What steps do I need to take when reviewing my pathology or lab reports?

PENDING REVIEW

1. Go to Inbox > Pending Review on the EHR (iPad) to see all orders for which results have come in but have not yet been signed off on
2. Swipe from right to left on an order to preview the result and requisition
3. Tap on the order to be reviewed
4. Tap on the location (A1, B2, C3, etc.) to open up the review screen

Note: Tapping the patient’s name in red will take you to their chart.

DETERMINING NEXT STEPS

The review screen is used to do things like add the diagnosis to the patient’s chart (ASSESSMENT), select a follow up treatment plan for the patient if applicable (PLAN), create To Do tasks for your staff (TO DO), address any available MACRA measures (MACRA), and generate a letter to the referring or primary care physician if desired (REFERRAL) all on one screen.

1. Under ASSESSMENT, change the Diagnosis to the diagnosis to be recorded in the patient’s chart (you can view the result PDF by clicking Result Preview in the bottom left)
2. If you want to mark this problem Resolved right away (no follow-up required) do so in the Problem Status field
3. If needed, add a follow-up plan for treatment by clicking on Add New Plan under PLAN (this will place that patient in the Planned folder in the Inbox after sign off)
4. Create a TO DO task for your staff to contact the patient (to communicate the results to the patient and/or schedule the patient for a follow-up procedure)
5. If the patient has any available MACRA measures, toggle each switch on/off depending on whether or not you met the measure requirements (if measures are not addressed here, they will need to be addressed back in the progress note from that date of service)
6. If needed, add a letter under REFERRAL to have the system generate a letter with the results to be shared with the primary care or referring physician (this will place that letter into Inbox > Referrals after sign off)
7. Click Save as Template at the bottom of the screen if this is a standard way you would like to fill out the review screen in the future

SIGNING OFF

Once the review screen has been filled out according to the steps above and you are prepared to create a record of this diagnosis in the patient’s chart, click Done in the upper right-hand corner to sign off on this report. Once you click Continue, the order will go into Inbox > Archive and the result will be locked. If you do not wish to sign off, click Cancel. Once signed off, the order cannot be moved back into Pending Review.

Once the result has been signed off:

1. The system will create a virtual encounter (which can be found in the patient’s chart under Encounters > Virtual) that includes the diagnosis selected in the review screen
2. If a treatment plan was chosen in the review screen, the patient will go into Inbox > Planned
3. Any To Do tasks added in the review screen will go to the assignee’s To Do folder
4. Any referral letters added from the review screen will go into Inbox > Referrals

REVIEW TEMPLATES

Review templates speed up the review process by populating the review screen automatically with some predefined information such as a diagnosis, treatment plan, and To Do task for your staff. For example, I can save a template for when I get a result of a BCC where the Diagnosis is BCC, the plan is Excision of BCC, and the To Do task asks my staff to call the patient to share the results and schedule an excision. That way, when I get a result of a BCC, I can populate the review screen with these details from my templates rather than having to fill out each section of the review screen one by one.

To save a template, fill out the review screen to your liking and click Save as Template at the bottom of the review screen.

To use a template, click Populate From Templates under ASSESSMENT and choose that template. The review screen will then pre-populate based on your template settings.

To edit a template, click Populate from Templates and click the red "i" to the far right of the template you want to edit.

MULTIPLE DIAGNOSES

You have the ability to add multiple diagnoses for the site you are reviewing by clicking Problem List in the bottom left-hand corner and Add Problem. The system will duplicate the initial problem, but click the second problem to be taken to the second review screen where you can change the Diagnosis. For example, if the patient has a result that states two possible diagnoses (Hypertrophic Actinic Keratosis with possible features of Squamous Cell Carcinoma in situ), you can diagnose and create next steps for both problems from two different review screens.

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