Additional documentation is needed when an encounter involves completion of internal office procedures (such as suture removal or a tetanus booster) or the drawing of a specimen for a lab test. This documentation includes the name of the performing clinician, date and time, as well as related comments and instructions.
1. If you haven't already, select the patient and go to the EOV encounter view.
2. Click the link for Orders or Procedures (as applicable) in the associated column. (Applies only to encounters from your practice.)
3. For each entry in the upper left pane, click the order or procedure name and complete the data entry pane on the right.
For orders, enter general patient information, selecting the source of the lab (MGH internal or external lab), the date and time, as well as the clinician who collected the specimen.
For procedures, enter general patient information, indicating if the procedure was done, and if so, by whom and any related comments or patient instructions.
4. Click OK to accept your entry or OK Next to accept your entry and move to the next order or procedure listed in the left pane.