Lab Data

Lab data can be accepted into MedInformatix using one of the automated Lab Interfaces (which are all separate products) such as the HL7 Interface or the ASTM Interface. Some data, however, needs to originate from one of the users in the practice, or needs to copy data sent by another provider to the MedInformatix system.

These tests can be recorded in a format that is compatible with data accepted electronically using the action property #LABEDIT. This Lab data entry screen is shown below:

#LABEDIT (Diagnostic Test Entry screen) requires advanced setup and keeps its configuration data in a file called LAB.TBL and this is found in the OUTLINE directory. If you wish to copy the behavior of #LABEDIT to your existing tree, you may copy LAB.TBL into your Decision Tree directory.

In the Lab View, there is a button called Add/Modify Target and a column called Target Value. Using the new button, one can specify a patient specific target value for a particular Lab observation/test. The value is alphanumeric. One can remove an existing value or modify an existing value, however, a historical record of the target values for that patient is stored premanently with an inactive status for future reporting needs.

Working with Lab Data

To use the Diagnostic Test Entry screen:

Select the desired test by picking from the library of tests listed in the Diagnostic Tests combo box. This will display the applicable observations that belong to the test series or family. In the example below, selection of the Diagnostic Test “CBC" lists the observations in this series which starts with Calcium levels. Complete any and all observations for which there is data.

Enter the Observation Value by clicking in the desired observation field, and then entering the observation test results in the pop up screen. The screen also includes the option to include comments, such as date, time and source. If there is an abnormal result, the Abnormal Flag is set on this screen, which provides a visual alert to the provider reviewing the lab data that appears in the Abnormal column.
If an abnormal value is found, set the Abnormal Flag by using the appropriate Abnormal field dropdown arrow.
Click the Save Results button to save and store the entered data. This data can be viewed in the Decision Tree using the #LABVIEW action property. It can also be displayed immediately from this screen by clicking on the Lab History button on the lower left corner of the window.
If a correction to the lab data is necessary, right-click over the appropriate item and select Lab Edit from the menu. The Diagnostic Test Data Entry screen opens.
Navigate to the appropriate test, and then click in the Observation field of the item to be edited to open the Observation Entry screen. Remove the data and click on Ok. Then open the screen again to enter the appropriate date.
Click on Save Results to save the newly entered information.

When printing a lab for a specific order, a message will appear in a pop-up screen for users letting them know that a specific date needs to be selected.

Printing by Observation ID is allowed in the Labs View screen.

Some strict rules apply to the editing of existing lab data.

You may edit lab data only if it was entered today.
Only the original person creating the data may edit. If authorized to do so, one may delete a value by erasing the contents of the value field.
Any new entry made will overwrite any prior entry for the same observation time.

Diagnostic Test Template

The previous discussion on the Diagnostic Test Entry screen focused on entering lab data. This section will describe how to set up the tests that will be used for data entry.

The choices in the #LABEDIT action property that appear in the Diagnostic Test combo box are predefined as templates.

Diagnostic Test Templates are created under the menu option PREFERENCES. Select CLINICAL SETUP TABLES and scroll down to F LAB TEST TEMPLATES, which opens the Lab Test Template screen.
Once at the Template screen, create a new template by first clicking the NEW button which clears all data on the screen.
At the Diagnostic Test field, define or enter the diagnostic test name (or series name).
Fill in the Observation code, Observation Name, Units and Norma Range by simply entering the information in the appropriate fields.
Once all information is entered, click the Save Test Template button.

It is important to note that the Observation Code must be a unique value (not greater than 10 digits) assigned to each Diagnostic Test Observation. There must be no duplicates found in any other template, unlessthe value is the same.

For example, if two templates are created called Panel – Lipids and Panel – Liver Function. In many cases patients on lipid lowering medications require a liver function test. It may then be the desire of the tree designer to include the tests AST and ALT (liver function tests) in both templates. In this case, it is correct to use the same Observation code of ALT and AST in both templates since these are the same values.

The reason that Observation codes have to be unique is that these codes are the basis of storing historical data for an observation. Thus misuse of the code will result in analysis problems occurring later on.

It is also important to note that an Observation name is required, however, Units and Normal range are both optional.

Lab Test templates are stored in LAB.TBL

Example contents of \DIM\OUTLINE\LAB.TBL

[Diagnostic Tests]

1=CBC w/Diff

2=Blood Chemistry

3=Drug Levels

4=Glucose,Serum,Fasting

5=Glucose,Finger Stick

;6=Health Maintenance

7=Hemoccult

8=Hgb A1c

9=H. Pylori

10=Oximetry

11=Panel-Arthritis

12=Panel-Hepatitis

13=Panel-Lipid

14=Protime/INR,Finger

15=Protime/INR,Serum

16=PSA

17=Strep Screen

18=TB Test

19=UA, Complete

20=Urine, Dip

21=Urine Pregnancy Test

22=Vision Screen

[H. Pylori]

1=H. Pylori|||HPYLORI|

[Vision Screen]

1=Visual Acuity OD||20/15-20/20|VISION|

2=Visual Acuity OS||20/15-20/20|VISION|

[Strep Screen]

1=Strep Screen|+/0|neg|STREPSCRN|

[Oximetry]

1=O2 Sat|||O2SAT|

[CBC W/DIFF]

1=White Blood Cell Count|thous/mcl|3.8-10.8|WBC|

2=Red Blood Cell Count|mill/mcl|3.90-5.20|RBC|

3=Hemoglobin|g/dl|12.0-15.6|HGB|

4=Hematocrit|%|35.0-46.0|HCT|

5=MCV|FL|80.0-100.0|MCV|

6=MCH|PG|27.0-33.0|MCH|

7=MCHC|%|32.0-36.0|MCHC|

8=RDW|%|9.0-15.0|RDW|

9=Platelet Count|thous/mcl|130-400|PLT CT|

10=Absolute Neutrophils|cells/mcl|1500-7800|ABSOL NEUT|

11=Neutrophils|%||NEUTROPHIL|

12=Absolute Lymphocytes|cells/mcl|850-4100|ABSOL LYMP|

13=Lymphocytes|%||LYMPHOCYTE|

14=Absolute Monocytes|cells/mcl|200-1100|ABSOL MONO|

15=Monocytes|%||MONOCYTE|

16=Absolute Eosinophils|cells/mcl|50-550|ABSOL EOSI|

17=Eosinophils|%||EOSINOPHIL|

18=Absolute Basophils|cells/mcl|0-200|ABSOL BASO|

19=Basophils|%||BASOPHIL|

[DRUG LEVELS]

1=Digoxin|mcg/l|0.5-2.0|DIGOXIN|

2=Theophylline|mg/l|5.0-20.0|THEOPHYLL|

3=Phenobarbital|||PHENOBARB|

4=Dilantin|mcg/l|10.0-20.0|DILANTIN|

[GLUCOSE,SERUM,FASTING]

1=Fasting Blood Glucose|mg/dl|70-125|FGLUCOSE|

[GLUCOSE,FINGER STICK]

1=Glucose|mg/dl|70-125|SGLUCOSE|

[TB TEST]

1=TB Test|mm|neg|TBTEST|

[HEMOCCULT]

1=Hemoccult|+/0|neg|HEMOCCULT|

[HGB A1c]

1=Hemoglobin A1c|%TOTAL HGB|<6.5|HGB A1C|

[PANEL-ARTHRITIS]

1=Rheumatoid Factor (0-39)|IU/ml|Negative(Normal)|RA 0-39|

2=Rheumatoid Factor (40-79)|IU/ml|Weakly Reactive|RA 40-79|

3=Rheumatoid Factor (>or=80)|IU/ml|Positive|RA >OR=80|

4=Sed Rate|MM/HR|< or = 30|SED RATE|

5=Uric Acid|||URIC ACID|

[PANEL-HEPATITIS]

1=Hepatitis B Surface Antigen|||HBsAG|

2=Hepatitis B Surface Antibody|||HBsAB|

[PANEL-LIPID]

1=Triglycerides|mg/dl|<200|TRIGLYCER|

2=Cholesterol, Total|mg/dl|<200|CHOL TOTL|

3=HDL-Cholesterol|mg/dl|>34|HDL|

4=LDL-Cholesterol|mg/dl (CALC)|0-130|LDL|

5=Total Cholesterol/HDL Ratio|(CALC)|<4.98|CHOL/HDL|

[PROTIME/INR,FINGER]

1=Prothrombin Time|Seconds|9.0-11.5|PROTIME|

2=INR|Seconds|2.0-5.0|INR

[PROTIME/INR,SERUM]

1=Prothrombin Time|Seconds|9.0-11.5|PROTIME|

2=INR|Seconds|2.0-5.0|INR|

[UA, COMPLETE]

1=Color||Yellow|COLOR|

2=Appearance||Clear|APPEARANCE|

3=Specific Gravity||1.001-1.035|SPEC GRAV|

4=pH||4.6-8.0|PH|

5=Glucose||Negative|UGLUCOSE|

6=Bilirubin||Negative|BILI|

7=Ketones||Negative|KETONES|

8=Occult Blood||Negative|OCCULTBLD|

9=Protein||Negative|PROTEIN|

10=Nitrite||Negative|NITRITE|

11=Leukocyte Esterase||Negative|LEUKOCYTE|

[URINE, DIP]

1=Specific Gravity||1.001-1.035|U SP GRAV|

2=pH||4.6-8.0|U PH|

3=Glucose||Negative|U GLUCOSE|

4=Bilirubin||Negative|U BILI|

5=Ketones||Negative|U KETONE|

6=Occult Blood||Negative|UOCCULTBLD|

7=Protein||Negative|U PROTEIN|

8=Nitrite||Negative|U NITRITE|

9=Leukocyte Esterase||Negative|U LEUKOCYT|

[URINE PREGNANCY TEST]

1=Urine Pregnancy Test|Positive/Negative|Negative|U PREGTEST|

[PSA]

1=Total PSA|NG/ML|< or = 4.0|PSA|

[HEPATIC PANEL]

1=Albumin|G/DL|3.2-5.0|ALBUMIN|

2=Bilirubin, Total|mg/dl|0.0-1.3|BILI TOTAL|

3=Bilirubin, Direct|mg/dl|0.0-0.4|BILI DIRCT|

4=Bilirubin, Indirect|mg/dl (CALC)|0.0-1.3|BILI INDIR|

5=Alkaline Phosphatase|u/l|20-125|ALK PHOS|

6=AST (SGOT)|u/l|0-42|AST|

7=ALT (SGPT)|u/l|0-48|ALT|

[Blood Chemistry]

1=Albumin|G/DL|3.2-5.0|ALBUMIN|

2=Albumin/Globulin Ratio|(CALC)|0.8-2.0|ALB/GLOB|

3=Alkaline Phosphatase|u/l|20-125|ALK PHOS|

4=ALT (SGPT)|u/l|0-48|ALT|

5=AST (SGOT)|u/l|0-42|AST|

6=Bilirubin, Total|mg/dl|0.0-1.3|BILI TOTAL|

7=Bilirubin, Direct|mg/dl|0.0-0.4|BILI DIRCT|

8=Bilirubin, Indirect|mg/dl (CALC)|0.0-1.3|BILI INDIR|

9=BUN|mg/dl|7-25|BUN|

10=BUN/Creatinine Ratio|(CALC)|6-25|BUN/CR RAT|

11=Calcium|mg/dl|8.5-10.3|CA|

12=Chloride|meq/l|95-108|CL|

13=Creatinine|mg/dl|0.5-1.4|CR|

14=Creatinine Clearance|||CR|

15=Globulin|g/dl (CALC)|2.2-4.2|GLOBULIN|

16=Glucose|mg/dl|70-125|GLUCOSE|

17=Potassium|meq/l|3.5-5.3|K+|

18=Protein, Total|g/dl|6.0-8.5|T PROTEIN|

19=Sodium|meq/l|135-146|NA|

20=T3 Uptake|||T3|

21=T4, Total|||T4|

22=T4, Free|ng/dl|0.8-1.8|T4 FREE|

23=TSH|micro IU/ml|0.4-5.5|TSH|

24=Uric Acid|||URIC ACID|