Orders and Referrals

The Orders/Referrals tab is used to create lab and diagnostic test orders and provider referrals. Depending on the encounter type, the Orders/Referrals tab displays as its own tab or as a subtab of Orders/Procedures.

If a patient has pending orders, a green flag () displays next to the tab name.

Orders/Referrals is available in the following encounter types: Exam, Multi-System, Procedure, Reconciliation, Telephone, and Urgent Care. Orders is available in Immunization.

  • The Add Order Favorites list and order Note Add from Favorites list are customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select Orders from the Tab list
  • The Clinic Administrator can customize the CPT Modifiers and HCPCS Modifiers by going to Tools > Preferences > CLINIC > Clinic Wide Form Data > Begin Edit and selecting Orders from the Tab list
  • The Clinic Administrator can set the orders Reminder default time span in Clinic Settings: Alerts/Reminders/CDS
  • The referral Reason for Referral/Notes Add from Favorites list is customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select Referrals from the Tab list
  • The referral ICD Code Add from Favorites list is customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select Assessment from the Tab list
  • Task assignment Groups for referrals are customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Application Settings > Message/Task Groups
  • The selection list for the Task Description Add From Favorites is customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select Task List from the Tab list
  • The referral CPT/HCPCS Add Favorites list utilizes the Add Order Favorites list

The orders list displays all pending orders for a patient and any new orders added during the visit. The list displays the order Status, Category, Name, CPT, HCPCS, or SNOMED Code, and Note information.

  • Select the order to view more details. The details display in the area above the orders list
  • Select Bill to bill an order for the encounter
    • An order must have at least one indication to be billed
  • The order Status can be updated directly from the orders list

  1. Go to Encounter > Orders/Procedure > Orders/Referrals
  2. Click Add
  3. Select a favorites Category and select an order code or click Search CPT Master List or Search HCPCS Master List
    1. If using the CPT or HCPCS Master List, search for and locate the order code and click Save
  4. From the Add Order(s) window, add or update any of the following fields as they relate to the order:
    • # of Units: type a value in the numeric field
    • Reminder: select the checkbox and specify the time frame to send an order reminder to the Message inbox
    • Lab Result Format: choose from Numeric, Positive/Negative, or Other
    • Modifier: add up to four modifier codes from the selection list or click Search Mod List to search for and select a code from the CPT or HCPCS Modifiers master list
    • Note: type a information about the order or for the patient in the text field or click Add from Favorites, select one or more notes, and click OK
    • Indication: add up to four indications from the patient's active problem list
    • Ordering Provider: defaults to the user adding the order
      • Adding an indication does not assess the problem for the encounter
    • Bill: select if the order will be billed for the encounter
      • An order must have at least one indication to be billed
    • Status: choose from Pending, Complete, or Not Performed
      • Optional: if Complete is selected, populate the date field with the date the order was completed. If left blank, the order completed date will default to the encounter date
      • Optional: if Not Performed is selected, select a Not Performed Reason
  5. Click Add

  1. Go to Encounter > Orders/Procedure > Orders/Referrals
  2. Select one or more orders
  3. Click Print
  4. Type the name of the facility to which the patient is being sent in the Location field

  5. Optional: select Sign to add an electronic signature statement for the Ordering Provider

  6. Click Print Preview or Print

Select the order and click Delete, then click Yes to confirm decision to delete. Orders added in the encounter will be removed immediately.

To delete a pending order from a previous encounter, select the order and click Remove. The order will display in orange text until the encounter is finalized and will not display in any subsequent encounters

  1. Select the order and click Change
  2. Add or update any necessary information
    1. The CPT/HCPCS code cannot be changed
  3. Click Save

Select the order and click Add Indication(s). Select up to four indications from the patient's active problem list.

Sevocity Best Practice: Add Indication(s) should only be used for orders without any indications. Using Add Indication(s) will replace any existing indications for the order.

Orders can be routed to other users in the clinic for review or to perform tasks related to the order.

  1. Select the order and click Assign/Route
  2. Populate the Due Date for the task or leave defaulted to the current date
  3. Select a Priority for the task or leave defaulted to Normal
  4. Populate the Task Description
    1. Click Add from Favorites and select one or more items from the list or type the task description in the free text field
  5. Search for and select a user or group for task assignment
    1. Multiple individual users, multiple groups, or a combination of users and groups can be selected
  6. Click Save to assign and route the task

Select an item and click the Up arrow to move the item up one place in the list

Select an item and click the Down arrow to move the item down one place in the list

The Referrals section displays any referrals created in the encounter.

  1. Go to Encounter > Orders/Procedure > Orders/Referrals
  2. Click Add
  3. Select a user from the Requested By list
  4. Populate the Refer To and/or Specialty fields
    1. A contact can be selected from the Patient Contacts, User Contacts, or Clinic Contacts list or by clicking Custom to create a custom contact
    2. A specialty can be selected from the Specialty list or by clicking Custom to create a custom specialty
  5. Select the Summary of Care Record Provided checkbox
  6. Populate Reason for Referral/Notes by clicking Add from Favorites and selecting one or more items from the list or by typing directly in the free text field
  7. Add an ICD Code and/or CPT/HCPCS code
    1. An ICD code can be selected from the patient's active problem list or by clicking Add from Favorites to select a favorite ICD‑10 or search the Master List
    2. A CPT or HCPCS code can be selected by clicking Add to select a favorite order or search the Master List
  8. Click Add to create the referral or Add Another to create another referral

After an encounter is finalized, any referrals created in the encounter can be viewed in the Referrals tab in the patient chart.

Referrals can be routed to other users in the clinic for review or to perform tasks related to the referral.

  1. Select the referral and click Assign/Route
  2. Populate the Due Date for the task or leave defaulted to the current date
  3. Select a Priority for the task or leave defaulted to Normal
  4. Populate the Task Description
    1. Click Add from Favorites and select one or more items from the list or type the task description in the free text field
  5. Search for and select a user or group for task assignment
    1. Multiple individual users, multiple groups, or a combination of users and groups can be selected
  6. Click Save to assign and route the referral task

  1. Select a referral and click Send
  2. Optional: Select Include clinical summary from additional encounter(s) checkbox to send one or more additional encounters with the referral
  3. Populate the Subject and message body fields
    1. Select a favorite from the Subject selection list or click Custom and type a subject
  4. Optional: Click Add in the Labs section to attach one or more lab results
  5. Click OK to send

If the Include clinical summary from additional encounter(s) checkbox was selected:

  1. Select one or more encounters from the Select Encounter(s) window
  2. Optional: select an encounter and click View to view the encounter
  3. Optional: click Get Previous 5 Encounters to view more encounters
  4. Click OK

For steps on performing other tasks associated with referrals, see Referrals at the chart level.

 

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