List of ICD Codes, is automatically displayed.Order No: This is generated by the system on saving the order, as per settings in property, Rad Params > rad.orderno.prefix and rad.orderno.length.
Order Date: This is set by default to current date.
Patient: Is the selected Patient in the current encounter.
Comment: This can be used to send special instructions to the Radiology. Click Comment to open a multi line edit control dialog box where these details can be entered. After the Rad order is sent the entered comments can only be seen but not edited. After the Rad order is sent, and no comments are entered, the button is disabled so that the user knows for sure that there are no associated comments.
Label Print icon: Click on the icon to print labels as per requirement. The system invokes the Label Printing popup.Status: This is set by the system as:
- E - Entered on clicking Save by a user who has been assigned entry rights only.
- A - Approved on clicking Save by a user who has been assigned approval rights.
- O - Ordered on clicking Send.
- R - Results Received on entry of the received results.
- C - Complete on approval of entered results.
- Complete and Reviewed on reviewing the completed Rad Order Results.
Results (Required) By: Select the date by which the Radiology is expected to return the results for the first 3 Urgency types. In case the Urgency is Scheduled, the Label changes from Results By to Scheduled On.
Provider: Is the Ordering Provider. If a new Order has been created by a logged in Provider, this will be set to the Login Provider. If a new Order has been created by a logged in Nurse, this will be set to the encounter Attending Provider. Note that the ordering Provider can be different from the attending Provider.
Recurring Rad Order: If the user had clicked on an existing Rad Order, whose status is Approved, a Recurrence button appears. Click on this to repeat this Rad Order multiple times.
Note: the subtle features,
- For new Rad Order, Recurrence button is not displayed.
- For existing Rad Order which has not been repeated, Recurrence button is displayed.
- For existing Base (Original) Rad Order which has been repeated, A message is shown “Recurs X times”
- For existing Non Base Rad Order which has been repeated. A message is shown “Base Rad Order on “. A trash can is also shown to delete this specific instance of repeated Rad Order .
- In case of recurring Rad Orders, the delete Button is used to delete all instances of recurring Rad Order for a base Rad Order.
Radiology: Select one of the vendors from
the vendor list. This is not mandatory, as patients may have their own preferred
radiology labs or vendors.
Required Data: In case of an ordered test some additional information like patient's height, weight, or blood pressure maybe required that could influence the results, this additional information is called as Required data. On save of the Lab Order, the system knows the list of Ordered Tests. For the selected Vendor (other than Any Lab), the Vendor Test Master has a provision of defining the List of Vital / Physical / HPI / ROS /Specialty / Social History Tests whose values need to be reported to the Lab while ordering the Test. The system now makes a union of these tests (two order tests may require the same Vital test like Weight) and presents the list along with the values entered for them in this encounter.
Test Alert:is enabled when an alert is defined in radiology test definition from Settings > Configuration > Radiology > Tests
X-Ray Jacket No.: Enter the X-Ray Jacket No if applicable.
Tests: Click on the "+" button
to select the applicable tests.
• The Test Selection pop up has three Tabs:
✓ The first Tab displays a list of Provider preferred
Rad Tests,
✓ The second Tab displays the complete list of Rad
Tests,
✓ The third Tab is Order Set, It displays the list of all existing order sets. User may select any one of the templates. All the tests in the selected
Order Set are added to the current Rad Order along with the ICD codes, if they are present.
• The fields displayed for selection include the Test name, the
Grouping Category and flag to indicate Panel / Test. The user can sort the
Tests by any one of these fields. By default the list appears sorted by
Test name.
• All the selected tests appear in the table below.
Adhoc Tests: The Provider might need to Order
a Test which he does not find in the list. The system has provision to handle
such a possibility. The system provides a test category by the name Adhoc
tests (under Settings > Configuration > Tests > Rad > Category).
This special record cannot be deleted. The user may however change the name.
User may further define one or more tests under this category (Settings
> Configuration > Tests > Rad > Tests). If one or more of such
tests were selected in the test selection, the user will get a provision
to edit the test name. He can enter the test description of his choice and
send the Rad Order. This edited name is tracked for Rad result also. However
note that it does not modify the Test Master. For a new order if the same
adhoc test is selected, user will need to edit the name again as per new
requirement.
ICD:
• A list box appears on each line of
the selected test. The default selection is None. Besides this option
it contains all the ICD codes selected under Assessment for the current
encounter. The user may select appropriate code to serve as a basis for
justification if required later. A proper selection can also help the Provider
make a good statistical analysis of the tests which were ordered for various
problems.
Note: Support has been provided to assign multiple ICDs to a Radiology test on Radiology Order screen (GoTo patient Encounter > TOC >Radiology Order). The feature is property dependent i.e. if the property, rad.order.tests.assign.multipleICD is set as 'Y' then it is possible to assign multiple ICDs to individual Radiology tests from Radiology Order screen.
• User can also add ICDs dynamically to the list box by clicking only 
button
• User can add Past ICD codes (from Past Medical History) by clicking on Add Past ICD Codes icon: 
Instructions: User can add any instruction for the Radiologist for individual tests from here.
Actions: This option is available only for Inhouse radiology and the options available are: Pending, Done, Failed.
MN: MN or Medical Necessity notes that can be entered by clicking on the icon: 
Save:
• Rad Order is saved.
Note that User is able to create a Rad Order without having to type in any
characters. The system validates if the selected tests are supported by
the selected Rad. If they are not supported an error is displayed.
• If the Login Person is a Provider, or has Approve rights, the status of Order
is set to Approved.
• If a Nurse creates an Order without Approve rights, an Alert is send to
the Provider, so that he can Approve it. If the Nurse has Approve rights,
Only a Notification is send to Provider informing him about the Order.
Send: An order for the test can be sent
to the Radiology either by Fax, E-mail, Print and Mail. An order
can be sent only after its Status is changed to Approved. Once the Order
is sent, its Status changes to Ordered and it cannot be edited.
Statistics: Click to get a list of tests
ordered by the same Provider, in the last 180 days, using one or more of the
ICD Codes assigned to the current patient. The pop-up window shows the tests
and the frequency in descending order.
The Rad orders can be printed as per the Clinic's format. This format can
be defined under Settings > Configuration > Report Templates >
Rad Order. Certain Rads can insist on their own pre-printed stationary.
The position of every test is fixed on the form. These coordiantes (alongwith
Vendor specific test code) can be set under Settings > Configuration
> Tests > Rad > Vendor Tests.
Provider Involved:
- Primary Provider: The primary Provider of the Patient, defined in his Registration.
- Attending Provider: The Provider whose appointment was taken / Who created the encounter. Normally this must be same as Primary Provider, unless he is not available.
- Rad Ordering Provider: The person who actually Created and Approved the Rad Order. Normally this must be same as Attending Provider.
Order Set Button: This button is displayed only when a Provider logs in. The current Rad Order can be saved as a template by the Provider. This button displays the list of all existing Order Sets. User may decide to overwrite an existing Order Set or create a new one. Select one of the Order Set. All the tests in the current Rad Order along with their details like ICD, are saved in the selected Order Set overwriting any exisintg information. The Provider can thus make Order Set of often ordered tests for various common ailments. This button and the
button
are shown if the property, Order Sheet
>rad.orderset.use, is set to Y.Access Control: The User can come to this screen by many routes, in each case the Orders Accessible will be different.
1. Encounter > Rad Order.
The Orders which can be selected are the ones belonging to:
Selected Patient and
Selected Encounter and
Ignore External Rad
(No constraints on Status)
2. CPOE - Rad Order (Log in person is a Provider)
The Orders which can be selected are the ones
whose Status = Entered / Approved / Ordered and
Ignore External Rad and
Login Person = Attending Provider/ Rad Ordering Provider/ Primary Provider
(at the time of Ordering)
3. CPOE - Rad Order (Log in person is a Nurse and there is a Selected Provider in Tool Bar)
The Orders which can be selected are the ones
whose Status = Entered / Approved / Ordered and
Ignore External Rad and
Selected Provider = Attending Provider/ Rad Ordering Provider/ Primary Provider
(at the time of Ordering)
The drop down list of Provider in the Tool Bar, will be those to whom the Log in Nurse has been assigned.
4. CPOE - Rad Order (Log in person is a Nurse and All Providers Selected in Tool Bar)
The Orders which can be selected are the ones
whose Status = Entered / Approved / Ordered and
Ignore External Rad and
Any Provider to whom she is assigned = Attending Provider/ Rad Ordering Provider/
Primary Provider (at the time of Ordering)
5. CPOE - Rad Order (Log in person is other than a Provider or Nurse)
Ideally they would not have access rights to this option. If they are given rights then
The Orders which can be selected are the ones
whose Status = Entered / Approved / Ordered and
Ignore External Rad
6. Messages
If the Provider has received an Alert / Notification for a Rad Order, he clicks on the Messages, and it brings him to this screen with ONLY ONE Rad Order, namely the one referred to in the messages.