In an Electronic Health Record (EHR), the “Orders and Results” section is crucial for documenting and managing diagnostic tests, treatments, and their outcomes. Here’s what should be included:

Orders

• Order Details
  • Test/Procedure Name: Specific name of the diagnostic test, imaging study, or procedure ordered.
  • Description: Detailed description of the test or procedure if necessary.
  • Indication: Reason or clinical indication for ordering the test or procedure.
  • Priority: Level of urgency (e.g., routine, urgent, stat).
• Date and Time
  • Order Date/Time: When the order was placed.
  • Expected Completion Date/Time: When the test or procedure is expected to be completed.
• Ordering Provider
  • Name and Contact Information: Provider who ordered the test or procedure.
• Instructions
  • Preparation Instructions: Any specific instructions for the patient (e.g., fasting requirements).
  • Technical Instructions: Details relevant for the execution of the test or procedure.

Results

• Result Details
  • Test/Procedure Name: The name of the test or procedure whose results are being reported.
  • Results Values: Actual results or findings from the test or procedure, including numeric values, qualitative descriptors, or images.
• Date and Time
  • Result Date/Time: When the result was obtained or reported.
• Interpretation
  • Result Interpretation: Clinical interpretation of the results, often provided by a healthcare provider or a lab technician.
  • Reference Ranges: Normal ranges or values for comparison, if applicable.
• Status
  • Result Status: Indication of whether the result is pending, final, or requires further action.
• Follow-Up Actions
  • Recommendations: Any follow-up actions required based on the results, such as additional tests, referrals, or changes in treatment.
  • Patient Communication: Documentation of how and when the results were communicated to the patient, including any patient education provided.