Getting diagnostic results into the chart

Diagnostic results reach the chart at three levels: a PDF report filed as a document, a short fixed set of values captured as structured observations, or interface-level exchange with no manual entry. Discrete capture is the right first target, because it lets results be trended, graphed and queried, and it can be started this week.

A report filed as a scanned image satisfies a documentation requirement and answers no question you can ask across a panel.

How do diagnostic results get into the EMR?

Document delivery. The report arrives as a PDF and is filed. Visible to a clinician reading that chart, invisible to everything else. Fast to set up, and where most practices stop.
Discrete result capture. A short fixed set of values is entered as structured observations. Now they can be trended, graphed and queried.
Interface-level exchange. Results flow in as structured messages with no manual entry. Highest effort, and the only level that scales to a whole panel.

Why is discrete result capture the right first step?

Level one is not enough, because the entire clinical argument for repeat measurement rests on comparison, and a PDF cannot be compared with anything by a computer. Level three is the correct destination and is a project with its own timeline and its own budget conversation. Level two captures most of the value for a fraction of the effort, and it can be started this week.

Which test results should be recorded in the EMR?

Ankle-brachial index, left and right.
Toe-brachial index, left and right.
Sudomotor conductance, hands and feet.
Heart rate variability summary index.
Orthostatic blood pressure change.
Resting energy expenditure.
Lean body mass and fat mass.
Cognitive screening score.
Conditions of measurement — fasting state, caffeine, nicotine, time of day, medication timing.

That last one is the field most often omitted and the one that makes every other field comparable. Without it a trend is a guess.

How do you keep charted results usable?

Choose the fields once and never change them. A field quietly redefined destroys the trend it was created for.
Have the person who performed the study enter the values, at the time of the study. If it falls to the reviewing clinician it happens inconsistently.
Keep the narrative report as well. Discrete values do not carry waveform morphology or the interpreting clinician’s reasoning.

How does discrete data help quality reporting?

Several of these values feed the clinical domains that quality programs consume — body mass index and follow-up, blood pressure, diabetes care, falls risk and cognitive assessment. Data captured discretely is auditable and comparable year over year in a way that an attestation is not. MIPS and quality reporting.

Frequently asked questions

What does EMR integration mean for diagnostic test results?

It means results reach the chart in a form the record can use. There are three levels: a PDF report filed as a document, a short fixed set of values entered as structured observations, and interface-level exchange, where results flow in as structured messages with no manual entry. Only the last two let results be trended, graphed and queried.

Is a scanned PDF report in the chart enough?

No. A filed PDF satisfies a documentation requirement, and a clinician reading that one chart can see it, but it is invisible to everything else. The clinical case for repeat measurement rests on comparison, and a computer cannot compare a PDF with anything. Keep the narrative report, and capture the key values as discrete data as well.

Who should enter test results into the chart?

The person who performed the study, at the time of the study. When entry falls to the reviewing clinician, it happens inconsistently. Choose the fields once and never change them, because a field that is quietly redefined destroys the trend it was created for.

Why record fasting, caffeine and time of day with the results?

Because the conditions of measurement are what make every other field comparable. Fasting state, caffeine, nicotine, time of day and medication timing all belong in the record. It is the field most often left out, and without it a trend is a guess.