CPOE Quick Refresher

Transcription

CPOE Quick Refresher
CPOE Refresher Topics
• Order Viewing
• Discontinuing an Order
• Order Filtering
• Order to Admit
• Order Sorting
• Transferring a Patient
• Order Entry
• Provider-Collected
• Order Search Options
Specimens
• Order Picklists
• Ordering a Diet
• Personal Favorites
• Communication Orders
• Signing Orders
CPOE: Order – Viewing
In the orders
tab – Clicking on
any order will give
you additional
options
Details – Opens the Order Detail Form (ODF)
Revise – Not used – Discontinue orders and place new
History – History for the order (when it was placed,
acknowledged, completed, and who did those tasks)
Results – view associated results
Revise Status – Active  In Progress  Complete
CPOE: Order – Filtering
Filter options are found on the left side of the page
Click the arrow to view the drop down box.
The current options may vary due to
system modifications. There is an option to
filter on laboratory orders which will show
the status of all lab orders to date.
CPOE: Order - Sorting
• The drop down arrow shows the sort choices
• Both a primary and secondary sort of orders can be
performed.
• Click the OK button in the sort drop down box to
perform the sort function.
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CPOE: Order Entry
• To enter a new order click on the Orders tab
• Next click on add order
• You can then use order search, order picklists, or your
favorites to choose the particular order desired.
• Some fields are auto filled based on your sign on.
• Sign the order to complete the order entry process
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CPOE: Search Options
Searching for an order can be done based on common
orders, patient based orders, order sets, personal favorites,
or a general search
• This screen opens
when you click on add
order
• This offers you the
different picklist
options
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CPOE: Search Options - 2
Searc
Keyword search
Use “All”,
“Meds”, “Labs”
to narrow search
Common Favorites
List
Commonly used
orders by category
• You can search by
keyword or from the
common favorites list
by category
• The common search
by keyword option can
be narrowed by using
the “All”, “Meds”, or
“Labs” buttons
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CPOE: Search Options - 3
Searc
• You can search
Patient Based
orders according
to a problem or
a diagnosis
• You can also
perform a generic
search with
additional filters
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CPOE: Order Picklists
• The session details have
some auto-populate fields.
• These apply to all orders
placed during this session
regardless of picklist used.
• Choose “Add” or “Add &
Close” to finalize the orders
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CPOE: Personal Favorites
• Order directly from your
Personal Favorites
• You can add to and organize
your favorites during an order
session
• The system does not update
your favorites if changes are
made to common orders.
This can cause order entry
errors. You should update
your favorites on a regular
basis.
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CPOE: Add Order to Personal
Favorites
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CPOE: Order Sets
• Search only within
Order sets
• You can also
search for order
sets by typing
keyword ‘CPOE’
on common tab.
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CPOE: Signing Orders
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CPOE: Discontinue Orders
• Click the box of the order you want to discontinue.
• Select ‘Discontinue’
• Sign the order by clicking the Sign Orders button in the
lower right hand corner of the screen
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CPOE: Order to Admit
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CPOE: Order to Admit - 2
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CPOE: Order to Admit – 3
• Fill in
diagnosis
and team
contact
info
• Click on
plus sign
to add
diagnosis
(instructions on
next slide)
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CPOE: Add Diagnosis
• Search for diagnosis
by code or
description.
• There are limiting
fields available if
needed
• Select the primary
admitting diagnosis
from the displayed
selections – Choose
only ONE diagnosis
• Click ‘Add’ then ‘OK’
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CPOE: Transfer a Patient
Complete TLoC whenever:
•Transferring a patient from one level of care to another (ie ACCU  PCU)
•When a patient returns from a procedure (ie Surgery 2500, GI lab M/S)
•**NOTE: You do NOT need to complete TLoC when a patient stays same level of care,
but moves rooms (ie M/SM/S), or is going to a procedure (OR) just order “Transfer to”
STEP 1: Order the Transfer
1. Add order
2. Search ‘Transfer to’
3. Add & Close
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CPOE: Transfer a Patient - 2
4.
5.
6.
Indicate the unit you want the patient to transfer to and
Complete all information in the order detail form (Tele/no tele/
Primary team contact info/Diagnosis)
Select ‘Order and Finish’
DO NOT FORGET TO SIGN YOUR ORDER
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CPOE: Transfer a Patient - 3
1.
2.
STEP 2: Complete Transfer Level of Care
Select ‘Transfer level of care’ from orders screen
Address ‘Current orders ‘ (must indicate continue, hold, or discontinue) - Orders listed in the Current
Orders tab have future scheduled activity and must be acted upon in order to complete the Transfer Level
of Care session.
Choose to
continue ,
hold,
discontinue
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CPOE: Transfer a Patient - 4
3. Address ‘Orders Not Yet Complete’ as applicable (WILL continue unless you select to D/C)
Non-Formulary Medication orders, Medication orders with a Future Hold time or Future
Resume time indicated from Pharmacy and past-dated orders that can only be D/C’d
are placed on the Not Yet Complete Orders tab - no action is required on these orders.
4. Select ‘Add to Order Session’ & SIGN orders. Your transfer order process is complete!
Orders will
continue
unless D/C
is selected
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CPOE: Provider-collected
Specimens
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CPOE: Provider-collected
Specimens - 2
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CPOE: Ordering a Diet
 If ordering a common diet, simply check the box next to “Diet – Adult” and choose the radial
button next to the desired diet, then Add & Close.
 If order a diet not listed, click on to open the Order Detail Form and specify the desired diet25
(**Hint – click on the WORDS to open the Order Detail Form)
CPOE: Ordering a Diet - 2
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CPOE: Ordering a Diet - 3
If a previous diet was ordered,
“revoke” the previously
ordered diet and “keep” the
current diet being ordered
IMPORTANT REMINDERS
DO NOT use free text or “nurse
communication” orders to place a
diet order
 DO NOT use diet to order
Supplements, these should be
ordered under separate
supplement order
Speech recommendations
should be placed under separate
order: “Speech Therapy
Recommendations & Orders”
Do not revise a diet order or the patient
will not receive any diet until the next day.
Always discontinue the current diet and
order the new diet.
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CPOE: Communication Orders
• Free-text orders to used to COMMUNICATE with other disciplines
(Nursing, Pharmacy, Respiratory Therapist)
• DO NOT use communication orders to order:
MEDICATIONS, LABS OR DIETS
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