• CPOE stands for Computerized Physician Order Entry. Proper implementation of CPOE is crucial to reducing medical errors. CPOE feature is an integral part of PROGNOCIS, allowing user to place lab orders, radiology orders, and prescription. It also lets user store lab and radiology results when they are received.
• The Rad Results will be received either by E-mail, Fax, or Postal Mail. The system allows the user to enter the results. The encounter review tag, ENC_REVIEW__RAD$ allows User to Radiology results in text format.
• A search pop up displays the list of Rad Orders with Status as Ordered / Results Received / Complete ie. Results Approved but not reviewed. On selecting one of the Rad Orders the details are retrieved and displayed.
Field Description :
Order No: The Order number is generated as per property, rad.orderno.prefix and rad.orderno.length, on save of the Order from the menu option: Radiology Order.
Order Date: It is the date when this order was generated and saved. When the Order is Send / Print / Fax for the First time, the Order Date is changed to Current Date and if Results (expected By) Date is less than Current Date it is set to Current Date.
Patient
:
Click on icon to display the selected patient's contact details; the details displayed depend on the Form Template defined in property
patient.contactinfo.template Lab: This displays the name of the Radiology vendor where the radiology order was sent to and recieved from.
Address: The button displays the address details of the Radiology vendor other than the Inhouse Radiology vendor
DOB: This displays the Date of Birth of the patient along with the gender details.
Status: This displays the current status of Radiology results i.e Complete or not.
Results Date: This date is automatically set by the system to current date. User can override this date and select another date from Calendar.
Doctor: For Rad Orders generated from PrognoCIS, the ordering Doctor's Name is displayed. If the Order was direcly imported from a HL7 message or attached using the Message > Attach Center menu option, then the Radiology is considered as external (to PrognoCIS) and the name displayed as External Doctor.
Comment: This displays the specific comment that was added during the order generation. The comment can only be viewed and not edited. The inclusion a comment within the lab order is confirmed if the button is displayed with a check sign and the button remains disabled if no comments are associated with the lab order.
X-Ray Jacket No. : Enter the X-Ray Jacket Number.
Review Results: This option if selected indicates that the result has been reviewed.
review button: Click the button, invoked popup displays the review comment. User can enter the review comment specific to the radiology order.
HM button: The result updated or added here will be get updated on Health Maintenance screen and vice versa.
Included in Encounter: This displays if the radiology result is added in encounter or not.
RESULTS TAB
Del: Select the checkbox against the each test and saved, deletes the component test(s) from the Radiology result.
Tests: The list of radiology ordered tests is shown, grouped by the Category.
ICD: This displays the ICD code for selected radiology test.
Instructions: Instructions specific to each test entered in the Radiology Order are displayed.
button: If there were one or more radiology images attached
for this test, clicking on this button opens a pop up to dispay a slide
show.Results: Allows the Doctor to enter comments for each test of the Radiology results received.
Abnormal: When the Ordering Doctor reviews the Rad Results, he can flag a test result as abnormal by checking this box. This could be on the relevance to the particular Patient / Encounter.
button: Attach radiology images. If images are attached, the
count is displayed to the right of this button.Remarks
button:
Enter HL7 notes in invoked popup specific to each test entered in the Radiology Order. Type, Location, Notes: These three columns will be displayed only if the results are imported from HL7.
REMARKS TAB
Enter notes on the Rad results here using this multi-line edit control.
ATTACH TAB
The Attached file is displayed by default. If nothing is attached, it will be Blank.
Attach
• The Rad results may be received as a document file. The file could either be in the form of a Word document, Text file or a Graphic file. The Rad results could also be paper documents. Result can also be as a Fax Paper output, OR Fax softcopy image file. In this case, scan the paper documents and paste the scanned images in one Word document.
• The Radiology images could also be attached individually to each test. The attach button on click invokes File Upload popup. The attached images of Radiology are defined with type such as Images, or Narrative, or Images and Narrative.
• To attach images individually to specific test - Select the test name from the Result drop-down list (image attached individually to a test is viewed from the Result tab.)
Note:
The number next to the attach button indicates the number of attachments available for the test.
The number of attachments is displayed on a single Test Images popup.
A maximum of five attachments can be attached to a test.
User has a provision to add a new image from the Test Images popup as well. The button, add new on click invokes File Upload popup for radiology attachments to help User browse and attach additionally a new image to the test directly. The difference in the popup is that the Result drop-down list displays single option that of the selected test so that the image is directly attached to the test.
- - Click on Zoom button displays the magnified version of the attachment in a separate popup.
- - click on Delete button to delete the attachment.
Note:
To increase MU count User needs to upload attachments of type ‘Images' and/or of type ‘Images and Narrative' only then a MU count increments.
The types of attachments are represented as I – Image only; I/N – Image with Narrative; N – Narrative only.
A maximum of five attachments is allowed.
Save: Results can be Approved only if
a) Remarks Tab has some entry
b) Attach Tab has an attachment
c) Each of the Ordered Test has a Result entered Or Abnormal Checked.
Rad Order Results are saved. If the Login Person is a Doctor, or has Approve rights, the status is set to Complete.
If a Nurse without Approve rights enters results, status is set to Results Received and an Alert is send to the Doctor, so that he can Approve it. If the Nurse has Approve rights status is set to Complete, and Only a Notification is send to Doctor to inform him.
Status: At every step, the progress of the Rad order is monitored by the system. The Status is set automatically to R, indicating Result Received, once the results are entered and saved. It is updated to C, indicating Complete, once the doctor approves the results. When a Rad Result is subsequently reviewed, it is frozen and cannot be edited. Till then it can be edited by a person with Approve rights.
The User can come to this screen by many routes, in each case the Orders Accessible will be different.
Access Control: The User can come to this screen by many routes, in each case the Results Accessible will be different.
1. Encounter > Radiology Result.
The Orders which can be selected are the ones belonging to
Selected Patient and
Selected Encounter
Status = Results Received / Complete
2. CPOE - Radiology Result (Log in person is a Doctor)
The Orders which can be selected are the ones
whose Status = Ordered / Results Received / Complete and
Order Results is Not Reviewed and
Ignore External Rad and
Login Person = Attending Doc / Rad Ordering Doc / Primary Doc
(at the time of Ordering)
Note the results can be edited only by Rad Ordering Doc.
3. CPOE - Radiology Result (Log in person is a Nurse)
The Orders which can be selected are the ones
whose Status = Ordered / Results Received / Complete and
Order Results is Not Reviewed and
Ignore External Rad and
Selected Doctor = Attending Doc / Rad Ordering Doc / Primary Doc
(at the time of Ordering)
4. CPOE - Radiology Result (Log in person is other than a Doctor 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 = Ordered / Results Received / Complete and
Ignore External Rad and
Order Results is Not Reviewed
5. Message
If the Doctor has received an Alert / Notification for a Rad Order Result, he clicks on the message, and it bring him to this screen with ONLY ONE rad Order, namely the one referred to in the message.
Encounter TOC, Rad Result option:
A number is displayed in round brackets ( ) which indicates the count of such previously Ordered Radiology Orders whose results need to be reviewed.
User is expected to click on review Button, to enter One single, comprehensive review note for all applicable Last Radiology Orders (whose results have been Authorized) for that Patient Encounter.
save button: Click the button to save the radiology result record in PrognoCIS.
delete button: Click the button to delete the radiology result record from PrognoCIS; a prompt, confirming your delete action is displayed.
reset button: Click the button to reset the recently entered changes in the record before it was saved.
action.. button: User clicks on action button and select the rad task to be performed from the action list. This action needs to be communicated to the concern staff. The action could be e.g. Inform Patient immediately, repeat the tests.