The Clinical Test or Result form element allows healthcare providers to document clinical tests and their results in a structured format that maintains LOINC codification. This feature is part of the ONC HTI-1 certification updates to support USCDI v3 Health Status Assessments.
Overview | Adding Clinical Test & Result | Search & Select a Clinical Test | Code Attachments | Documenting Clinical Test & Result in Clinical Note
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Overview
The Clinical Test or Result element enables providers to:
- Document clinical tests such as EKG, ultrasound, and laboratory tests
- Capture test results in a standardized, structured format
- Ensure LOINC-based codification for interoperability
- Include test data in CCDA exports
Adding Clinical Test & Result in Clinical Form Management
Users can insert one or more Clinical Test & Result elements into a clinical form. Each element allows for single clinical test entries.
Steps to Add the Element
- Navigate to Clinical Form Management
- Open or create a form
- Select Clinical Field from the form elements
- Choose Clinical Test or Result as the observation type
- Configure the test parameters
Search & Select a Clinical Test
A single-select search field labeled "Clinical Test" enables users to search for tests from the LOINC database.
Search Results Include:
- Clinical Test Name - The descriptive name of the test
- LOINC Code - The standardized LOINC identifier
Once Selected:
- Label/Description - Auto-populated based on the LOINC code but can be edited by the user
- LOINC Code - Stored and used to codify the entry (not editable by the user)
- Unit of Measure - Derived from the selected LOINC and displayed as read-only
Code Attachments
Upon selecting a test, the LOINC code is automatically attached and cannot be edited.
Additional Code Attachments
Users may optionally add additional code attachments at the form level, including:
- CPT - Current Procedural Terminology codes
- HCPCS - Healthcare Common Procedure Coding System codes
- ICD-10 - International Classification of Diseases codes
- Custom codes - Practice-specific or other coding systems
This flexibility allows providers to associate multiple relevant codes with a single test for billing and documentation purposes.
Documenting Clinical Test & Result in Clinical Note
When using the Clinical Test or Result form element in a clinical note, providers can document:
Result Value
Users can enter either:
- Numeric result - For quantitative tests (e.g., "120" for blood pressure)
- Text result - For qualitative tests (e.g., "Positive", "Negative", "Normal")
Test Date
Users can enter the Date when the test was performed or resulted using the date picker field.
If both DATE and RESULT fields are empty, nothing will render in the Clinical Note PDF. This prevents incomplete or placeholder entries from appearing in patient documentation.
Narrative Note Display
A customized note field is automatically generated for each test entry using the following default format:
{{Question}} on {{dateValue}}: {{value}}Example Output:
"Blood Glucose on 01/15/2026: 105 mg/dL"
Customization
This note format is editable within the form builder, allowing you to tailor the text output for display in the clinical note. You can modify the template to match your practice's documentation style or clinical preferences.
Structured Data Capture
- Data is captured in a structured format suitable for LOINC-based codification
- Maintains data integrity and standardization
- Enables accurate data retrieval and reporting
Clinical Note Display
- Test results appear in the clinical note using the customized note format
- Readable and professional presentation
- Integrates seamlessly with other clinical documentation
CCDA Integration
- Data is included in Consolidated Clinical Document Architecture (CCDA) exports
- Stored in a way that reflects the HL7 CCD structure
- Supports interoperability with other healthcare systems
- Enables seamless data exchange for continuity of care