POC Results Entry Configuration

User Role Definition

A System Administrator must enable the POC forms for each user role that needs access.

1. Go to Avatar PM > RADplus Utilities > System Security > User Maintenance > User Role Definition.
2. Select the user role to define.
3. Choose Select Forms for User Access.
4. Enable access for the user role to the POC Results Entry and POC Results Entry Configuration forms.
5. Submit to save.

POC Results Entry Configuration

Search for the POC Results Entry Configuration form, or go to Avatar CWS > Results > POC Results Entry Configuration.

► Facility Definition

1. Confirm facility information is populated correctly under Facility Definition.  The data here is defaulted from what is entered in the Facility Defaults form.
2. If changes should be made, select File Facility Definition and update with the necessary modifications.

► Dictionary Definition

If an observation within the POC test should be a dictionary, this section is used to define the specific dictionaries.  For example, pregnancy status could be set up as a dictionary with code/values to indicate the observation. (0 – Not Pregnant, 1 – Pregnant)

1. To add a dictionary, under Add/Edit/Delete Dictionary, select Add. This enables the fields to be configured.
2. Enter a Dictionary Name in the required field.
3. From the Select Dictionary Code drop-down, select -Create New.
4. Enter a Dictionary Code in the required field.
5. Enter a Dictionary Value in the required field.
6. In the Is This The Normal Reference Range? required field, select Yes if the dictionary code is considered normal.
   Note: At least one dictionary code must have a normal reference range.
   • If No is selected, the field to search for an Abnormal Code is enabled. These are defined in Dictionary Update for CWS. select Results File. Example: 40078 Test Results/Observations - Abnormal Flags (HL-7 Table 0078).
7. Add any Comments (optional).
8. Select File Dictionary to submit.

Note: Individual dictionary codes can also be deleted by clicking on the Delete Dictionary Code button when a dictionary code is selected.

► Observation Definition

This section is used to set up individual observation(s) that are eligible to be associated with a test.

1. To add an observation, under Add/Edit/Delete Observation, select Add. This enables the fields to be configured.
2. Search for an Observation ID Code. This searches codes from the LOINC database.
3. The Field Name defaults based on the Observation ID Code selected.  This can be modified if needed.
4. Observation Value Unit may also default based on the Observation ID Code selected (ex. mL, units). This can be modified if needed.
5. Select an Observation Value Field Type.
   • If Decimal is selected, enter a whole number in the Decimal Places field to indicate the acceptable number of decimal places for the observation value.
   • Select Integer to define an observation that only accepts integers.
   • Select String to define an observation that accepts a string. Technical Range, Sex/Age Range, and Reference Range fields are disabled for String type observations.
   • If Dictionary is selected, the Dictionary field populates with previously defined dictionaries from the Dictionary Definition section (above). Technical Range, Sex/Age Range, and Reference Range fields are disabled for Dictionary type observations.
6. In the Technical Range field, enter a range in a number format (Ex: 0-10). This field enforces data validation so only decimals or integers within the defined range are acceptable observations.
7. In the Sex/Age Range dropdown, select -Create New.
   • In the Sex field, select an option.
   • In the Age Range field, enter a range in a number format (Ex: 18+). Enter 0+ to indicate all ages.
8. In the Reference Ranges dropdown, select -Create New.
   • In the Is This The Normal Reference Range? field, select Yes if the defined reference range is considered normal.
   • If No is select, search for and select an Abnormal Code. These are defined in Dictionary Update for CWS. select Results File. Example: 40078 Test Results/Observations - Abnormal Flags (HL-7 Table 0078).
9. Enter the Reference Range in a number format (Ex: 0-5). A reference range may not contain a value outside the technical range.
10. The Save as Vital Sign field should only be used if:
    • You have added an additional field using Site Specific Section Modeling to the Vitals Entry form AND
    • That additional field is capturing an observation related to a POC test.
      Note: Saving an observation as a vital sign allows for continuity of documentation if you previously had an observation captured in Vitals Entry that instead is captured using POC Results Entry.

► Test Definition

This section is used to create test(s) that are associated to previously defined observation(s).

1. To add an observation, under Add/Edit/Delete Observation, select Add. This enables the fields to be configured.
2. Enter a Test Name.
3. Search for a LOINC Code. This searches codes from the LOINC database.
4. Select the associated Order Code(s) for the test.
   Note: The order codes included are defined in Order Code Setup with an order type category of Lab.
5. Use the Default Specimen Type and Default Specimen Site fields to require and/or default values during the lab collection process in eMAR.
   • Specimen Type is defined in Dictionary Update for CWS. Select Results File. Example: data element 40487.
6. The Associated Form field is used if additional data outside of the specific observation values should be captured during the eMAR collection OR during POC results entry.
7. The Document at Collection or Results Entry field is used to indicate where the associated form data should present to the user.
   • An example of form data to document at collection would be for an ABG Test to indicate site, puncture attempts, ventilation mode, etc.
   • An example of form data to document at results entry would be additional information related to COVID testing. (Ex: exposure or contact tracing)
8. Select Yes to Include Form Data as Results Comments to save the filed associated form data as results comments.  Regardless of what is answered here, the associated form always files data to its respective RADPlus modeled table.
9. Select 1 from the Observation Order dropdown.
10. Search for observations previously defined from the Observation Definition section.
11. Indicate whether the observation should be required.
12. Select File Test to submit.

To associate additional observations, repeat steps as needed until all the observations are associated with the selected test.

► eMAR Results Entry

This section is used to designate specific observations as additional data elements that can be captured in eMAR.  This is most used when the test results are immediately available after collection.  Another use case is to reference/document POC results as part of a medication administration. (Ex: Warfarin medication administration dosing could be dependent on PT/INR POC test result)

Notes:

• Configuring POC test results to be captured in eMAR does NOT include all the same functionality as capturing the test results from the POC Results Entry form.
• Observations associated to a dictionary definition is not supported with eMAR Results Entry.
• Technical ranges are not enforced with eMAR Results Entry.
• The process to correct/void results entered through eMAR Results Entry is documented differently from using the POC Results Entry Form.

1. To add eMAR result, under Add/Edit, select Add. This enables the fields to be configured.
2. Enter an eMAR Additional Data Element Title.
3. In the Test field, select a test previously defined in the Test Definition section.
4. In the Observation field, select an observation related to the selected test that was previously defined in the Observation Definition section.
5. In the Time Window for selection of previously entered readings in eMAR field, enter the time in minutes.
   • This can be used to reference a previously filed test result on the additional data tab in eMAR within ‘x’ minutes.
6. Select File to submit.

Upon filing, the defined eMAR Additional Data Element Title appears within Order Code Setup in the following fields:

• Additional Data Elements to Include in Avatar eMAR (Administration)
• Additional Data Elements to Require in Avatar eMAR (Administration)
• Additional Data Elements to Include in Avatar eMAR (Results)
• Additional Data Elements to Require in Avatar eMAR (Results)

After associating the defined eMAR Additional Data Element Title to an order code in Order Code Setup, the defined observations can be captured in the Additional Data (Administration) or Additional Data (Results) section in eMAR. For lab orders, they are collected in the Additional Data (Specimen Collection) section in eMAR.