Quick Guide to Inpatient Orders by Students

Transcription

1 Quick Guide to Inpatient Orders by Students For more detailed information on ordering medications, refer to the user guide Neehr Perfect EHR Quick Guide to Ordering Meds (for students). In the patient chart, order menus are found in the Orders tab. This is the patient order menu located on the Orders tab. Pay close attention to which order menu you need to select based on the location of the chart you are working in Inpatient or Outpatient. The exception: To order any labs, for inpatient or outpatient, select the IN PT LABORATORY menu. The EHR will automatically list the labs available based on the location of the chart. 1

2 Orders in an inpatient chart 1. The first step when working an Inpatient chart is to make certain the chart is in an Inpatient setting and a Provider has been selected. The Provider will always be your instructor unless you are told otherwise. Click on the box that reads Current Provider Not Selected. Once you have the Provider selected and have verified an inpatient admission, click OK. 2

3 2. Go to the Orders tab. Select the Order Menu that is needed to complete the order. In this example, we will be ordering an Inpatient unit dose med for a patient chart. 3. The medications you see listed on this screen are Quick Orders. You may select one of them if you would like. Clicking on ORDER ANY INPT MED gives you access to all Inpatient medications in your EHR formulary. Click on ORDER ANY INPT MED. 3

4 4. Complete the Medication Order. If you leave out any information, or have entered the order incorrectly, the EHR will give you a pop-up box with the details of what you must correct before accepting the order. Once you have entered the order, click on Accept Order. 5. At this pop-op, click Accept Order. The EHR is letting you know that it is checking on this EHR only and not with other EHRs on the Internet. 4

5 6. Once back on the Orders tab, you can now release the order. Being a student you cannot place an order and sign the order as a provider. The steps you will be following are placing an order on behalf of a provider (or on behalf of your faculty.) 7. Highlight the order(s) and click on the Action Menu > Release without MD Signature. 8. Check the order for accuracy. Click Continue. 5

6 9. Click on the Policy button and click OK. You are releasing these orders per policy. If you attempt to release the orders per a verbal or telephone order you will receive an error message and you will not complete the order process. 10. Release the order by entering your Username. Click OK. 6

7 11. This screenshot shows the order released with a status of Pending. This status is related to the EHR program, the Auto-Pharmacist. The Auto-Pharmacist acts as a real pharmacist does in practice by electronically approving and releasing the order. 12. Click on the File Menu > Refresh Patient Information to have the order move from Pending to Active. 13. To place an order for an IV fluid, select the IV Order Menu. Enter all of the information needed to complete the order. Note that the Duration or Total Volume is entered as 90 days. This can be set for any duration. But keep in mind, if you enter the order for 8 hours it will truly expire in 8 hours. Check with your instructor for the Duration of the order. Click on Accept Order when completed. 7

8 14. To place other orders for the Inpatient Setting, click on any of the other Order Menus that are appropriate for inpatients, i.e.: A/D/T, Procedures, etc. For this example, click on the PATIENT CARE Order Menu. 15. The orders you see listed on this screen are Quick Orders. You may select one of them if you would like. Or by clicking on TEXT ONLY ORDER you are able to enter free-text orders. This Order Entry is used frequently for vital signs, diets, consults and so on. It allows more freedom in the content of the order. Click on TEXT ONLY ORDER. 16. Enter the order as you would like it to show in the chart. Optional: selecting the Start Date/Time and Stop Date/Time. Once you have entered your order click on Accept Order. 8

9 17. Once back on the Orders tab you can now release any orders you have entered. Follow the same steps as you did with steps #6-12 of entering inpatient orders. 18. Check the order for accuracy. Click Continue. 19. Click on the Policy button and click OK. 20. Release the order by entering your Username. Click OK. 21. Click on the File Menu > Refresh Patient Information to move any Pending orders to Active. 22. Note that the orders have a Service category. This is not an important element of the order and does not affect who can see or fulfill the order. The most important part of any order is the order itself, the start date, stop date and the order status (pending, active, expired, or discontinued). 9

10 What else can I do with orders? Most commonly used Actions Change This allows you to change any component of an order. I.e. the dose, or add a comment. Copy to New Order Use this option when an order has expired and you need to Reactivate the order. This will also reactivate the medication in the emar allowing the medication to be documented in the patient s emar as being given, using a barcode or not having a barcode available. Use this option instead of the Renew option for expired medications. Hold - Only active orders may be placed on hold. Orders placed on hold will continue to show under the ACTIVE heading on the profiles until it is removed from hold. An entry is placed in the order s Activity Log recording the person who placed/removed the order from hold and when the action was taken. Flag - You can flag an order to draw attention to it. When an order is flagged, the order will appear on the Orders tab with a red box in the service column. The order will remain flagged until someone "unflags" the order. CPRS (the EHR) records the name of the person who flagged the order and the date and time that it was flagged. Unflag - You can remove the flag from an order very simply. You can enter a reason for removing the flag, but CPRS does not require you to enter a reason. In the order's detailed display, CPRS will record the name of the person who removed the flag and the date and time that person removed it. Verify - shows that the nurse has seen the order. When a nurse (or student) verifies an order, the nurse's initials are then placed in the appropriate column on the Orders tab. 10

11 Different Views of orders Selecting Custon Order View is the most commonly used option. You may select All to view all orders ever written in the chart. You may select to change the Chronolgoical Sequence of the orders. 11