Procedure support

A procedure visit can have pathology specimens and prescriptions linked to its consultation record. A specimen includes its type, collection date, accession number and processing state. The state can be Ordered, Collected, Received, Tested or Rejected. A prescription identifies medication, lot number, quantity, unit and the team member who authorized it. These records let the clinician and reviewer find the supporting work from the same encounter as the clinical note.

For a visit where a specimen is collected, the Licensed Clinician records the specimen against that encounter. The team can then see its current state as processing proceeds. If a specimen is rejected, the record stays visible for follow-up. For a prescribed medication, the clinician records the medication and authorization on that same encounter, so the next reader can identify what was recorded and by whom.

• Encounter link. Use the consultation as the reference for each specimen and prescription.
• Specimen state. Keep collection and processing status visible with the accession number.
• Medication record. Record medication, quantity, unit, lot number and authorizing team member together.

Agree when staff create an Ordered specimen record and who updates Collected, Received, Tested or Rejected. Decide how an external pathology provider’s accession number is returned to the practice and entered. For medication, agree how the team verifies the authorizing clinician and the correct units before saving a record. If an external lab or dispensing system is involved, plan that connection and its reconciliation separately.

The Licensed Clinician manages both specimen and prescription records. Clinical Reviewer can read them with the consultation and other clinical evidence. The Clinical Coordinator manages the visit, so the team should agree what the coordinator needs to see before marking it completed. Keep the handoff focused on the patient and encounter rather than relying on a standalone specimen number.

Open a procedure visit that is in progress. Add a specimen with the encounter, type and collection date, then move it through Ordered, Collected and Received. Enter an accession number when available and verify the reviewer can find it from the visit. Record a prescription on that encounter with medication, lot, quantity, unit and authorizing clinician. Rehearse a Rejected specimen and check that it remains visible in the specimen record. Finally compare both records to the consultation before the visit is completed.

• Specimens in transit — Find ordered, collected and received specimens with their encounters.
• Review queue — Open visits awaiting review of their supporting evidence.
• My consultations — Let the clinician locate their procedure visit before adding records.

Follow procedure support and consultation and documentation. See integrations when planning lab exchange.