Most of the clinics nowadays have an integrated lab which is aimed at making the life of a patient easier. Those old days, when a doctor would order investigations and then by the time patient comes back with the report, the doctor would have lost all tracks of the patient thus leading to start from scratch, are over. With the advancement in the healthcare industry and people getting more conscious about their health, its time for the providers to step up and make sure they come up with all those things that could make a patients life easier. Also, at the same time, a properly maintained lab can ensure more revenue for the clinic.
With Clinicea, maintaining an in-house laboratory has become very simple. The entire workflow of Investigations, from ordering the investigation to the sample being collected, recording of the result, result getting reviewed by the practitioner and calling the patient for a follow-up, all this can be managed from one single screen with Clinicea. Also, tracking investigation details of a patient, be it yesterday or 5 years back, can be easily done with the help of a powerful Search feature. Here is how you can simply do it in 5 steps:
Step 1: Order Investigations
A practitioner would order the investigations to a patient from the EMR. This can be easily done by adding the Investigations clinical section to the Case Sheet where the patient visit is being recorded. Now, click on the + button beside Investigations and this will populate a set of all the investigations that are there in the clinic. Add the investigations that you want to order to the patient by clicking on the + button beside the respective investigations. For a step by step guidance on how to order investigations, you can refer to How to Order Investigations.
Once the visit has been recorded, all the investigations that have been ordered will be auto-populated on the screen of the lab technician without having to inform him/her in person. Now, the question is where should the lab technician start from. Simply imagine that a blood test has been ordered and visualize the sequence events that should follow.First, the sample of the blood needs to be collected. The collected sample can either be tested in the clinic itself or may be sent to a third-party Lab to conduct the tests and provide the clinic with the results to be recorded. This introduces step 2 of managing Investigations- Collect Sample.
Step 2: Collect Sample
Here, the lab technician will click on the name of the Investigation for which the sample is being collected as depicted in the above image. For example, to collect the sample for CBC blood test of patient Rahul Srivastav, the technician will simply go ahead and click on the investigation name listed below the respective patient.
The purpose of this section is to formally record the name of patient, investigation name, sample reference number and name of staff collecting the sample. There are other details also like the Lab name this sample should be sent to, the specimen that should be collected ex: urine, blood, stool etc. All of this information appears only if set in Investigations. Put in some notes if required.
Once the details have been put in click on print, it will provide a small sticker with all the relevant details (as shown in the above image) to paste to the container with the collected sample for easy reference purpose in the future. As soon as the sample is collected, the respective investigation name will be removed from Collect Sample Section to prevent any duplicacy and confusion amongst the staff members.
Step 3: Record Result
This section helps very systematically record the various observations of an investigation conducted on a particular patient.Once clicked on this tab, it will provide with a display similar to that of Collect Sample. Simply click on an investigation name to start recording the result. The following screen is provided to continue with rest of the process:
As visible from the image, recording the result of an investigation is made very simple with Clinicea. It will automatically fetch the investigation name, the date when it was ordered by the practitioner, the date when it is being recorded and the name of the practitioner. The record date can be changed if needed. Apart from this, there are five sections for systematically recording all the details of an investigation which are as follows:
Result: This is a drop-down to select the summarized result of the investigation which may vary amongst Normal, Abnormal, or Borderline. Other options provided are Recorded and Not Recorded.
Scanned Report: There are often investigations which have separate report cards generated, for example, electrocardiogram which has a detailed report to go through and just putting Abnormal or Normal won’t add much value. For that simply scan the report produced and then upload it from this section of the respective investigation. The uploaded data would be safely saved for future reference purpose.
Table: Put in the readings of the parameters that have been examined. In case the parameter being recorded has a numeric value it can be very simply understood if the same for the patient is normal or abnormal provided you set a reference range while creating the clinical item parameter.
Text: There are some investigations which do not require such parameters being examined. For example, Radiology investigations are ones wherein the Radiologist have to go through test results and put in the observations in text format in writing. For that, you will simply need to select the Text tab and write in the respective observations.
Notes: In case there are some notes to put in for future reference, though they might not necessarily be a part of the observation, put in the same over here in the Notes field specifically designed for this purpose.
Apart from this, there is also Critical Lab Result for recording the details of how the critical results (results that have a high impact on patient health) were handled by the staff members. This will help in accountability of staff members and also in future should there be any case which accuses your clinic of mishandling the reports.
Once the details of the investigation have been recorded, save the result. Once saved, it will automatically be showing in the Medical Summary of the patient under Last 5 Investigations. This is not all. These investigations showing in Medical Summary of the patient will be color-coded according to the criticality of the same. For Normal they will be displayed in green, for Abnormal in red, for Borderline in Yellow, for Recorded in Blue and for Not Recorded in Grey. One click on the investigation name from the Medical Summary will automatically redirect the practitoner to the same screen where the result was recorded for easy reference of reports from the EMR.
Step 4: In-Tray
Once the result of an investigation has been recorded by the lab technician and saved, the same will be moved to In-Tray section of Investigations. This section is solely for the practitioner to go through the recorded result of the patient and take a decision on whether the same needs to be called for follow up or not. Either of this can be done very easily with just one click.
If the patient has to be called for a Follow-up, just click on Follow Up button. This will provide the practitioner with a small text window to put in some notes for the nurse who would be following up the patient and save. Once done the Investigation would be moved to the Follow Up section.
If there is no need to call the patient for a follow-up, select NAD which insinuates ‘No Abnormality Detected’.
Step 5: Follow Up
This section is for the staff who is vested with the task of following up with the patients called for the same. Select the name of the Investigation, similar to how it is done for Collect Sample or Record Result. Once selected, it will redirect the staff to an interface similar to the Record Result along with a flyout to put in notes pertaining to the follow-up and also there is a drop-down to select the status of the follow-up: Due, Completed or Dismissed. That’s it. Once done, save the page. In case the status of follow-up as kept Due, it will continue to show in the list of pending follow-ups otherwise it will be moved from the queue.
This result can be searched for any time by searching with the name of the patient and selecting the required investigation name.
This covers the entire flow of Investigation- from the investigation being ordered to the same being followed up.
Clinicea also supports investigation recording for walk-in patients should you cater to them. The core work-flow would remain the same barring the first part of ordering investigations from the EMR. In this case, the receptionist can directly bill the walk-in patient for the investigations to be done using the Bill Investigation Orders tab in Investigations section. For more information regarding the same, please refer to How to Bill Investigation Orders