Anatomy of a Lab Test EHR Laboratory Package for Small Sites without a Laboratory Professional Resource Patient Management System

Session Objectives At the end of this session, participants should be able to examine and describe the Anatomy of a Laboratory test and understand RPMS Lab package terminology: Test name vs. synonym vs. print name. Panel vs. single test. Data Name – Format of test results. Laboratory collection samples and collection samples. Required vs. non-required tests. Site specimen: –Reference ranges (Units of Measure).

Session Objectives (cont.) Site specimen: –Critical values (Units of Measure). –Linearity (performance ranges). Explain importance and use of Package Inserts for POC tests. –Define and use Result comments. –Define Requesting Provider. –Describe Ordering Location. –Describe Quick Order. –Describe “Point-of-Care”.

Terminology – Anatomy of a Lab Test Collection samples – Collection samples allowed for this test whether collected by laboratory or ward personnel. CPT code – Specific code needed for billing a laboratory test Critical values – The value whereby the results of the test indicate danger for a patient and require immediate intervention

Terminology – Anatomy of a Lab Test (cont.) Testing range – The range for which a laboratory test is accurate found in the package insert. The testing range describes values outside the reference range (linearity). LOINC – Specific code standardizing laboratory tests with a national data base Nature of order – Refers to how laboratory tests are ordered: Written, Policy, Verbal, Telephone

Terminology – Anatomy of a Lab Test (cont.) Ordering Location – Clinic from which the test was ordered. Package insert – An insert provided by the manufacturer included in the laboratory test kits. Panel – A group of tests ordered together under a single name i.e CBC, UA, Lytes, CMP, Lipids Point-of-Care – Diagnostic testing at or near the site of patient care. Waived tests. Print name – Short name for a test printed on a label limited to 7 characters. This prints on the interim report if the test name is greater than 14 characters.

Terminology – Anatomy of a Lab Test (cont.) Quick Order – An order that allows a care provider to order a test easily and quickly with minimum editing in the EHR. Required test – A test that when ordered must be resulted, or it remains on the incomplete test list and shows as pending in EHR. Reference ranges – Is a defined set of established normal patient values for a test that a health professional uses to interpret results.

Terminology – Anatomy of a Lab Test (cont.) Result or Canned comments –Tests can be resulted with a narrative or group of text. This can be free text or can be set up so that a few characters are entered, that expand into longer phrases. Requesting Provider – A Care provider ordering the test who assumes responsibility for the results. Single test – One test resulted with one result. Synonym – Any other name that the test may be called or searched by Test name – The name given the test in file 60, the Lab Test File

Screen shot of Lab Test in File 60 Select VA FileMan Option: Enter or Edit File Entries INPUT TO WHAT FILE: LABORATORY TEST// EDIT WHICH FIELD: ALL// –Select LABORATORY TEST NAME: GLUCOSE –NAME: GLUCOSE// –TEST COST: –Select SYNONYM: BLOOD SUGAR// ? – Answer with SYNONYM: – BLOOD SUGAR – FBS –TYPE: BOTH// –SUBSCRIPT: CHEM, HEM, TOX, SER, RIA, ETC.// –LOCATION (DATA NAME): CH;2;1// (No Editing) –Select INSTITUTION: DEMO HOSPITAL// – INSTITUTION: DEMO HOSPITAL// – ACCESSION AREA: EKTACHEM// –UNIQUE ACCESSION #: –UNIQUE COLLECTION SAMPLE: –LAB COLLECTION SAMPLE: BLOOD // ^

Screen Shot of a Lab Test in file 60 (cont.) –REQUIRED TEST: YES// –PROCEDURE (SNOMED): –*QUICK INDEX: –EXTRA LABELS: –HIGHEST URGENCY ALLOWED: ROUTINE// –FORCED URGENCY: ROUTINE// –PRINT NAME: GLUCOSE// Reserved: –PRINT CODE: –PRETTY PRINT ENTRY: –PRETTY PRINT ROUTINE: –PRINT ORDER: 12.9// –NATIONAL VA LAB CODE: –CATALOG ITEM: –EDIT CODE: –*BATCH DATA CODE: –EXECUTE ON DATA REVIEW:

Screen Shot of a Lab Test in File 60 (cont.) –Select SITE/SPECIMEN: SERUM// – SITE/SPECIMEN: SERUM// – REFERENCE LOW: 65// – REFERENCE HIGH: 105// – CRITICAL LOW: $S(AGE<1:30,1:50)// – CRITICAL HIGH: $S(AGE<1:300,1:500)// – INTERPRETATION: – 1> – UNITS: mg/dl// – TYPE OF DELTA CHECK: – DELTA VALUE: – DEFAULT VALUE: – THERAPEUTIC LOW: – THERAPEUTIC HIGH: – Select *AMIS/RCS 14-4: – CPT CODE:// – PANEL (CPT): – Select FOREIGN COMPUTER SYSTEM: – LOINC CODE: // –Select SITE/SPECIMEN:

Screen Shot of a Lab Test in File 60 (cont.) –GENERAL PROCESSING INST.: –Select LAB TEST: –Select COLLECTION SAMPLE: ? – Answer with COLLECTION SAMPLE: – BLOOD SERUM RED TOP –Select COLLECTION SAMPLE: –GENERAL WARD INSTRUCTIONS: – 1> –REQUIRED COMMENT: –DATA NAME: GLUCOSE// –CULTURE ID PREFIX: –Select VERIFY WKLD CODE: –Select ACCESSION WKLD CODE: –*ASK AMIS/CAP CODES: –COMBINE TEST DURING ORDER: –CIS TEST CODE: –Select SITE NOTES DATE:

Questions & Discussion