Documenting Labs

This lesson with walk through the workflow of entering Lab results.

Creating a New Lab Result.

Creating a New Lab Result.

Click on the green + in the Labs Chart Section.

Select Template

Select Template

To alphabetically sort list click on the header Name or Description. The name of the lab is the information that was entered into the shortcut box when lab docuplate was created. The description of the lab is information that was entered into the description box when the lab docuplate was created. Highlight the desired lab template and select OK.

Document Task

Document Task

This will automatically create a Document Task item.  Click Add.

Enter Results

Enter Results
  1. Enter lab values.
  2. Enter lab tech initials.
  3. This area is a free text area used specifically for CLIA documentation. In this section please include where the lab was performed, the address of the facility, and who enter the result.  This is very important documentation.  All lab results must have this information to be CLIA compliant.

Scanning Labs Into the Labs Chart Section

Scanning Labs Into the Labs Chart Section

Scanning a patients lab result into the Labs chart section will not count as a structured lab to meet the meaningful use requirement.  When a document is scanned into the Labs chart section, users will be prompted with a Meaningful Use alert (see screenshot above).  

Users must select Yes or No to indicate if the lab test contains results that are in a positive/negative or numerical format on the scanned lab.  This will allow SOAPware to properly calculate the total number of labs during the EHR reporting period whose results are either in a positive/negative or numerical format and are incorporated as unstructured data.  

Scanning labs into SOAPware will increase the provider's denominator for this measure (the numerator will not increase unless the lab is incorporated as structured data).

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