| SH | Social History | An understanding of past and current activities that includes significant information like Marital Status, Occupational History, Hobbies, Addictions, Activities etc. |
| VI | Vital Indicators | These include the Weight, Blood Pressure, Pulse Rate, Respiratory Rate and Body Temperature of the patient. |
| HP | History of Present Illness | A description of the patient’s present illness from the first sign and/or symptom to the present. |
| RS | Review of Systems | An examination of body systems seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. |
| PH | Physical Exam | Detailed Examination of the body parts. |
| SC | Specialty | Standard Examinations and Questions related to the Doctor's Specialty. |
| SF | Surgery Forms | Questions related to Surgery/Procedure Forms. |
| LB | Lab Tests | The various laboratory tests viz. ABO and Rh, RBC Count, WBC count etc. |
| RL | Radiology Tests | The various radiology tests viz. X-Ray, MRI etc. |
| Image | Attach Image | User selects the respective image file and then clicks on the zoom button to view the image file details to be attached. PNG, JPEG, GIF, and BMP are the type of image files that can be attached. The maximum size for attaching the image file is 4 MB. |
All these are Group Types in the Application.
The Interface to define the details is same for all the above Type
The printed form for any of these tests will have one thing in common. There is a broad Class/Category and specific tests below it. Consider Labs, the Classes/Category can be Panels, Hematology, Cultures and a number of tests under each. Like wise Review of System can have Classes like Major Body organs Heart, Eyes, and a number of specific parts / tests to be observed. On the other hand Vital Indicators are too few and may not need any Class, but no harm in defining a single Class/Category for the same.
Code: On adding a new Test, the Test code is Auto generated. User is allowed to edit the Test Code at any time. This Code is mandatory and must be unique. If the Test is of system level then the word, 'System' displays beside the code and thus a User cannot make any changes to the test.
Name: Enter the name of the test.
Type: Applicable to only Lab / Rad Tests.
The main Types are:
- Both where the Order Test / Result Test is same(retained for backward compatibility).
- Panel Test consists of Orderable Tests i.e tests with type as Both or HL7 Order.
- HL7 Order Test. These are Tests which are specified in OBR segment in HL7 Lab Order / Result. Each of this test contains one or more test of the type HL7 Order Result.
- HL7 Order Result. These are Tests which are specified in OBX segment in HL7 Lab Result
Unit: Define Unit of Measure for the test.
Sex : By default it is Both. Other options are Male and Female.
Sequence No. : While displaying all tests within a Class, they will normally appear sorted by Name. However the user might prefer to see ‘Pulse’ before ‘BP’. To facilitate this, enter a Sequence No. The actual sort order within a Class will be Sequence No., Name wise. With this mechanism it is not necessary to define the Sequence No. for all entries, nor is it necessary to have the Sequence No. unique. It can be changed any number of times, without any side effects.
LOINC Code: It is to enter the LOINC code for the test.
LOINC Code for Answer: It is to enter the LOINC code for the specific Answers list. This field is available only for Social History tests.
Result Type: To facilitate formatting tests and accepting results in a proper way, it is also important to define the type of result expected. The result type can be:
| Boolean | Yes/No e.g. Response to, Is eye site Normal? It can also be set to No / Yes (default No). |
| Numeric Range | Pulse within 0 – 200 |
| Fraction | Decimal values can be entered. e.g. Temperature 94.6F |
| Set of Values | Yellow / White / Reddish for Color of eyes/ nails. These are user defined set of values. The very first value is assumed to be the normal reading. This ensures proper validation. During test execution if the reading is any other than the first specified value, the system considers this as abnormal. |
| Multi Select | The definition part of allowed values is identical to that under Set of Values. However, in Test Execution when this test is used it will allow the user to make multiple selections. |
| Text | A narrative text upto 512 characters with no validation. Practically a user is expected to use this for smaller text of upto 30 characters, so that it is easily readable. |
| Notes | A narrative text upto 512 characters with no validation. User gets the provision of clicking on a notes button at the time of execution to pop up a large box to read the complete notes / edit them. |
| Pick List | Works like Multi Select, except that while entering results, user can also edit the selected result values. |
| Date | To accept the date. Eg. LMP. User is provided with a Calendar Icon to pop up a calendar and select a date at the time of execution. |
| When | User is provided with a Calendar Icon to pop up a calendar and select a date, or enter any Text like Jan 2000. |
| Clock Time | Saves server Date Time |
| Formula | User can define a Formula using Test Code
(of Numeric / Fraction Types), numbers and operators +-*/. User of
Brackets ( ) is also supported. E.g. (ORGWT - THISWT) * 100 / ORGWT
to get the percentage weight loss. Also, to define a result type
formula, you can specify the formula as BMI and BSA.
This formula is re-computed on every save. Additional special functions supported are: MAX(List of comma separated test Codes) MIN(List of comma separated test Codes) AVE(List of comma separated test Codes) These functions consider the Test value applicable in the current encounter being considered. Note that there are no brackets. If these key words are used. User need not remember and specify the formula to Compute the values. |
| Date Calc | User can specify a Test (of Date type) and any formula which reduces to a number. The program computes the new date considering the computed positive or negative offset. E.g. LMP + 40 * 7 to get the Estimated Delivery Date. |
| Tag | User can use any String with Tags (Patient or Encounter Tags) |
| Master Search |
User can enter any one of these Text Values, ICD, ICD:UserCategory, ICD:PREF, CPT, CPT:UserCategory, CPT:PREF, HCPC, HCPC:UserCategory, HCPC:PREF, DRUGS, DRUGS:IH, DRUGS:PREF, DRUGS:DEAXY, SUPPLIES, SUPPLIES:IH, SUPPLIES:PREF, DRUGNAME, DRUGNAME:PREF, MEDICS:ALL, MEDICS:DR, MEDICS:RD, MEDICS:RN, MEDICS:ST, MEDICS:BL, LABTEST, LABTEST:PREF, RADTEST, RADTEST:PREF, CONSULT, GROUPS:TypeCode. At the time of Test Execution i.e. Vital/HPI/ROS... entry, a Search button appears after this Test. A click on the button invokes appropriate search, so that user can select the required name of ICD/CPT/Drug as required. The selected Name becomes part of the test result. User can select up to 5 records from search. Existing selection will be overwritten. Multiple selections will be Comma separated. Note: IMO search popup is displayed with the ICD9 and ICD10 codes when the text value is ICD. |
The supported Result Types can be set using the property, Test Parameters > test.resulttypes.
Depending on the Type of result selected, the requisite fields to define the valid Numeric Range OR Valid Set of Values will be either shown or hidden.
Note that with this Structure the Test Definition is very generic. It could mean a physical test like Taking Temperature, OR it could even mean asking a Simple Question like “Number of Cigarettes smoked per day”.
If the result type is set of values or multiselect, the list can be shuffled using the Move Up and Move Down buttons.
CPT/HCPC: Click Name [+] button to invoke CPT/HCPC popup to choose codes (CPT/HCPC/SNOMED) to be assigned.
It is mandatory to specify at least one of the three names given for the disease. The user name will be used to specify this CPT/HCPC code in PrognoCIS. Since the names are imported from the External CPT/HCPC database the user is allowed to change the name according to User's nomenclature.
SNOMED: click on the button to select a SNOMED code from the Search popup.
SNOMED Search popup:
Associate either an ICD or CPT/HCPC code to search for respective SNOMED code.
ICD: Select ICD option to search for ICD associated SNOMED code.
CPT/HCPC: Select CPT/HCPC option to search for either CPT associated or HCPC associated SNOMED code.
Code Description: Select this option to either enter a SNOMED code or the description of code directly in the 'Search' field to search for results.
SNOMED code: Select this option to enter a SNOMED code directly in the 'Search' field to search for results.
Search texbox: Enter either code description or the SNOMED code according to the option selected as the criteria for search.
Search button: Click 'Search' button to display the filtered list based on the option selected.
Selected: The field displays the codes that are selected from the list.
Clear: On click, clears the selection from the ‘Selected’ field.
Group Number : For Tests having the Question Settings in property, Applicable Test Fields > applicable.test.fields.VT/HP/RS/PH/SC/SH, this field will appear. This is a mode where a set of questions belonging to a Group Number are asked. Depending on the response to each question it is possible to zoom to another set of Questions.Sub Grp: (Number) can be specified for each option of Boolean Result Type OR Set of Values Result Type. This is the Group Number Question set which will be poped up if the specific answer is chosen by the user while entering the HPI / ROS during the encounter. This can also be specified for Result type Numeric or Fraction. This is the Group Number Question set which will be poped up if the result lies outside the normal range. If the property, prognocis.zoom.anygrpno is set to N, then the subgroup number must be greater than the main group number.
Report Sentence: The user can define the format of the sentence in which this test result should be presented when used in the progress notes. This sentence can use one or more of the following tags:
- <TEST> This tag gets replaced with the test name.
- <ISARE> If the result contains multiple selections, ARE is used otherwise IS is used.
- <RESULT> Prints the test result entered.
- <REMARK> Prints the test remarks entered.
- <BOOLRESULT> This is applicable to tests with result type Boolean only. Depending upon the result, one of the two texts entered using the Special Text, button get printed.
- <UNIT> It is a test unit.
- <GENDER> The word He or She is used depending on the sex of the Patient selected.
- <HISHER> The word His or Her is used depending on the sex of the Patient selected.
- <TICK> If the test result type is Boolean and the non default option is selected, a tick mark is printed on a new line.
- <NL> New line
- <PLURAL> Appends a ‘s’, if "comma" or "and" are found in the Result Text.
- <SUBTEST> This tag can be used if there are subtests applicable. On entering data, if the user zooms to other tests from the current one, all the subtests sentences are concatenated and they replace this tag in the main test sentence. This makes it a powerful tool to build composite sentences using the nested tests.
- <CONTRA> Prints concatenated String of Results not selected from Multiselect.
- <PT xxxx> These are any of the Patient Tags used in Progress Notes. Please note that this Tag begins and ends in Square Brackets [ and ], unlike all other tags.
- All patient tags from progress notes can be used here. Please note that patient tags are with square brackets.
- Two Tags <MBULRESULT> and <MNOSRESULT> for Tests with Result Type as Multi-select. The M indicates Multi-select. The BUL indicates Bullets and NOS for serial numbers.
- The tag, <LBSOZ> prints the weight values in pounds and ounces.
Consider options selected: Sharp, Intermittent, and Radiating
Test Sentence was <NAME> is < RESULT >
Output: Pain is Sharp, Intermittent, and Radiating.
Test Sentence was <NAME> is < MBULRESULT >
Output: Pain is
- Sharp
- Intermittent
- Radiating
Output: Pain is
- Sharp
- Tearing
- Dull
Note: Proper serial numbers are assigned to
options.
If these tags are used for Tests whose result Type is NOT
Multi-select, they will be processed as normal <RESULT> tag.
There is an additional construct using a conditional statement which needs special emphasis. A test sentence can be specified as IF(=xyz^sentence1^sentence2)
This essentially means if the result satisfies the specified condition use sentence1, otherwise use sentence2.
The frist character after IF( is the operator used for evaluation).
The permitted operator are
= Equal to
> Greater than
< Less than
The string following the operator (xyz) is the one used for comparing with the current test result using the specified operator. Please note that this is a string comparison.
Sentence1will be used for printing in the report if the first condition is evaluated to be TRUE.
Sentence2 will be used for printing in the report if the first condition is evaluated to be FALSE.
Sentence1 and sentence2 can be defined using any of the above-defined tags.
The additional information required only for Lab Tests are mentioned below.
Panel Check Box: Many standard tests can be combined to form a Panel of tests. If this is checked, the fields for Result types will be hidden and a Table list appears. The test required under this panel can be defined here. Note that one test can appear under more than one Panel.
Add: Applicable to only Lab / Rad Tests.
Hide: Applicable to only Lab / Rad Tests.
CPT Code: All Lab and Radiology Tests have an associated CPT Code. Select one by clicking the adjoining button. CPT Codes can also be selected for Specialty Tests depending on property Test Parameters > test.specialty.cpt=Y.
Abnormal Phrases Button: Clicking this button, a popup opens up in which Phrases for Abnormality can be added and/or deleted.
If a test is used in any test execution, it should ideally not be modified as it can result in a change in the progress notes for an earlier closed encounter. A property, Tests Parameters> tests.used.messagetype, if set to E does not allow the user to edit the test once it has been used in any encounter. If the property was set to W the program allows the modification but warns the user accordingly.
save: Click to save the details.
delete: Click to delete the respective test.
reset: Click to reset the values of the test to the previously saved values.
replace: Click to replace the test with another test selected from the Tests search popup.
importXls: Click to import the tests from the attached xls into PrognoCIS.
Note:
This button is available only through Admin login.