Adding an order (or visit)

To be able to add an order, a patient needs to be registered first.  (Captured into the RIS system with limited information or complete information and/or an existing patient should have been searched and verified before adding an order.)

Different scenarios

• New patient
  • For a new patient, limited information capturing: - once mandatory information for the patient and payment method has been completed.
  • Click ‘Save and Close’ to open Order Entry page.

• In this case, (limited info entered) the system will prompt the user to complete all information.  You can bypass this instruction by selecting YES.  (NB: should only be used if you are capturing with limited info when complete information is not available)  The order entry page will populate where order information will be captured.

• For a new patient, complete information capturing: - once all patient information, payment information, complete guarantor information and addresses, employer information are completed, click ‘Save and Close’ to open the Order Entry page. 
  • In this case, the system will only prompt the user when continuing from medical aid page to guarantor page to employer page to complete information if the user failed to complete all fields.  In this case, select NO and review your information entry to ensure that all fields are completed before continuing to the Order Entry.

• For an existing patient: - regardless whether limited or complete information has been provided for this entry, verify and modify all fields (patient information, payment information, guarantor information, employer information as well as next of kin (if applicable)) before continuing to Order entry. 
  • After verifying and updating Patient information, Payment method, Guarantor information, Employer and Next of kin, click ‘Save and Close’ to launch the Order Entry page.  In this case, the system will only prompt the user to complete information if the user fails to complete all fields. Click NO and review the information before entering the Order information. Click Save and Close to revert to the Order Entry page, where order information will be captured.

NOTE:  Minimum mandatory information needed when adding an order

For schedule entry only: -

• Referral physician
• Procedure (examination)

For complete capturing: -

• Referral physician
• Priority
• Mobility (if applicable)
• Patient Class
• Hospital number (if applicable)
• Ward (if applicable)
• Procedure (examination)

Capture the order:

On the Order Entry page, select:-

• +Add Procedure 

A list of Protocols to select from will display.

(Note that the modality is greyed out. The list of available protocols will be determined by the modality of the station you have selected on the scheduler when capturing the patient. For example, if you have selected a time slot in the CT column on the Schedule Chart, only CT protocols will be available to select from).

• Select a required protocol by adding a key word in the description and search.

All available and combination protocols for the specific modality and search criteria will be reflected.  (Refrain from using ‘Multi-region’ – this should only be used in rare cases where a combination protocol is not available.)

• Select the protocol required and click Add.  (Note: if you select more than one protocol, a 'job card' will be created for each selected protocol.  Bear in mind that default combination protocols have already be created.  Always select a combination for multiple studies required as far as possible)

• The selected protocol will be added to the order.  The protocol will reflect in Red.  This is an indication for the user that there are mandatory fields missing.  You will not be able to Save and Close this entry until all mandatory information has been completed. 

(The selection can be modified by selecting the protocol name and click on remove - a new selection can be done as described above) 

• Enter the Physician Information 
  • Type the surname of at least the first 3 letters of the surname, a list of possible referral physicians will be visible. 

• Select the required physician by clicking once on the name, the physician's information will be added to the order.  (Note that the Protocol name changed to blue when the referral physician has been added.  Depending on the practice's requirements, if an ICD10 code is marked as mandatory information by the practice, the protocol will reflect red until the referral physician and the ICD10 code are entered. )

• Enter all other fields depending on the availability of the information and the need to enter the information. 
  • Possible entries:
    • Priority (default = ROUTINE) - select from dropdown list.
    • Patient Class (default = OUTPATIENT) - select from dropdown list.
    • Hospital # (no default - free typing field)
    • Mobility (default = WALKING) - select from dropdown list. 
    • Department (default selected according to the department selected on the Schedule Chart)
    • Ward (no default) - select from dropdown list. 
    • Internal Status (default = Anything) - select from dropdown list (selections are customizable according to practice requirements. 
    • Follow up Status (no default) - select from dropdown list
    • Order date (auto selected according to the date the order are created) 
    • Order Reason (no default) - Order reason can be created as a dropdown or free typing according to practice requirements. (currently not in use)
    • Internal notes (free typing field) - this information is not visible on any other pages.  (currently not in use) 
    • Comments (free typing field) - this field will be visible on the Radiology worklist, Visit properties and other financial pages.  The information entered in this area should be financial information only.  Eg.  Authorization information and/or payment arrangements with the patient and/or arrangements with the Medical Aid. 
    • Authorization# (greyed out for all modalities where authorization is not required) - Authorization number can be entered for CT, MR and or other protocols where auth is required. 

• Questionnaire - digital questionnaire not in use

• Prep.Instructions 
  • These are for information purposes only.  If no questionnaire or Prep-instructions have been as part of the configuration for the specific selected protocol, there will not be any information to view.  
  • For Prep. Instructions entered, select the button to view the prep instructions.  This will help the receptionist during the booking process to inform the patient of any preparation to be done before the examination. 

• Diagnostic Code (ICD10) - for most practices the entering of an ICD10 code at reception is mandatory (in this case, the Protocol will flag red if not entered and you wil not be able to complete the order entry)
  • Select the Diagnosis Code button to enable the user to select ICD10 codes for the visit. 
  • Enter the ICD10 Code if know or search by description 
  • Click search to view all possible ICD10 codes for the criteria entered.

• Select the ICD10 code on the left and use the > (arrow) to push the ICD10 from the library onto the active field on the R. 
• Click Apply

With all the required information added, the order can be completed.

You can complete the order by using:

• Save and Close
• Order Modify
• Check In

• Using Save and Close
  • This option will save the entered information and place the order into the selected timeslot on the Schedule chart in a Scheduled status without requiring any immediate further action.  
    • To perform any other actions with the saved order 
      • Use the R-click option and select the action 
      • Click on the Patient's name to open Visit Properties to update information 
      • Click on the Accession number to open the Order modify page to modify information. (see following point on using order modify for more information on this action)

• Using Order Modify
  • The system will save the ordered schedule into the selected timeslot on the Schedule Chart (as per above example) and open the Order Modify page.  
    • This option will be used when you need to:
      • scan document,
      • print documents
      • add an auth number
      • change the auth status or modify any of the preselected entries
      • add Order Comments
      • adjust the fee lines in the Exp charge

• Select Save and Close after all additional information has been added or modified.  The order entry on the Schedule Chart will be in Scheduled status.

• Use Check in
  • This action will do one of two things:
  • 1.  Check the patient in (for all Protocols where Auth is NOT required) - The Order status will change to Arrived on the Schedule chart. 

     

• 2.  Open the Visit Management page to allow the user to add an Auth number before the check-in process can be completed. 
  • Click on the Auth Number field to populate the Auth entry page
  • Enter the Auth number > click Save
  • After the Auth number is entered > Click Check In

• The Order will be in an Arrived status on the Schedule Chart.