The provider walks into the exam room at 9:05. The patient's last labs are fourteen months old. The controlled substance agreement hasn't been reviewed in over a year. The urine drug screen that should accompany the opioid prescription renewal hasn't been ordered. All of this is discoverable in twenty seconds of pre-visit preparation. None of it was prepared before the appointment.
The Lab Recency Audit
Labs (<3 months), Labs (3-6 months), Labs (6-12 months), and Labs (>1 year) create the four-tier recency classification for the patient's laboratory results. A patient with labs in the under-three-month window is visit-ready for most chronic disease management encounters. A patient whose most recent labs fall in the greater-than-one-year bucket needs lab orders placed before or at the encounter — and the provider needs to know this before the appointment, not during it.
The four-tier structure is more useful than a simple "has labs / no labs" binary because clinical relevance varies by condition and by the specific test. HbA1c for a well-controlled diabetic patient may be adequate at six months. Coagulation studies for a warfarin patient at INR monitoring are inadequate if they're more than three months old. The recency tiers create the framework; the clinical judgment about adequacy applies within each tier based on the encounter reason.
Lab Orders — appearing twice in the template to accommodate orders at different workflow stages — handles the orders that need to be placed. An order placed during the pre-visit preparation, before the provider enters the room, means the patient can have blood drawn immediately after the appointment rather than returning for a separate lab visit.
Compliance Verification
Controlled substance agreement on file? and Urine drug screen in last 6 months? are the two fields that address controlled substance prescribing compliance — the documentation requirements that accompany opioid and other scheduled medication prescriptions in most primary care settings.
The controlled substance agreement is the signed document in which the patient acknowledges the prescribing terms — single prescribing provider, single pharmacy, no early refills, consent to drug screening. If it's not on file, the prescriber is exposed to regulatory and DEA compliance risk. If it's been more than twelve months since the last review and re-signing, the agreement is typically considered lapsed. The pre-visit record makes this check explicit and timed.
The urine drug screen in the last six months is the verification layer — the confirmation that the patient is using what's prescribed and not using what's not. A pre-visit flag that this screen hasn't been done within the required window means the order goes in at this visit, not at the next renewal appointment.
Encounter Preparation
Reason for Encounter, Encounter Forms, Encounter Date, Last Annual Wellness Visit, and Account Number complete the pre-visit preparation record. The last annual wellness visit date determines whether a wellness visit should be combined with today's encounter or whether a separate visit is overdue. Encounter forms prepared and ready before the visit start mean the clinical interaction focuses on the patient, not on administrative setup.