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Result Entry, Manual

Clinical Laboratory Information System Client Server (CLICS)

I. PRINCIPLE:

The Manual Results Entry screen provides a mechanism for manually entering laboratory test results and comments into the LIS.

II. PROCEDURE:

  1. Open Manual Results Entry:
    Click on the Manual Result Entry button located on the Lab Palette or choose “Manual Result Entry” from the Screens drop-down menu on the menu bar.
      
  2. Type in the test accession number and press TAB to advance to the next field.
  3. Type in the test configuration code and press ENTER.
    Note: If the test configuration code is not known press the Alt+t keys. The "Search by Test Name" pop-up window will appear:
    1. Type in a few letters of the test name and press ENTER, a list of test names that match the search criteria will fill the scroll window.
    2. Using the up/down arrow keys, select the desired test name and press ENTER or using the mouse, click once on the desired test name and the selected name will fill the Test Description field.
  4. Resulted by Lab: The resulted by lab may be changed if the results are being entered manually at a site other than the site performing the test. Click on the field to open the drop-down menu and select the desired location. Results entered will then be assigned to the selected location. (Example: results generated at Finley but entered at Cathedral Square, the operator at Cathedral Square can select Finley Laboratory so the site running the test gets proper credit for the test.)
    changed to

  5. The patient name and test name will display along with the collection date. If results of other tests with the same accession number have already been entered the collection time will also be displayed.
    1. If the collection time is blank type in the collection time.
      1. If the collection date and/or time is different from the date and time displayed the discrepancy must be investigated. If other testing with the same accession number has been collected at a different date and time DO NOT change the collection date and time. The current test must be cancelled and reordered in the appropriate computer system. After a new requisition has printed, the specimen must be re-identified and registered. (Refer to the “Specimen Re-Identification” and “Specimen Registration” procedures.) Use the TAB key to advance to the next field.
      2. Future collection dates are not allowed. If a future date was entered on an interfaced order the “Collection Date” and “Collection Time” fields will be blanked out and the cursor will default to the “Collection Date” field. In addition, if the collection date/time entered exceeds the resulted date/time in the database by more than 12 hours, a warning message will appear when exiting the “Collection Time” field. This message is a cautionary alert and will not prevent the user from releasing results.
    2. Type in the initials of the person that collected the specimen and press TAB to advance to the first result field.
      Note: If the phlebotomist is unknown, type in "unk" for the initials. This is a required field and must be filled.
  6. Laboratory Alerts are displayed in a box to the right of the test result highlighting “Legend”, these alerts may be pertinent to specimen handling and/or testing. Laboratory Alerts may be added or removed via the Patient Registration screen. (Refer to the “Patient Registration” procedure for further instructions.)
  7. Type in the appropriate result for each analyte:
    Note: When a result is entered in an analyte field and the cursor is advanced by tabbing, the analyte name will highlight in light blue. Only results with the analyte name highlighted in light blue will be saved.
    1. If the result is numeric, type in numeric characters including the decimal point, if the number is expressed as a decimal.

      Note: The background color of any numeric result that falls outside its expected range, critical or unlikely limits will be as follows after exiting the result field:
          • YELLOW indicates the numeric value is “Abnormal”,
          • RED indicates the result is “Critical”, or
          • MAGENTA indicates the result is “Absurd”; absurd values need to be checked for transcription or other errors.
    2. If there are text values pre-defined for the analyte:
      Note: A “text value” is any result that contains one or more non-numeric character(s) (e.g.: “<1.0” or “Positive”). Text values defined in the database as “Abnormal” will be highlighted YELLOW.
      1. When the cursor is inserted into a result field, a yellow field will overlay the right side of the screen listing all pre-defined text values for that analyte.
      2. A scroll bar will appear on the right side of the yellow text value field if the number of pre-defined text values exceeds the space provided. Move the pointer arrow directly over the up/down arrow boxes located at the top/bottom of the scroll bar, respectively, and click the left mouse button to scroll the field in the direction the selected arrow is pointing.
        Note: If it is necessary to scroll the text value field to find the appropriate text value, the cursor must be re-inserted into the appropriate result field before attempting to enter a result.
      3. A keyboard short cut key (alpha or numeric) precedes each text value. Type in the short cut key and TAB, the associated text value automatically insert into the result field.
      4. The yellow text value field displayed will disappear by tabbing out of the result field or by moving the pointer arrow directly over the field and double clicking the left mouse button.
        Note: If a result is inserted into the wrong analyte field and a previously saved result is overwritten it can be restored as follows: using the mouse, move the pointer arrow directly over the analyte name for the results field inappropriately changed and either click the left mouse button once to restore if the analyte name is highlighted in light blue or twice if the analyte name was not highlighted in light blue. (The first click will highlight analyte name light blue and the second click will restore the overwritten result.)
    3. Manual Peripheral Blood Smear (mPBS) result entry in CLICS: for CBC with Differential and WBC with Differential. Currently this screen is not available for Hemogram, Hemoglobin & Hematocrit or Platelet Count.
      Click on the mPBS button.

      Refer to “
      Peripheral Blood Smear (PBS) Review, Technologist/Pathologist” procedure.
  8. Continue to complete all appropriate result fields using TAB to advance from field to field.
    Note: The analyte names will highlight in light blue only if results are entered or changed in a field. If a result is not entered in a field and it is appropriate to save the blank (null) field, the analyte name must be highlighted in light blue to advance the result status for "Release" at a later time.
    1. To highlight a single analyte name with a blank result field:
      Using the mouse, move the pointer arrow directly over the desired analyte name to the left of the result field and click the left mouse button. Repeat this step prior to saving for each analyte in which a blank is the appropriate result.
    2. To highlight all analyte names:
      Using the mouse, move the pointer arrow directly over the “Highlight All” button and click the left mouse button or choose “Highlight All” from the “Function” drop-down menu on the menu bar. All analyte names will be highlighted in light blue.
  9. Adding comments:
    1. Lab Comments: Internal non-reportable comments that are printed on the requisition regarding the testing, test result, the specimen collection or the sample integrity that are not to be reported, are typed into this field. Press TAB to advance to Reported Comments field.
      Note: Comments that are entered at the time of Order Registration in the LIS or HIS will appear in this field. Any comment that is not pertinent can be removed (e.g.: “none”, “patient going to x-ray”, “specimen already drawn”, “patient coming from admitting”) or comments pertinent to the results that are entered at time of order can be transferred to the "Reported Comments" field using the copy/paste functions (i.e.: select the desired text and copy the text (Ctrl+c), insert the cursor into the Report Comment field and paste the text (Ctrl+v)).

      If a Canned Comment is to be inserted, insert the cursor in the Lab Comment field and right click on the mouse to access the Canned Comment selections or select Canned Comments from the Function menu on the menu bar.
      Canned Comments function:
      1. Using the mouse, insert the cursor in the comment field where the canned comment is to be entered.
      2. Choose “Canned Comments” from the “Function” drop-down menu on the menu bar to display the list of Canned Comments or right click on the mouse to access the Canned Comment selections.
      3. Scroll to the desired comment or press the first letter of the comment short name to automatically scroll to the list of canned comments beginning with that letter (e.g., press m and the list will scroll to the comments with a short name beginning with the letter m, such as, Mayo: Refer to separate Mayo Medical Laboratory report).
      4. Using the mouse, double-click on the desired comment and the comment will be inserted in the comment field where the cursor is located. If the comment is to be entered in both fields, either place the cursor in the other comment field and repeat this process or use the copy/paste function (i.e.: select the desired text and copy the text (Ctrl+c), insert the cursor into the appropriate field and paste the text (Ctrl+v)).
    2. Report Comments: Comments regarding the testing, test result, the specimen collection or the sample integrity that are to be reported with the test results, are typed into this field.
      Note: A number of frequently used comments are available under the Canned Comment function.

      Canned Comments function:
      1. Using the mouse, insert the cursor in the comment field where the canned comment is to be entered.
      2. Choose “Canned Comments” from the “Function” drop-down menu on the menu bar to display the list of Canned Comments or right click on the mouse to access the Canned Comment selections.
      3. Scroll to the desired comment or press the first letter of the comment short name to automatically scroll to the list of canned comments beginning with that letter (e.g., press m and the list will scroll to the comments with a short name beginning with the letter m, such as, Mayo: Refer to separate Mayo Medical Laboratory report).
      4. Using the mouse, double-click on the desired comment and the comment will be inserted in the comment field where the cursor is located. If the comment is to be entered in both fields, either place the cursor in the other comment field and repeat this process or use the copy/paste function (i.e.: select the desired text and copy the text (Ctrl+c), insert the cursor into the appropriate field and paste the text (Ctrl+v)).
  10. Press the Ctrl+s keys to save the results entered. The screen will refresh.
    Note1: Only results with the analyte name highlighted in light blue will be saved and their status advanced.
    Note2: If the results being saved are amended results, i.e. results were previously released and now are being amended, the save event will trigger the automatic insertion of a Canned Comment “Test results have been amended.” along with a timestamp of when the change occurred. This comment will be visible when the results are displayed for review and release in the CLICS Transcription Result Review and Release screen. Refer to the “
    Results Review/Release, Transcription” procedure.
  11. Continue entering other patient results following steps 2 through 9.
  12. Press and hold the Ctrl+F4 keys to close the screen when finished.
    1. 05-23-95 M. English
    2. 01-24-96 M. English (Revision: II.3.Note; 6.B.Note; 7.Note)
    3. 03-25-96 M. English (Revision: II.G.2.a. through d.)
    4. October 1999 M. English (Revised: II.D. red highlight changed to light blue; II.G.Note added)
    5. March 2001 M. English (Revised: CLICS version; section II.1. & 9.)
    6. May 2002 M. English (Revised: collection date screening added)
    7. July 2008 M. English (Revised: II.5. laboratory alerts added)
    8. September 2009 M. English (Revised: II.6.C.manual pbs added)
    9. November 2011 M. English (Revised: II.4. changing resulted by lab)

Comprehensive Review:

Interim Review:
February 2010 K. Wernimont (Revised: II.8.A.)
March 2011 L. Begle, M. English (Revised: II.4.A.a.)

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