Topics Procedure Search:  
Introduction: A procedure is a course of action intended for or performed on an individual with the objective of improving health, treating disease or injury, and making a diagnosis. From the Procedure screen, a provider can order a procedure for a patient, which can be performed inside the same clinic or outside in a surgery center, generate a Procedure Order for himself or any other doctor, enter results of a procedure or attach them, review those results, and quickly refer to them when needed. This can be done during a patient encounter from the Encounter TOC Procedure menu or independently from the CPOE Procedure menu at any time.

Note the following information about the Procedure Order screen:
  • When a new procedure test is added from the CPOE → Procedure menu, the procedure is attached to the patient's latest open encounter. However, if all encounters of the patient are closed, then the procedure is attached to the patient's Face Sheet encounter (FS). A user must have the required access rights in order to read, create, update, or delete the procedure from the CPOE → Procedure menu.
  • Procedures are categorized into types such as Internal (for procedures done within the clinic) and External (for procedures done in an external clinic). Procedures are "marked" as Internal or External from the Procedure Master screen.
  • The Procedure Order UI is divided into two sections: the Order Details section, which displays the Procedure Order details, and the Tabs section, where users can enter Procedure Results.
  • When the user navigates to this screen for the first time after starting an encounter, the screen loads as blank by default.
  • When a user navigates to the Procedure Order screen, the latest procedure that was either ordered or resulted in the current encounter will be loaded by default.
  • For a Procedure Order, the result is linked to the encounter in which it is added; i.e., when the user creates a Procedure Order in one encounter but adds a result for this order in another encounter, then this Procedure Result will load and be displayed by default on the Procedure Order screen in the encounter in which the result was added.
  • If there is no procedure ordered or resulted in the current encounter, but this encounter's appointment was linked to a Procedure Order while scheduling an appointment, that order will be loaded on the Procedure Order screen. If there is no such procedure, then the screen will be blank.
  • When there are two Procedure Orders in the same encounter for a patient, the order that was updated last in this encounter loads by default on this screen.
Paragraph Note Note: The Procedure Order screen provides the option to
  • Visit a patient's past ICD, Face Sheet, Document List, and Doctor Form.
  • Copy from existing procedures present in the patient's encounter.
  • Review the results of procedures performed.
  • Assign an optional CPT/HCPCS.
  • Enter review comments for the results received.
 Fields Description:

New Consult Order Add: Clicking this button invokes the Add New Procedure Order popup, which consists of two mandatory fields, Patient and Procedure, and a Type field. The Patient field displays the patient's name. The Type field with In-house and External radio buttons allows a user to select the type of procedure to be performed. The Procedure field displays the name of the procedure. Click the icon to invoke the Procedure Search popup and select the procedure to be added. Click Ok to open the Procedure Order; otherwise, click Cancel to close the popup.

Search for Consult Order Search: Clicking this button invokes the Choose the Order search popup, which displays all the Procedure Orders of the patient.

Preview Icon Preview: Clicking this icon for Procedure Orders displays the details of the Procedure Orders (with the statuses Entered, Approved, or Ordered), followed by the pre-procedural details. Clicking this icon for Procedure Results (with the status Result Received) displays the Procedure Order details, followed by attachments (if available), and pre-procedural details (if a print template is available). If the user does not answer any tests and does not add any notes from the Procedure Order Notes Icon Notes icon, but attaches a file using the Attachment button on the Attachment tab, then clicking the Preview icon displays only the attachment in the Procedure Order preview popup.

Icon for Print Order Print: Click this icon to print the Procedure Order.

Icon for FAX Order Fax: Click this icon to send the Procedure Order via fax.

Icon for emailing Order Email: Click this icon to send the Procedure Order via email.

Navigation Arrows: Click the navigation arrows to switch between orders.

Properties: This button is visible only to users with read access to the Properties Master screen. Access to this button is granted to enhance user functionality. Clicking the Properties button opens a popup presenting a list of properties from the Properties Master screen in PrognoCIS that cater to procedures.

Order Details

The Order Details tab displays the Procedure Order details.

Procedure Name: Displays the name of the selected Procedure Order.

Icons: Separate icons for In-House and External Procedure orders are displayed next to the Procedure Name field. Here,
  • Icon - External Procedure Orders
  • Icon - In-House Procedure Orders
1 Visit hyperlink: The 1 Visit hyperlink is visible when the property ordersheet.freqsession.visit.setblank is turned Off, and the value of the Total Visit field defaults to 1 in the popup invoked by clicking this hyperlink. This default value appears as a hyperlink, allowing users to edit it if necessary. The functionality of the default value is governed by the state of the ordersheet.freqsession.visit.setblank property.

Scheduled Date: This field displays the date for which the Procedure Order is scheduled. By default, this field is blank. When the Order Status of the Procedure Order changes to Ordered (Printed/Faxed/Emailed), the Scheduled Date label becomes a hyperlink and the field is grayed out. If the Scheduled Date was not selected while ordering a procedure, the Scheduled Date field autopopulates with today's date. Click the hyperlink to invoke the Calendar popup and select another date. The selected date is displayed in the Scheduled Date field. The Scheduled Date cannot be backdated. The date in this field can be changed only until the Order Status of the Procedure Order is Ordered (Printed/Faxed/Emailed), after which the hyperlink is removed. By default, the date on which the Procedure Order is generated is set as the Scheduled Date.

Note: The Scheduled Date cannot be changed if the "Type" is set to "Stat".

The fields such as Actual Date, Performed By, Order By, Reason, and the ICD link remain editable for orders with the statuses 'Entered' and 'Approved'. Once results are entered or attached, only the Performed By and Actual Date fields are editable. Clicking the Patient Name link navigates to the patient's Face Sheet.

PreAuth Status: This field displays the current status of the pre-authorization (PreAuth). For this field to appear, the following prerequisites must be met:
  1. The property prognocis.rfa.enabled must be set to On.
  2. The property rfa.order.types must include PR - Procedure.
  3. The Requires Authorization checkbox must be selected for the Encounter Type used in the encounter (configured in the Encounter Types Master screen).
When a new lab procedure is created, the PreAuth Status displays as Unprocessed. As the RFA progresses, the RFA Response Status selected on the PreAuth Tracking screen is reflected next to this label. If a test from the Settings → Configuration → PreAuth Exception list is ordered, the PreAuth Status displays PA Not Required. If multiple tests have different RFA Response Statuses, a comma-separated list of statuses is displayed. The possible statuses that can appear include: Appeal, Appeal Sent, Approved, Denied, InProcess, Modified, PA Not Required, Pended, RFA Sent, Sandhagen, and Withdrawn.

For the statuses Complete and Reviewed, none of the fields remain editable. For order statuses and their descriptions, refer to the following table.

Sr.No.
Status
Description
1. Entered The order is created, and the user does not have approval rights.
2. Approved The order has been approved; the user has the required approval rights.
3. Ordered The order has been sent via print or fax. If the HylaFAX property prognocis.fax.hylafaxapi is turned On on the Properties Master screen, the Procedure Order is sent via the HylaFAX functionality. In this case, the status of the order can be viewed by clicking the hyperlinked Order Status, which invokes the Status popup.
4. Results Received Results for the order have been entered or attached.
5. Complete & Reviewed The order has been reviewed.
6. Deleted The order has been deleted.

Checklist tab, Procedure tab and Attachments tab

Results are added from these three tabs.
The newly created order displays the order details with the status 'Entered'—unless the user has access rights defined for CPOE, in which case the order status displays as 'Approved'.
The order status changes from 'Entered' or 'Approved' to 'Results Received' if the procedural form details are entered and saved, and also if any attachments are added to the order form and saved on the Attachments tab.

The Procedure tab for an external procedure displays a text editor with editable fields such as Subject (only if the status is 'Entered' or 'Approved'), the Fax Coversheet option, and Attach (only if the status is 'Entered' or 'Approved'). The functionality of the Procedure tab is similar to the existing functionality of Letters-Out. The text area displays the Letter Template HTML associated with the Procedure (External) Master. It is possible to edit the procedure notes only if the status of the order is 'Entered' or 'Approved'. Notes entered in this tab are displayed in the Procedure Note section of the patient's Health Summary. The Attach icon, on click invokes Document List Search to choose an attachment from. A Refresh icon is present on the Procedure tab for external procedures. For open encounters with the Entered or Approved order status, this icon is enabled, whereas for closed encounters with the order status Ordered (Printed/Faxed/Emailed) or above, this icon remains disabled. Click the Refresh icon to see a message in a popup on the Procedure Order screen. This message reads: Do you want to recreate the letter template? Any information that was added manually in the letter content will be lost. The Yes, No, and Cancel buttons are shown with this message. If the user clicks the Yes button, the message popup closes and the following actions occur: the data added in the header section of the Procedure Order is saved; the Letter Template is updated with the data saved in the header section of the Procedure Order; and the updated Letter Template is saved on the Procedure Order. If the user clicks the No button, the message popup closes, the data added in the header section of the Procedure Order is saved in the header section, and no further actions occur. If the user clicks the Cancel button, the message popup closes and no changes are made to the screen.

The Procedure tab for an internal procedure displays columns such as Elements, Result, Abn, and Remarks. The user can enter results here.

The Pre-Procedural tab remains disabled if the procedure does not have an associated Pre-Procedural template. The Pre-Procedural tab is available for entering details if the procedure has an associated Pre-Procedural template.

Note for the paragraphNote: Filling and saving a Pre-Procedural form does not affect the order status (i.e., there is no change in the status of the order).
ICD: Users can assign ICD codes from the Patient Assessment screen by clicking this hyperlink.

Note:
  • The limit for the number of ICDs that can be assigned is defined in the property order.assign.max.icds. This is an admin-level property, and values can be entered in the range of 4 to 25. The default value is set to 25.
  • The total number of ICDs will be selected automatically depending on the rule set in the property order.assign.icds.rule and the value entered in the property order.assign.max.icds.
    For example, if the value of the property order.assign.icds.rule is set to "A" and the value of the property order.assign.max.icds is set to 10, then only the first 10 ICDs from the entire list (Assign ICD popup) will be selected automatically.

Type: The Type dropdown displays the options Routine and Stat. By default, the value set in the Type dropdown is Routine.

Optional CPT or HCPC CPT/HCPCS button: The CPT/HCPCS button is enabled if the procedural template has optional CPT/HCPCS codes assigned.

Past ICD Past ICD icon: Clicking the Past ICDs icon displays the list of past ICDs associated with the encounter.

Face Sheet Face Sheet icon: Clicking the Face Sheet icon displays the Encounter Face Sheet.

Document List icon Document List icon: Clicking the Document List icon displays the document list associated with the patient.

Copy Procedure Icon Copy icon: Clicking the Copy icon displays the list of procedures ordered in the past.

Procedure Order Notes Icon Notes icon: Clicking the Notes icon invokes the Notes popup to add comments regarding the selected procedure.

Doctor icon: The Doctor Form icon is enabled if the procedural template has an associated doctor form.

Reveiw Order Icon Review icon: The Review icon is enabled when the order status is 'Results Received' and, when clicked, invokes a popup to enter review notes.

Hint for the given section Hint:

v The templates used are the Procedure Order Template (as selected in the Procedure Master) and the Pre-Procedural template (assigned in Clinic Forms). If the print template of the Procedure Order is not defined, the system uses the default template for preview and print. If the print template of the Pre-Procedural form is not defined, then the Pre-Procedural details are not displayed in the preview and print.
v No fax, email, or download options are available for internal procedures.
vWhen a new procedure is added from CPOE → Procedure, the procedure is attached to the patient's latest open encounter. However, if all encounters are closed, the procedure is attached to the Face Sheet encounter (FS).
vA user must have the required access rights to read, create, update, or delete a procedure from the CPOE menu.

Action buttons

Save: Clicking the Save button either creates a new record if it does not exist or updates the changes in an existing record.

Delete: Clicking the Delete button invokes a prompt to confirm deletion of the record. The system deletes the record if the Ok button is clicked.

Reset: Clicking the Reset button reverts the field values to the last saved changes.

*Fields marked with an asterisk (*) are mandatory.

Note: The property enc.procedure.order.tags determines the list of fields to be printed for procedure tags ENC_PROH_TAGS_TBL$, ENC_PROH_TAGS_STR1$, ENC_PROH_TAGS_STR2$, and ENC_PROH_TAGS_STR3$, along with their Title, Tag, and Extension (if applicable).
See Also: Protocol | Procedure | Lab Order | Radiology Order |