The Orders screen is used to create, manage, and organize patient services, laboratory orders, supplements, IV therapy orders, and diagnostic-related services during an encounter.

Services

The Services tab within the Orders and Procedures screen is used to add, manage, and bill patient services performed during an encounter. Providers can search and select services, assign modifiers, document units and charges, configure billing settings, and arrange service order priority.

• Select/Search Service: Used to search and select services to add to the encounter.
• Show Prices: Displays pricing information for available services.
• Favorite / All: Filters service selections between favorite services and all available services.
• Modifier: Used to assign a billing or procedural modifier to the selected service.
• CPT II Modifier: Used to assign CPT II modifier information when applicable.
• Units: Used to document the number of service units.
• Units Charge: Displays or documents the charge amount per unit.
• Sales Tax: Displays or documents sales tax associated with the service.
• Contract Price: Displays contract pricing information for the selected service.
• CLIA: Used to document CLIA-related information for laboratory services when applicable.
• Remark: Used to document additional service-related comments or notes.
• NDC: Used to document the National Drug Code associated with the service when applicable.
• Mammography Cert No.: Used to document mammography certification information when required.
• Measure: Used to select or document measurement-related information.
• Service Date: Used to document the date the service was performed.
• Billable / Bill Only To Patient / None: Determines how the selected service should be billed.
• Save: Saves the entered service information.
• Arrange: Allows services to be reordered or arranged within the service list.

The lower grid displays entered services including service name, modifiers, units, unit charges, line charges, contract price, service date, diagnosis, sales tax amount, estimated payment, remarks, billing status, CPT II modifiers, and service priority order. Services can also be edited, deleted, or reordered directly from the grid.

Orders

The Orders tab within the Orders and Procedures screen is used to create and manage laboratory, radiology, and diagnostic-related patient orders during an encounter. The screen allows providers to select orders, assign CPT and ICD codes, document collection and due dates, configure modifiers and units, enter instructions, and manage lab order workflows.

• Labs / External Labs: Used to filter or select internal and external laboratory workflows.
• Service Categories: Allows to select service category from all the available service categoties.
• Order Set: Allows predefined order sets to be selected for faster order entry.
• Superbill Set: Allows predefined superbill sets to be selected.
• Lab Order Set: Allows predefined laboratory order sets to be selected.
• Manage Lab Order Set: Opens lab order set management options.
• Add To Favorites / Remove From Favorites: Adds or removes orders from the favorites list.
• Select Order: Used to search and select an order.
• Service: Documents the selected service name.
• Loinc Codes: Used to document LOINC codes associated with the order.
• CPT Code: Displays or documents the CPT code associated with the order.
• ICD Codes: Associates diagnosis codes with the selected order.
• Modifier: Used to assign billing or procedural modifiers.
• Order Date: Documents the order date and time.
• Due Date: Documents the required completion date for the order.
• Units: Used to document the number of ordered units.
• NDC: Used to document the National Drug Code when applicable.
• CLIA: Used to document CLIA-related laboratory information.
• Mammography Cert No: Used to document mammography certification information when required.
• Instruction: Used to document order-related instructions.
• Stat: Indicates the order should be processed urgently.
• Approval Required: Indicates the order requires approval before processing.
• Allergy List Reviewed: Indicates patient allergy information has been reviewed.
• Save Future Order: Saves the order as a future order.
• Order Status: Displays or updates the current order status.
• MU Stage 2 Status: Displays Meaningful Use Stage 2 related order status information.
• Measure: Used to document measurement-related information.
• Body Site: Used to document the related body site for the order.
• Save / Save And Close: Saves the entered order information.
• Save/Care Task: Saves the order and creates an associated care task.
• Lock / Unlock: Locks or unlocks the order record for editing.
• Send Labs / Send Radiology: Sends laboratory or radiology orders for processing.
• Print: Prints the selected order information.
• Send To Portal: Sends the order information to the patient portal.
• Save As Lab Order Set: Saves the entered order configuration as a reusable lab order set.

The lower grid displays entered orders including service name, CPT code, lab code, lab type, lab status, accession number, ICD codes, modifier codes, and workflow actions including edit, deactivate, and mark historical.

Patient Past Orders

The Patient Past Orders tab is used to review previously entered patient orders and add selected historical orders to the current encounter. The screen displays prior order information including test results, order date, CPT codes, ICD codes, service name, provider, facility, instructions, modifier codes, accession numbers, patient copy status, approval requirements, contrast information, fasting requirements, and organization details.

• Add To Todays Orders: Adds selected historical orders to the current encounter orders list.
• Select to Show in Note: Marks selected historical orders to appear in the patient note as historical information.

Favorites

The Favorites tab is used to review and select commonly used or saved favorite orders and services for faster order entry. The screen allows providers to search favorite records using CPT codes or service names and quickly add selected favorites to the current encounter workflow.

• CPT Code: Used to search favorite orders or services by CPT code.
• Service Name: Used to search favorite orders or services by service name.

Labs

The Labs tab within the Orders and Procedures screen is used to create, manage, and track laboratory orders during an encounter. The screen allows providers to select laboratory services, assign CPT and ICD codes, document order and due dates, enter instructions, configure order status settings, and manage laboratory workflows.

• Labs / External Labs: Used to select internal or external laboratory workflows.
• Order Set: Allows predefined order sets to be selected for faster order entry.
• Lab Order Set: Allows predefined laboratory order sets to be selected and managed.
• Manage Lab Order Set: Opens laboratory order set management options.
• Add To Favorites / Remove From Favorites: Adds or removes laboratory orders from the favorites list.
• Select Order: Used to search and select laboratory orders.
• Service: Displays or documents the selected laboratory service.
• ICD Codes: Associates diagnosis codes with the selected laboratory order.
• CPT Code: Displays or documents the CPT code associated with the laboratory order.
• Order Date: Documents the laboratory order date and time.
• Due Date: Documents the required completion date for the laboratory order.
• Instruction: Used to document laboratory order instructions.
• Price: Displays pricing information associated with the laboratory order.
• Stat: Indicates the laboratory order should be processed urgently.
• Approval Required: Indicates the laboratory order requires approval before processing.
• Allergy List Reviewed: Indicates patient allergy information has been reviewed.
• Save Future Order: Saves the laboratory order as a future order.
• Order Status: Displays or updates the current laboratory order status.
• Body Site: Used to document the related body site for the laboratory order.
• Save / Save And Close: Saves the entered laboratory order information.
• Save/Care Task: Saves the laboratory order and creates an associated care task.
• Lock / Unlock: Locks or unlocks the laboratory order for editing.
• Send Labs / Send Radiology: Sends laboratory or radiology orders for processing.
• Print: Prints the selected laboratory order information.
• Send To Portal: Sends laboratory order information to the EHR portal.
• Save As Lab Order Set: Saves the entered laboratory order configuration as a reusable laboratory order set.

The lower grid displays entered laboratory orders including service name, CPT code, lab code, laboratory type, lab status, accession number, ICD codes, modifier codes, and workflow actions including edit, deactivate, and mark historical.

Supplements

The Supplements tab is used to document, manage, and bill patient supplements during an encounter. The screen allows providers to select supplements, document quantities and pricing, apply discounts and taxes, enter directions, and configure billing-related information.

• Select/Search Lot: Used to search and select supplement lot information.
• Select/Search Service: Used to search and select supplement services or products.
• Price List: Used to select the pricing list associated with the supplement.
• Payment Case: Used to select the payment or insurance category associated with the supplement.
• Quantity: Used to document the supplement quantity.
• Quantity Charge: Displays or documents the charge amount associated with the supplement quantity.
• UPC: Used to document the supplement UPC information.
• Discount: Used to apply discount information to the supplement charge.
• Tax: Displays or documents tax associated with the supplement.
• Service Date: Used to document the supplement service date.
• Directions: Used to document supplement usage instructions.
• Frequency: Used to document how often the supplement should be used.
• Save/Update: Saves or updates the supplement information.
• Cancel: Cancels the current supplement entry.

The lower grid displays entered supplement records including supplement name, quantity, service amount, supplement charges, discount, tax, service date, directions, billing status, bill-to-patient status, and duration information.

The Supplements screen also includes a Supplements History tab used to review previously entered supplement records. The Supplements History screen displays historical supplement information including encounter date, CPT code, and service name.

Diagnostic Results

The Diagnostic Results tab is used to document, review, and manage diagnostic result information associated with patient services and procedures. The screen allows providers to select a provider, assign report dates, associate CPT codes or services, and enter diagnostic result details.

• Provider: Used to select the provider associated with the diagnostic result.
• Report Date: Used to document the diagnostic report date.
• CPT Code: Used to search and associate CPT codes or services with the diagnostic result.
• Diagnostic Result Entry Area: Used to document diagnostic result information and findings.
• Save: Saves the entered diagnostic result information.