Aim:
1) To reduce redundant and unnecessary specimen collection from patients with a new order entry strategy
Background:
As a tertiary referral center, we see many patients who require multi-disciplinary care. A majority of our patients receive care from multiple providers in different specialties, and as a result these patients often have redundant lab tests ordered. This often results in submission of multiple specimens for overlapping tests in short periods of time. The ease of ordering tests on our EMR has not improved our ability to streamline lab test ordering and specimen requirements for patients. We seek to leverage the power of the EMR to improve coordination of care for patients.
Proposal:
1) Modify the EMR to have the order entry window appear parallel to a modified Results Display screen
2) Flag future labs that have been ordered by other providers and allow easy modification for additional tests that can be consolidated
3) Separate lab order entry panels into acute (1 time or short interval, recurrence) versus chronic (every 1-12 months, recurrence) to assist with the interface at the phlebotomy lab level
4) Modify chronic order sets to include a range of acceptable time ranges for lab draws to occur (+/- 1 month for example), and allow the phlebotomist to adjust the lab draw dates to minimize blood draws)
Example:
This is the standard results window for a patient who had labs checked on 1/1/2015.
| 1/1/2015 | 2/1/2015 | 3/1/2015 | 4/1/2015 | 5/1/2015 | 6/1/2015 | 7/1/2015 | 8/1/2015 | 9/1/2015 | 10/1/2015 | 11/1/2015 | 12/1/2015 |
CHEM PROFILE |
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Na | 135 |
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K | 4 |
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Cl | 105 |
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HCO3 | 24 |
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BUN | 10 |
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Cr | 1 |
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Gluc | 90 |
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AG | 6 |
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eGFR | > 60 |
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Ca | 9 |
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IRON/ANEMIA PROFILE |
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Ferritin |
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Iron |
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Transferrin |
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% Sat |
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CBC |
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WBC |
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RBC |
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HGB |
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Hct |
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Platelet |
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THYROID |
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Parathormone |
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TSH |
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Free T4 |
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Step 1: Nephrologist sees patient on 01/2015 and wants to check 1) chem-7 every 3 months x 1 year and 2) Parathormone every 6 months x 1 year. The following screen will display when future providers want to make additional lab order
| 1/1/2015 | 2/1/2015 | 3/1/2015 | 4/1/2015 | 5/1/2015 | 6/1/2015 | 7/1/2015 | 8/1/2015 | 9/1/2015 | 10/1/2015 | 11/1/2015 | 12/1/2015 | 1/1/2016 |
CHEM PROFILE |
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Na | 135 |
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| *** |
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| *** |
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| *** |
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| *** |
K | 4 |
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| *** |
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| *** |
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| *** |
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| *** |
Cl | 105 |
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| *** |
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| *** |
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| *** |
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| *** |
HCO3 | 24 |
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| *** |
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| *** |
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| *** |
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| *** |
BUN | 10 |
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| *** |
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| *** |
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| *** |
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| *** |
Cr | 1 |
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| *** |
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| *** |
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| *** |
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| *** |
Gluc | 90 |
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| *** |
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| *** |
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| *** |
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| *** |
AG | 6 |
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| *** |
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| *** |
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| *** |
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| *** |
eGFR | > 60 |
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| *** |
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| *** |
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| *** |
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| *** |
Ca | 9 |
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| *** |
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| *** |
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| *** |
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| *** |
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IRON/ANEMIA PROFILE |
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Ferritin |
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Iron |
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Transferrin |
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% Sat |
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CBC |
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WBC |
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RBC |
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HGB |
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Hct |
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Platelet |
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THYROID |
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Parathormone |
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| *** |
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TSH |
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Free T4 |
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Step 2: PCP sees patient on 03/01/2015. He wants to check an acute CBC and thyroid test to work up excessive fatigue. Since the patient already has a lab draw ordered for April, and the patient appears to be stable enough to have labs drawn in a month, the PCP orders a CBC and TSH/free T4 in April. PCP also knows that a chemistry panel is already ordered and does not need to put in a duplicate order. The phlebotomy system should recognize ALL orders placed for the April draw.
| 1/1/2015 | 2/1/2015 | 3/1/2015 | 4/1/2015 | 5/1/2015 | 6/1/2015 | 7/1/2015 | 8/1/2015 | 9/1/2015 | 10/1/2015 | 11/1/2015 | 12/1/2015 | 1/1/2016 |
CHEM PROFILE |
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Na | 135 |
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| *** |
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| *** |
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| *** |
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| *** |
K | 4 |
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| *** |
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| *** |
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| *** |
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| *** |
Cl | 105 |
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| *** |
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| *** |
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| *** |
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| *** |
HCO3 | 24 |
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| *** |
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| *** |
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| *** |
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| *** |
BUN | 10 |
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| *** |
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| *** |
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| *** |
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| *** |
Cr | 1 |
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| *** |
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| *** |
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| *** |
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| *** |
Gluc | 90 |
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| *** |
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| *** |
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| *** |
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| *** |
AG | 6 |
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| *** |
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| *** |
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| *** |
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| *** |
eGFR | > 60 |
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| *** |
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| *** |
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| *** |
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| *** |
Ca | 9 |
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| *** |
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| *** |
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| *** |
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| *** |
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IRON/ANEMIA PROFILE |
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Ferritin |
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Iron |
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Transferrin |
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% Sat |
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CBC |
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WBC |
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RBC |
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HGB |
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Hct |
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| *** |
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Platelet |
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THYROID |
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Parathormone |
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| *** |
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| *** |
TSH |
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| *** |
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Free T4 |
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| *** |
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Step 3: PCP has follow up appointment with the patient to review lab results. Because the patient has microcytic anemia, PCP ordered chronic Fe study and CBC every 6 months (colonoscopy plus other work up for patient) to see the response of treatment. PCP also wants to make sure bleeding is not brisk, so ordered an acute CBC in 1 month to ensure h/h stability. In additional, because of the stability of the patient’s kidney function, PCP messaged Nephrologist via APEX and requested shifting chemistry lab draw.
| 1/1/2015 | 2/1/2015 | 3/1/2015 | 4/1/2015 | 5/1/2015 | 6/1/2015 | 7/1/2015 | 8/1/2015 | 9/1/2015 | 10/1/2015 | 11/1/2015 | 12/1/2015 | 1/1/2016 |
CHEM PROFILE |
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Na | 135 |
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| 135 |
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| *** |
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| *** |
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| *** |
K | 4 |
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| 4 |
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| *** |
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| *** |
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| *** |
Cl | 105 |
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| 105 |
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| *** |
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| *** |
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| *** |
HCO3 | 24 |
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| 24 |
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| *** |
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| *** |
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| *** |
BUN | 10 |
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| 10 |
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| *** |
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| *** |
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| *** |
Cr | 1 |
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| 1 |
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| *** |
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| *** |
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| *** |
Gluc | 90 |
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| 90 |
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| *** |
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| *** |
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| *** |
AG | 6 |
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| 6 |
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| *** |
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| *** |
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| *** |
eGFR | > 60 |
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| > 60 |
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| *** |
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| *** |
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| *** |
Ca | 9 |
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| 9 |
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| *** |
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| *** |
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| *** |
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IRON/ANEMIA PROFILE |
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Ferritin |
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| *** |
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| *** |
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Iron |
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| *** |
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| *** |
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Transferrin |
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| *** |
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| *** |
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% Sat |
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| *** |
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| *** |
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CBC |
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WBC |
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| 8 | *** |
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| *** |
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RBC |
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| 4.5 | *** |
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| *** |
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HGB |
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| 9 | *** |
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| *** |
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Hct |
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| 27 | *** |
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| *** |
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Platelet |
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| 200 | *** |
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| *** |
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THYROID |
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Parathormone |
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| *** |
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| *** |
TSH |
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| 2 |
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Free T4 |
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| 15 |
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Step 4: Nephrologist receives the message from PCP. Since the nephrologist is going to see the patient in 07/2015, he decided to keep the lab draw ordered for July but shifted future labs to go in line with CBC/Fe study. In additional, the nephrologist also noticed the stability of the patient’s kidney function. He decided to change chemistry to q6 months, too. As a backup mechanism, the patient’s phlebotomist will also have the option to draw the patient’s 10/2015 and 11/2015 lab together.
| 1/1/2015 | 2/1/2015 | 3/1/2015 | 4/1/2015 | 5/1/2015 | 6/1/2015 | 7/1/2015 | 8/1/2015 | 9/1/2015 | 10/1/2015 | 11/1/2015 | 12/1/2015 | 1/1/2016 |
CHEM PROFILE |
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Na | 135 |
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| 135 |
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| *** |
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| *** |
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K | 4 |
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| 4 |
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| *** |
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| *** |
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Cl | 105 |
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| 105 |
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| *** |
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| *** |
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HCO3 | 24 |
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| 24 |
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| *** |
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| *** |
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BUN | 10 |
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| 10 |
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| *** |
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| *** |
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Cr | 1 |
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| 1 |
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| *** |
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| *** |
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Gluc | 90 |
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| 90 |
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| *** |
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| *** |
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AG | 6 |
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| 6 |
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| *** |
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| *** |
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eGFR | > 60 |
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| > 60 |
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| *** |
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| *** |
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Ca | 9 |
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| 9 |
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| *** |
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| *** |
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IRON/ANEMIA PROFILE |
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Ferritin |
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| *** |
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| *** |
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Iron |
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| *** |
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| *** |
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Transferrin |
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| *** |
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| *** |
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% Sat |
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| *** |
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| *** |
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CBC |
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WBC |
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| 8 | *** |
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| *** |
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RBC |
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| 4.5 | *** |
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| *** |
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HGB |
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| 9 | *** |
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| *** |
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Hct |
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| 27 | *** |
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| *** |
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Platelet |
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| 200 | *** |
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| *** |
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THYROID |
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Parathormone |
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| *** |
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TSH |
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| 2 |
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Free T4 |
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| 15 |
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Summary:
With the new ordering system demonstrated in the above case, we will be able to reduce the number of unnecessary and duplicate blood draws. Providers will also be more able to communicate easily in order to perform tests together and reduce waste. Lastly, this system will improve patient satisfaction and care by minimizing frustration for patients.
Commenting is closed.
Comments
This would be immensely
This would be immensely helpful. We know how nontrivial it is for our patients to go to the lab for phletobomy and should do everything we can to try to help them get what they need in an efficient manner.
I think that improving lab
I think that improving lab ordering would be a great thing. Right now, I spend a lot of time checking "future labs" ("approximate dates") etc to avoid patient's labs orders being "used up" in advertently.