Clinical -Investigations

Clinical - Investigations

In this article, you will learn how to manage a patient's medical investigations, create new requests and results, and edit, delete and change the status of existing requests and lab results from pathology and radiology providers. You are also able to create custom groups of tests and findings.

The Investigations page in a patient's clinical record displays a summary of the requests for investigation and lab results from pathology and radiology providers. There are two sections within the Investigations page - Requests and Results - and each of these sections will be covered individually in this tutorial.

 

Requests

By default, Investigations lands on the Requests section of the patient's Investigations summary. The summary displays a list of all investigation requests recorded for that patient. From here, you can quickly review the date, test name, requester, urgency and status of existing requests. 

Both outstanding, partially received and completed requests are visible in the summary. The progress of requests is reflected in the Status in the Investigations summary.

To Filter the Requests, click Filter to reveal a drop-down list, and select a filter from Type or Status, or a combination of both.

To search for a Request, click the Search box and type in a keyword from the Test Name. Press Enter and the system will display a list of the closest matches.
You can also search by Requested by and Provider.

 

Create a New Pathology Request

To Add a New Pathology Request, click New Pathology to open the pathology request form.

On the top half of the pathology request form, you can select or change the provider, requester and billing details. On the bottom half, you select the tests and clinical information that you are going to share with the pathology provider.

*NOTE: The pathology form will load with the patient's name, the default pathology service provider for your clinic, and your username as the requester. The patient's name cannot be changed; however, you can select your pathology service provider, and assign the request to another MediRecords user at your clinic.

To change the service provider, click on Service Provider and input some of the names of the provider you are looking for.

If you would like to scroll through a list, delete the input in the box and a list which you can scroll through is usable.

To assign the request to another user at your clinic, click Requested By to reveal a drop-down list of MediRecords users at your clinic.

To flag the request as urgent, click Priority to reveal a small drop-down form and select Urgent.

Definition of priorities based on their immediacy:
Routine - Normal priority
Urgent - A higher priority than Routine
ASAP - A higher priority than Urgent
STAT - Highest possible priority. E.g. an emergency

Complete the necessary fields for Priority Due By, Priority Phone and Priority Fax, and then click Save Urgency.

To change the billing method for the request, click Billing to reveal a drop-down list of billing options.

To adjust the order date, click the Calendar Icon to reveal a drop-down calendar.
To send the results to additional recipients, click Copies To reveal a drop-down list of Contacts. To send a copy of the results to the patient, click the Copy to Patient tick-box.

To select the tests for the pathology request, double-click the Test Name and it will appear in the opposite column. You can add multiple tests to the request.

 

To remove a test from the list, click the X next to the name.

To add a custom test to the request, click Custom Test and type in the Name of the Test. 
Press Enter and the test will appear in the list of tests in the request.

To add a set of tests to your favourites list, press and hold the Ctrl key (Control Key) and click the Names of the Tests to highlight the ones you want to add.

Click More to reveal a small drop-down form. Choose and type in a Name for a favourite, and then click OK.

 

The combination of tests will now be available as a Favourite in future pathology requests. Click All Requests to reveal a drop-down list and select Favourites.

To add the request to Today's Notes, click the Add to Today's Notes tick-box. To make the record of the request confidential, so that only you can see it, click the Confidential tick-box. 

To add details of a Cervical Screening, click Cervical Screening to reveal a small pop-up form. Complete the form with all the required details. Once you move your mouse away from the form or click on another part of the pathology request form, the pap test form will save your selections and close. 

To add details of the patient's condition or clinical findings to the request, double-click the name of the clinical finding and it will appear in the opposite column. You can add multiple clinical findings to the request. 

To remove a Clinical Finding from the list, click the X next to the name.

To add a set of clinical findings to your favourites list, press and hold the Ctrl key (Control Key) and click the Names of the Tests to highlight the ones you want to add.

 

Click More to reveal a small drop-down form. Choose and type in a Name for your favourite, and then click OK. 

The combination of Clinical Findings will now be available as a favourite in future pathology requests. Click All Findings to reveal a drop-down list and select Favourite.

If the patient is pregnant, click the Pregnant tick-box, and click the Calendar Icons to add the dates of the EDC (Estimated Date of Conception) and the LMP (Last Menstrual Period).

To set a reminder, click the Reminder tick-box, and click the Calendar Icon to add the reminder date.

Once the pathology request form is complete, click Save to open a print preview.

Once the form is Saved, the request will be visible in the Investigations summary.

 

To Print the request, tick the box next to the request and click More. Choose Print from the options and make sure the page is going to the right printer Destination, select Layout and Color if required, and click Print.

 

Create a New Radiology Request

To Add a New Radiology Request, click New Radiology to open the radiology request form.

The radiology request form is identical in its functionality to the pathology request form. The only difference is that tests relate to those available from the radiology provider, there is no Cervical Screening button, and you can request tests to the Left or Right Side of the body. 

 

Complete the form with all the required details and click Save to save the request or Save as Draft to save as a Draft.

Once the form is Saved, the request will be visible in the Investigations summary.

*NOTE: Once a request has been saved, the content cannot be edited, and the requested tests and chosen service provider cannot be altered. Existing requests can be opened to review the details of the request only.

*NOTE: You can only make amendments to a request if it's on Draft status and it hasn't been taken to the provider yet.

*NOTE: You can delete the request, and then create a new one. If you require additional tests for an existing request, you can either create a new request with the additional tests on it (which means you will receive the results separately from the provider). Or you can cancel the existing request with the provider, delete the request from the patient's record, and then create a new request with all the tests on it.

To Open a Request (either pathology or radiology) hover your mouse over the test name of the condition. When the mouse cursor changes to a Finger Pointer, click the Test Name to open the request.

Alternatively, click the tick-box next to the name of the to reveal a list of options. Click Open to view the details of the request.

Once you have finished reviewing the request, click X in the right-hand corner to close the form. 

To Delete a Request, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the request from the patient's record.

Click Yes to acknowledge the request will be deleted.

To Delete Multiple Requests at Once, click the Tick-boxes next to the names to reveal a list of options. Click Delete to permanently delete the requests from the patient's record.

Click Yes to acknowledge the requests will be deleted.

To Change the Status of a Request, click the Tickbox next to the name to reveal a list of options. Click Update Status to reveal a drop-down list, and select Outstanding, Partially Received or Fully Received.

*NOTE: You can only change the status of a request if they are currently in Draft and Outstanding status.

To Print a Request, click the Tickbox next to the name to reveal a list of options. Click More to reveal a drop-down list and click Print to open a print preview.

To Print Multiple Requests, click the Tick-boxes next to the names to reveal a list of options. Click More to reveal a drop-down list and click Print to open a print preview.

*NOTE: Make sure the page is going to the right printer Destination, select Layout and Color if required, and click Print.

Results

To switch to the Results section of the Investigations summary, click Results.

The Results section displays a list of all results that have been received and recorded for that patient. From here, you can quickly review the date, test name, requester, the provider that checked the results, the date it was checked and the status and any outstanding actions that are required.

The Filter functionality of Results is identical to the filter in Requests, however, in Results you can filter by Type, Status and Workflow Steps, or a combination of all three.

The Search functionality in Results is identical the one in Requests, however in Results you search for results using either the Test Name or the Provider Name that requested the results.

 

To Add a New Result, click New Result to open the results form. The results form will load with the Patient name, and your name as the user that Ordered the results.

*NOTE: The patient's name cannot be altered, however you can change the name of the user that Ordered the results.

The rest of the results form can be completed using simple drop-down lists, which are revealed by clicking the field name, or the Down Arrow next to the field name. The date fields can be changed by clicking the Calendar Icon, or manually typing in the date in DD/MM/YYYY format.

If you want to make the record confidential, so that only you can see it, click the Confidential tick-box. You can use free text to add details of the Tests, Results and Comments.

 

Scroll to the bottom of the form.

If you want to attach a file, like pathology results or X-rays, to save with the record, click Select files... to open a file explorer. Click to the select the file you want to upload. 

*NOTE: Supported document types: pdf, Png, jpg, and txt. Maximum allowed fil size is 20MB.

Once you have completed the results form, and imported any attachments (if required), click Save.
The newly created result will now appear in the Investigations summary!

To Open a Result, hover your mouse over the test name. When the mouse cursor changes to a Finger Pointer, click the Test Name to open the results.

To Edit a Result, click the Tick-box next to the name to reveal a list of options. Click Edit to open the results form.

Edit the form as required, and scroll to the bottom of the form, and click Save to apply the changes.  
To Delete a Result, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the result from the patient's record. Click Yes to acknowledge the result will be deleted.

To Update the Status of a Result, click the Tick-box next to the name to reveal a list of options. Click Update Status to reveal a drop-down list, and select Normal, Abnormal, Stable, Acceptable, Unacceptable or Being Treated.

 

To Mark a Result as Patient Notified, click the Tick-box next to name to reveal a list of options. Click More to reveal a drop-down list, and click Patient Notified.

To Mark a Result as Checked, click the Tick-box next to name to reveal a list of options. Click More to reveal a drop-down list and select Checked.

To Create a Clinical Action Regarding a Result, click the Tick-box next to name to reveal a list of options. Click More to reveal a drop-down list and click Create Clinical Action to open the clinical action form.
 
The clinical action form loads with the Owner, Type, Reason, Regarding (Patient), Due Date and Repeat fields filled in. All of these fields, excluding Regarding, can be changed by clicking the Down Arrow next to the field name. The Due Date can be changed by clicking the Calendar Icon.
Complete the clinical action form by adding a Reason and filling in details as you need, then click Save.

For more information on Clinical Actions and Tasks, please visit the Patient Activities Support Page.

To Print the Attachments of a Result, click the Tick-box next to name to reveal a list of options. Click More to reveal a drop-down list and click Print to open a print preview.

Check to make sure the page is going to the right printer Destination, select the Layout and Color if required, and then click Print.

To Print Multiple Results Attachments at Once, click the Tick-boxes next to the names to reveal a list of options. Click More to reveal a drop-down list and click Print to open a print preview.

 

The MediRecords App

TheMediRecords App has been designed so that patients can review their results as they get added to their clinical record. However, there are times when doctors may want to discuss results of the test face-to-face, particularly in cases where the results contain sensitive information about the patient's condition. Marking a result as Confidential will stop it from being sent to the patient mobile app. 

To Stop New Results being Sent to the MediRecords App, click the Confidential tick-box at the time the records are created.
To Stop Existing Results being Seen in the MediRecords App, open the record and click the Confidential tick-box.