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Ordering and Managing Labs and Procedures

Ordering labs and managing the results is a central part of patient care. This guide will walk you through how to create a lab order and how to manage the results once they are available in OpenEMR.

Prerequisite: Setting Up Procedure Codes

Before you can order labs or procedures, an administrator must load the necessary code sets into OpenEMR. In a standard installation, the system does not come with CPT or LOINC codes pre-loaded.

  • CPT Codes: Used for medical services and procedures.

  • LOINC Codes: Used for laboratory tests and observations.

Without these code sets, the search function in the order screen will not find any results. Please ensure your system administrator has completed this setup step.

Creating a Lab or Procedure Order

Lab orders are created from within a patient's encounter.

  1. Open the patient's encounter for the current visit.

  2. From the menu within the encounter, select Orders > Procedure Order.

  3. Click the Add button to create a new order.

  4. In the order form, you can search for the lab or procedure by name or code (such as CPT or LOINC).

  5. Select the appropriate test from the search results.

  6. Fill in any necessary details, such as the diagnosis associated with the order.

  7. Click Save. The order is now created and ready to be sent to the lab, either electronically or by printing a requisition form.

Managing and Reviewing Results

Once the lab results are back, they need to be reviewed and signed by the provider.

  1. Results that arrive electronically will often appear in the Message Center for the ordering provider.

  2. You can also view all results for a patient by going to their dashboard, finding the Lab Results widget, and clicking the pencil icon.

  3. This will show you a list of all lab results for that patient.

  4. Click on a result to view the details.

  5. The provider can then electronically sign off on the result to confirm it has been reviewed, completing the workflow.