Diagnostics and medication

Clinician enters a diagnostic order for a lab test or imaging study. The order identifies its test name, ordering person and encounter. Staff can distinguish Ordered, Collected, Resulted, Reviewed and Cancelled work. Collection intake is a meaningful step: the order should move to Collected when the specimen or imaging intake actually happens. An order date or test request alone does not say the collection occurred.

A diagnostic result belongs to its order and carries result text, result time, reviewer and review time. That relationship lets a clinician trace a result to the right request and encounter. Medication orders also attach to an encounter and identify the medication, dose instruction, prescriber, signed time and status. A draft prescription is separate from one signed by the prescriber. Check the prescriber’s privilege and the relevant patient context before a medication order is signed.

• Request. Clinician names the lab or imaging test and links it to the active encounter.
• Result. The result remains attached to the order through collection and clinical review.
• Prescription. Prescriber checks medication and dose instruction before signing the order.

Agree how laboratory and imaging staff identify an order at intake and who records collection. Set a common naming convention for tests. Decide who records result text and who performs clinical review; these can be different people. A separate laboratory or imaging system can supply result data through a connection, but the hospital should decide what becomes the authoritative review record. For medication, agree who may enter drafts and who is allowed to sign, based on verified privileges.

A clinician opens an active encounter and orders a lab test. The order begins Ordered with its test name and ordering person. At specimen intake, staff change it to Collected. When a result is recorded, it is linked to that order with its result time. The clinician reviews the result, records the reviewer and review time, and moves the order from Resulted to Reviewed. The encounter review queue then gives the care team a place to finish the clinical decision rather than mistaking the existence of result text for a completed review.

If treatment follows, the clinician prepares a medication order with a dose instruction. The prescriber verifies the details and signs it. A cancelled order stays distinct from the signed prescription. For an imaging case, the same order-to-result relationship applies, while the collection step describes imaging intake rather than a specimen handoff.

• Diagnostic collection queue — Find ordered tests waiting for intake.
• Diagnostic review queue — Find resulted tests needing clinical review.
• Medication orders awaiting signature — Check drafts before a prescriber signs them.

Rehearse the diagnostic review and care delivery paths.