computerized provider order entry - inpatient provider

Computerized Provider Order Entry - Inpatient

ProviderBasics

Introduction

• Computerized physician order entry (CPOE) is a system that allows direct entry of medical orders and instructions for the treatment of patients by a medical practitioner.

• The orders are communicated through a computer network to medical staff or other various departments responsible for fulfilling an order, including pharmacy, radiology or laboratory.

http://www.healthcareitnews.com/directory/computerized-physician-order-entry-cpoe

How to Open the Patient’s Chart

• Double click on the patient name

• Select Reviewing Only

• Click the OK button to close window.

Opening Orders• Click the Orders band in

the Menu to open the Orders section of the chart

• Then click the + Add button to open the Add Order Window

NOTE:To go directly to the Add Order window, click the +Add button in the Menu

Orders Section Overview

Add Order Button

Order Status Filter

Order ProfileVIEW

(MENU)

Orders: The 4 Basic Steps

1. Find the Order

2. Complete the Order Details

3. Sign the Order

4. Refresh the Screen

Overview of the Add Order Window

Patient Demographic Banner

Diagnosis

Problems

Find box Filter Order Type

Order Sets

How to View Reference Information

• Right click on the Paper ICON to the right of the Order:

– Then left click on Reference Information from the MENU

– When finished click the Ok button

How to Find an Order Set (Plan)

• Open the Add Order Window

• Type 3-4 letters of the Order Set title in the Find box

• Select the Order Set from the list

• When finished click the Done button in lower right corner

The Order Set is Now Listed in the View as “Planned Pending”

How to Remove an Order Set BEFORE Signing

• Right click on Order Set in the “View” section

• Then click Remove from the Menu

• The Order Set has been removed

Order Set Components• Tool Bar

– Merge View (view existing orders)

– Discontinue– (add order)

• Order Sets contain multiple orders for:– Admit/Discharge/Transfer

– Vital Signs

– Nursing Orders

– Laboratory

– Medicationso Sub-Phases

– ETC.

• Check the orders you wish to include in the Order Set

• More Details are available by clicking the down arrow

Order Set Components Cont...

How to Work With Sub-Phase Orders• Click the box to the

right of the double yellow ICON to open the Sub-Phase:

– Then select the Orders from the Sub-Phase you wish to add

– When finished click the “Return to ....” button to go back to the Order Set

Viewing the Sub-Phase

• The Sub-Phase is now listed in the View under the Original Order Set

How to Add an Order to an Order Set

• Click +Add to Phase:– Select Add Order

• Now Find the Order:– Type first 3-4 letters of

Order Set title in Find box

– Select Order from list– Click Done

Now Complete Details for New Order

• Yellow fields are mandatory

Working With Weight Based Medications

• When a weight based medication is selected:

– The Dosage Calculation Window will open with the “calculated dose” filled in with a dose based on the charted weight

Weight Based Medications Cont...

• If you wish to view the calculation used for the drug you’ve selected...

• Click the Formula button

• When done reviewing the formula, click Close

• When you have selected the dose:

– Click the Apply Dose button to close the window and add the weight based drug order to the Order Set

Weight Based Medications Cont...

Then Initiate the Order Set

• You MUST Initiate the Order Set before Signing

• When the Initiate button is clicked the check marks (items selected) will be replaced by light bulbs

To Further Filter the Initiated Order Set

• Click the Funnel ICON in the Tool Bar to view select items

• Click the Funnel ICON again to return to the default view (all items are visible)

Signing the Order Set• After Initiating the order, click

the Orders For Signature button in the lower right corner of the screen

• Then review the Order Set

• When finished click the Sign button in the lower right corner

• Then Refresh the screen

Note:The Name, Status and # of orders being placed will be listed at the top of the Order set

Duplicate Order Alert Window

• Review the Orders and click the appropriate action button below

• When finished, click the “OK” button to complete the signing process

Alerts will fire for the same Orderable name

Keep New Order

Remove New Order

Change New Order

Duplicate Order Alert Window Cont...

If you wish to remove the existing Order, click order to highlight, then select Cancel/DC•When finished click the “OK” button to go to the Review screen...

Alerts will also fire when an active Order exists

Duplicate Order Alert Window Review Screen

Now review the changes:• The Existing Order will be canceled (stuck-through)• The New Order will be added...

•When finished click the Sign button and Refresh the screen

How to View the Order Set After it has Been Signed

• Click the name of the Order Set in View:– Notice the status is now Initiated (active)

How to Modify an Existing Order

• Right click on the order:

– Then left click “Modify” from the Menu

How to Modify an Existing Order Cont...

• Now modify the order:

– When finished click the Orders For Signature button

– Then Sign and Refresh the screen

How to Cancel/Discontinue a Single Order

• Right click on the Order:– Then left click

“Cancel/DC from the Menu

The existing order will be struck-through...

–Now click the “Orders For Signature button

–Then Sign and Refresh the screen

How to Discontinue an Order Set

• Right click on the Order Set in the View:

– Then left click “Discontinue”

– When the Discontinue window opens click the OK button

How to Cancel an Order Cont...

• Now click the Orders for Signature button– The Orders are now struck-through

• Then click the Sign button and Refresh the screen

NOTE:If you get this far and want to stop the process, right click anywhere in the order and left click “Reset”

How to Co-Sign (Approve) Orders in the Message Center

• Open the Message Center:

– Click Orders to approve in Menu (# to approve in prentices)

How to Co-Sign Orders Cont...

• Double click on order in list

• Then Review the Order Details

• When finished select the appropriate Action button:

– Next (goes to next order on list)

– OK (done with this order, closes window)

– Ok & Next (done with this order, go to next order on list)

How to Complete Orders for Discharge (Depart)

• Open the Add Order Window

• Type discharge in the Find box

• Select the Discharge Order Set from the list

• When finished click the Done button in lower right corner

The Order Set is Now Listed in the View as “Planned Pending”

Now Complete the Order Set Details

• Check the orders you wish to include in the Order Set

• Add More Details by clicking the down arrow

• When finished click the Initiate button

• Now click the Orders For Signature button to continue the process...

Discharge Order Set Details Cont...

Do a Final Review Before Signing

• Then Click the Sign Button and Refresh the Screen

The Discharge Order Set is Initiated (Active)

How to Discontinue an Existing Order Set

• Right click on the Order Set in the View:

– Then left click “Discontinue”

– When the Discontinue window opens click the OK button

• The Orders have Been Struck-Through

• Now click the Orders For Signature button to continue

Discontinuing the Order Set Cont...

• Do A Final Review

• Then Click the Sign Button and Refresh the Screen

Discontinuing the Order Set Cont...

The Order Set Has Been Discontinued

Conclusion• We hope this Computer Based

Learning course has been both informative and helpful.

• Feel free to review this course until you are confident about your knowledge of the material presented.

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For further information about this module please contact Cinda Cowen at 226-5366