Documentation of TB/PPD testing and Resulting Read, Step-by-Step Guide

This step-by-step guide provides detailed instructions on how to document TB/PPD testing and resulting read in a healthcare setting. Following this guide will ensure accurate and thorough documentation, allowing for proper patient follow-up and care.

Catherine Caz Zuniga
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37 steps
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4 minutes

Open a New Nurse note, or if patient is here for a visit, a New Liberty FNC note. On the CC tab, choose Other from the System pick list

From the resulting List from the System Other, choose the PPD/TB Test from the pick list.

Once all CC's have been added, go to HPI Tab

Answer all Questions resulting from the PPD/TB Test.

Example of answering all questions

Example, answering all applicable PPD/TB questions

Next go to the DX tab of the visit note

In the search window, type in TB Screen then click on the Magnifying Glass to search the DX look up.

Choose by clicking the Tuberculosis Screening from the resulting pick list.

The item will be added to the right side of the screen.

Click "OK" to add this DX to the patient list

Once the DX has been added, go to the SP tab.

Choose the Adult Lab Services POC or the Peds Lab Services POC from the Left Column and choose the PPD/TB test from the resulting list.

Open the DPN to add additional information for this Procedure.

Add all needed information in the DPN that opens.

Example of adding all DPN information to the PPD/TB Test procedure.

Click "OK" once all information has been added to the DPN.

Continue adding any additional information needed for the note. Once you have added all to the note, Click "OK" to save and close this note.

Click "Complete Note" if you are done with your documentation.

Click "OK"

Click "No"

Click "OK"

Alert! You have completed documentation for the Admin of the PPD/TB test. Patient should be notified at this time to follow up in the applicable time frame for the read. The following steps review the documentation of that read for the PPD/TB test

When the patient returns for the read, look up the patient. Verify that the PPD/TB test was ordered by going to the Outstanding orders Icon.

Verify that the Visit Date that the PPD/TB test was given is 48-72 hour time frame for the reading.

If the time frame is correct Go to the Patient Results Icon.

Click on the Enter Lab results from the resulting window.

Click on the Magnifying glass to Look up Lab Test Templates

Clicking on the Diamond will sort all LIB ID's to the top to make finding the PPD/TB Test easier.

Choose the PPD/TB Test from the list

Click on the Magnifying glass on the outstanding SP/SO Mapping to search for the outstanding PPD/TB Test order.

Click "Search"

You should see the order appear. Click on the Blue name hyperlink

Click on the Magnifying glass on Resulted, or enter the current Date of the read in this field.

If you click on the magnifying glass, it will open a calendar for you to choose the current date. Click OK once you have chosen the date.

Enter the value of the Read. 0-5 are the normal limits.

Click "Create Review Result Data Message". Do this step to send a message to the provider if that is your office policy on reads. If not, disregard this and following steps.

Note on here the Provider is the ordering provider, and is defaulted when you check the Create Reviews Results Data. You can change the Reviewer by clicking on the Magnifying glass and looking up user you want to send this to. Once you have chosen the Reviewer, click on ok to close this window. You have now documented the PPD/TB read.