Manually entering lab results on a patient's chart

You can manually enter laboratory test results on a patient's chart. This is useful if you do not receive electronic lab reports from a specific lab provider, if you received the report as a fax, if you have scanned in a paper copy of the lab report, or if you are performing the test onsite. Manually entering lab results ensures you can graph these along with the other results and you have a complete view of a patient's lab results in one location.

You can add lab results from several areas of the patient's chart, as well as from the Inbox.

Each lab result you record is combined into one lab report that is saved in the Patient Files section of the chart. You can also send a copy of the lab report to providers' inboxes for their review.

📌 Note: You must have the Patients permission to manually add lab results.

Steps

1. Open the Lab report preview window from one of the following locations:

The patient Summary > Lab Results > click the + icon.
The patient Dashboard > Quick Menu > Lab Results > click the + icon.
Start/Open > Lab Results > click +Add lab results.
Start/Open > Patient Files > open an existing PDF and click +Lab results.
From the Inbox, open a file and click +Lab results.
📌 Note: If the file in the Inbox is not yet assigned to a patient, you must search for and select the patient before the Lab report preview window will open.

2. Record the general lab report information.

Field	Description
Laboratory	The lab company that reported the results (e.g. LifeLabs, Excelleris etc.).
Accession Number	The accession number provided on the lab report.
Date Collected	The date the lab tests were collected. Type a date or select one from the calendar.
Time Collected	The time the lab tests were collected. Type a time or select one from the list.
Ordering Physician	The provider who ordered the lab tests. If the ordering provider is from your clinic, select a provider from the list. To record an ordering provider that is not in your clinic, type their name. 📌 Note: Only active users identified with a Type of Practitioner in their Account information settings appear in this list.
Reported To	The providers from your clinic who received the results. For example, if another provider was cc'd on the report. Select one or more providers from the list. 📌 Note: Only active users identified with a Type of Practitioner in their Account information settings appear in this list. To record an ordering provider that is not in your clinic, type their name in the search field. When there are no matches, click +Add "provider's name". 💡 Tip: The number of providers selected appears on the right. To remove a provider from the field, select the x beside their name.
Send lab results to the above clinic members	Sends the lab report to the Ordering Physician and all selected Reported To providers. The report is sent once you save it. Clear the checkbox if you do not want to send the lab report to the clinic members. 📌 Note: If you did not select an Ordering Physician and/or a Reported To provider from the list, a warning appears below the field indicating that Lab results will not be sent to external providers. Because the providers are not in the CHR, the lab report is not sent to them.

💡 Tip: Click Additional fields to record the Date Requested, Time Requested, Date Reported and Time Reported.

3. Click +Lab Result to add lab results to the report.

4. Complete the fields for each lab result.

📌 Note: You must record either a Result or Notes for each lab result.

Field	Description
Category	The category or summary heading of the group of lab tests. For example, hematology, microbiology, urinalysis etc. The CHR has a built-in list of categories (listed at the end of this topic). As well, any categories from electronically imported lab results are available in the list. Begin typing and select one of these existing categories. 💡 Tip: If there is no matching category, you can type your own category. Custom categories are saved for future use.
Lab Test	The name of the lab test. Begin typing the name and select the test from the list. You can search for the full name (e.g. Hemoglobin A1C) or by any lab synonyms that are configured in your CHR (e.g. HbA1C). ⚠️ Important: You can type your own lab test but, if you do this, a warning appears indicating that free-typed lab tests cannot be graphed together. We recommend selecting a lab test name from the list to ensure consistency.
Result	The lab test value.
Abnormality	If the result is abnormal, select an option from the list such as High, Very high, Very low etc.
Units	Type the lab test units such as mmol/L, U/L, % etc. 📌Note: When you start typing the units, the CHR suggests options based on what you type.
Low	Type the value of the low end of the normal range.
High	Type the value of the high end of the normal range.
Note	Enter any notes related to the result. For example, if the result is abnormal but is expected or not concerning.

5. To add another lab result, click Save & add another. When you are finished adding lab results, click Save.

6. The lab results appear at the bottom of the Lab report preview window.

💡 Tip: You can edit or delete individual lab results or the category name before saving. When you hover your cursor over the edit and delete icons, a tooltip appears and the icons change colour. For more information, refer to Editing or deleting manually entered lab results.

7. Click Save to save the lab report. The lab report appears and is saved to the Patient Files section of the chart. If you choose to send the lab results to clinic members, they receive a new message in their inbox with the lab report.

📌 Note: If you created the lab results from a file in the Inbox, the +Lab results button changes to View Lab Report.

Updated January 30, 2024

Steps

Built-in list of lab categories