training Computerized Physician Order Management (CPOM): Medical Staff Training

training Computerized Physician Order Management (CPOM): Medical Staff Training

Table of Contents CarePoints Performance...4 VMView System Requirements...4 What is CPOM?...5 Current Encounter... 5 Inpatient Summary... 6 Documented Medications by History... 8 Medication Reconciliation... 8 Admission Medication Reconciliation... 9 Diagnoses and Problems... 11 Working with Diagnoses/Problems... 11 Adding Diagnoses/Problems... 12 Adding Diagnoses/Problems to Favorites Folder... 13 Display Options... 13 View Details... 13 View Comments... 13 View Problem History... 13 Modifying a Diagnosis/Problem... 14 Changing Problem Status... 14 Adding a Problem to the Diagnosis List and Vice Versa... 14 Medline Search in Diagnosis List or Problem... 14 Order Set & Orders Overview... 15 Orders Tab... 15 The Navigator... 16 The Profile View... 17 Additional Display Options & Customize View... 18 Customizing the Orders View... 19 Orders Buttons and Icons... 20 Order Statuses... 21 Order Sets... 22 Searching for and Selecting Order Sets and Orders... 22 Selecting Orders within an Order Set... 24 Sub-Phases... 25 Adding a Single Order to an Order Set... 25 Order Sentences/Details... 25 Merging Views... 26 Discontinuing an Individual Order in an Order Set... 26 Duplicate Orders... 26 Completing the Ordering Process for an Order Set... 27 Placing an Order Set in a Planned Status... 28 Initiating a Planned Order Set... 29 Viewing and Ordering Excluded Orders in an Order Set... 29 Discontinuing an Order Set... 30 Voiding an Order Set... 30 Favorites Folders... 31 Adding Order Sets and Orders to Favorites Folders... 31 Accessing Favorites Folders... 32 5/9/2011 2

Organizing Favorites Folders... 32 Deleting Orders from Favorites Folders... 33 Patient Care Orders... 33 Searching for and Selecting Orders... 33 Order Sentences... 33 Order Details Tab... 34 Signing Orders... 35 Canceling/Discontinuing Orders... 35 Viewing Order Details/Information... 36 Medication Orders... 36 Orders for Nurse Review... 39 Pharmacy Verify... 39 Physician Cosignature... 39 Transfer Medication Reconciliation... 40 Reconciliation History... 41 Depart Process... 42 Discharge Diagnosis... 43 Discharge Medication Reconciliation... 44 Prescription Writer... 45 Continuing IV Medications Post Discharge... 46 Orders... 47 Discharge Order... 47 Follow-up... 49 5/9/2011 3

CarePoints Performance Please take into consideration the impact that each of the factors listed below can have on CarePoints performance: A large number of incomplete records in Message Center will slow performance. Slowness will occur if custom patient lists are not maintained. Custom lists require the user to manually add and delete patients from the list. Individual patient records that contain a large amount of clinical information may slow performance. Increasing the search criteria perimeters beyond the Hospital designated look back can slow system performance. VMView System Requirements Below are the optimal/recommended and minimum system requirements to connect to Southwest General Health Center s VMView remote access solution. Operating System Optimal recommendation: Windows 7 (32 or 64 Bit) Memory, CPU and Disk optimal recommendations: 4 Gigabytes RAM, Intel Core i3 or greater 200MB free hard disk space. Broadband Internet Connection optimal recommendation: 5 MB download speed or greater. If you access from behind a firewall, tcp/udp port 4172 outbound must be allowed. Minimum Supported Requirements: Operating Systems supported: Windows XP SP3 (32 bit only) Windows Vista SP1 or SP2 (32bit only) Windows 7 or Windows 7 SP1 (32 bit and 64 bit) Mac OS X Leopard 10.5 and Snow Leopard 10.6 : *Due to technology limitations within the Mac Client, performance can be significantly slower. A Broadband connection of 5MB or greater is highly recommended. Memory, CPU and Disk requirements: Windows XP SP3: 2 Gigabytes RAM, Pentium 4 or greater, 200Mb free space. Windows Vista SP1 : 2 Gigabytes RAM, Pentium Core or Greater, 200Mb free space. Windows 7 (32 bit and 64 bit): 2 Gigabytes RAM, Pentium Core 2 or greater, 200Mb free space. Mac OS X Leopard 10.5 and Snow Leopard 10.6 2GB RAM, Pentium Core 2 or greater, 200 Mb free space. Broadband Internet Connection recommendation: 2 MB download speed or greater. If you access from behind a firewall, tcp/udp port 4172 outbound must be allowed. (Cable broadband is preferred over DSL. Please check with your city services department to see what Broadband options are available in your area) 5/9/2011 4

What is CPOM? Computerized Physician Order Management (CPOM) allows physicians to place Order Sets, medication orders and individual patient care orders on their patients from within the hospital, their office or home. It provides the physician with the opportunity to manage their patient s care from anywhere at any time. In addition, CPOM will improve the quality and coordination of care, provide standardization and efficiency across the organization while reducing errors and length of stay. Current Encounter It is important to be sure that the patient s chart is open to the correct encounter. Check by looking at the Status: Inpatient Admit and Dischg on the Demographic Banner (1). To change the encounter, click on the Location link (2). From the Custom Information window, double click on the correct encounter (3). Select Yes to change the chart to the selected encounter. Click OK. 1 2 3 5/9/2011 5

Inpatient Summary The Inpatient Summary pulls important information from various places within the patient s chart. It allows for interactivity with the chart and is designed to better facilitate the care and monitoring of the patient. Some sections will automatically default open while others remain collapsed. Temporarily expand or collapse sections by clicking on the plus and minus signs for each section. Certain sections provide a hyperlink to the information within the chart. For example, clicking on the section label for Labs will open the Result Review page within the chart. Hovering over a result with the cursor will display additional information about the result. Results can be graphed by double clicking on the underlined result category. 5/9/2011 6

The layout of the Inpatient Summary can be customized to meet each physician s needs. To do this, click on Customize located in the upper right corner. Click and drag the result headers to where you would like them to appear. Click on the (+) Expand or (-) Collapse icons to customize how you would like each section to display. Click on Save Preferences to save your customizations. Order Sets/Orders can be added directly through the +Add button on the New Order Entry tab of the Inpatient Summary TIP: The Inpatient Summary can be customize to assist with the physician s workflow. 5/9/2011 7

Documented Medications by History Documented home medications are the basis for accurate medication reconciliation. The Status icon for Meds History (located in the upper right corner) changes from an exclamation point to a checkmark on the Orders, Medication List and Document Medications by History pages when the Medication History is completed. Hovering over the status with the cursor displays information about the Meds History. TIP: Once an Admission Medication Reconciliation has been completed, the status of all home meds will change from Documented to Suspended. Medication Reconciliation Computerized Physician Order Management (CPOM) allows physicians to complete the medication reconciliation process electronically. The electronic process provides the patient with a clear, concise Discharge Medication Reconciliation. Reconciliation for Admission, Transfer and Discharge can be accessed from the Orders or Medication List pages. The button is located in the top left corner by the +Add and Document Medication by Hx buttons. 5/9/2011 8

Admission Medication Reconciliation Each medication must be addressed and the decision made whether to: Continue convert the home medication into an inpatient order Do Not Continue suspend the medication for the encounter Documented home medications are denoted by a scroll icon. Medications with the orange icon have not been addressed. The left side of the screen lists the medications prior to the reconciliation. The right side lists those after the reconciliation. Home medications display the status of Suspended after the Admission Mediation Reconciliation is completed. The Inpatient icon indicates medications that have been converted to an inpatient order. Medication orders that have required details will display the icon. 5/9/2011 9

Home medications do not always match with the hospital s formulary. Therefore, when converting a home medication into an inpatient order, a window may appear asking you to choose from the formulary list. TIP: This may also occur during Discharge Medication Reconciliation when continuing a medication at home or converting an inpatient order to a prescription. Once all medications have been addressed click the Reconcile and Sign button. The Admission Medication Reconciliation is complete which is indicated by the green checkmark icon. TIP: It is extremely important to complete the Admission Medication Reconciliation before entering any new inpatient medication orders. Not doing so will require Medications by History AND the new inpatient medication orders to be reconciled as part of the Admission Med Rec process. TIP: Signing an Admission Medication Reconciliation prompts for biometrics verification. 5/9/2011 10

Diagnoses and Problems Diagnoses are physician driven and only pertain to the current encounter. TIP: The Problem and Diagnoses lists are visible in the Order Entry window. The Problems functionality allows a caregiver to enter problems affecting a patient s health and are generally nursing driven. Problems follow a patient from encounter to encounter, providing a historical list of issues which the clinician can view from visit to visit. TIP: Problems should be reconciled upon admission and reviewed throughout they stay. They should be documented for the current encounter only. TIP: The Problem list features a duplicate checker to avoid entering the same problem more than once. Working with Diagnoses/Problems The functionality of working with both Diagnoses and Problems are nearly identical. The top half of the screen displays Diagnosis information entered while the bottom half displays Problem information entered. The Mark All as Reviewed icon allows the user to date and time stamp the list of Diagnoses and Problems in order to track the last time the lists were evaluated. 5/9/2011 11

Adding Diagnoses/Problems Click on the Add button in the appropriate section to add either a Diagnosis or Problem. The screen will focus on the type of entry chosen. In the Search box, enter the first few letters of the diagnosis/problem in the yellow required field. Click on the Binocular icon to search or hit Enter on the keyboard. Select the correct Diagnosis or Problem from the search window by either double clicking or highlighting the name and clicking OK. Once a Diagnosis/Problem is selected, enter important details and any comments. TIP: Verify that Classification defaults to Medical Clicking on the Show Additional Details link allows the user to enter more information about the Diagnosis/Problem. 5/9/2011 12

Adding Diagnoses/Problems to Favorites Folder To add a Diagnosis/Problem to the Favorites folder, highlight the name in the search list and click on the Add to Favorites button. This will prompt the user to select a folder or create a new folder in which to save the Diagnosis/Problem much like the process of adding an Order to the Favorites folder. Display Options Both lists allow the user to select what type of status displays: All, Active, Active & Inactive, Inactive, etc. Select from the appropriate drop down menu. View Details Right click on the Diagnosis/Problems and select View Details to view the information documented. View Comments Comments may be entered initially or when modifying a Diagnosis/Problem. The icon indicates the presence of a comment. Hovering over the icon will display the comment. View Problem History To view the history of a Problem, right click on the problem and select View Problem History. The history window displays entered and modified details. Updates are displayed in reverse chronological order. Click on the plus sign icon to expand and view older updates. 5/9/2011 13

Modifying a Diagnosis/Problem To update a Diagnosis/Problem right-click and select Modify The Diagnosis/Problem and previously entered information will display. Make the necessary changes or updates and click OK. Changing Problem Status Activating a Problem If an Inactive or Resolved Problem needs to be reactivated, Modify (see above) and change the Status in the drop down to Active. Canceling a Problem A Problem may be canceled by Modifying (see above) and changing the Status to Canceled in the drop down. A prompt will require the user to also choose a Reason. Inactivating a Problem A Problem may be Inactivated by Modifying (see above) and changing the Status to Inactive. The Problem will remain on the Profile in an Inactive Status. The change in Status will also display in the Problem History. Resolving a Problem A Problem may be changed to a Resolved Status by Modifying and selecting Resolved. The problem will remain on the Profile as a Resolved Status. The change in Status will also display in the Problem History. Adding a Problem to the Diagnosis List and Vice Versa To add from one list to another, either drag and drop or right-click and select Add to Problem List/Diagnosis. Medline Search in Diagnosis List or Problem Performing a Medline Search can help the user learn more about a Diagnosis/Problem by accessing reference materials and articles. Click the icon next to the Diagnosis/Problem. The Diagnosis/Problem name populates the search field. Make other selections pertaining to Category and Publication Type as appropriate. Select Search or choose Go to Citation Matcher to search by a specific journal or article. 5/9/2011 14

Order Set & Orders Overview Orders Tab Once Medications by History, the Admission Medication Reconciliation and Diagnosis has been completed, Orders Sets and orders may be entered on the patient. The Orders tab can be found around the middle of the Menu. This component allows you to view the orders and Order Sets entered on the patient, add order sets/orders for the patient, add diagnoses and problems and sign phone/verbal orders that were entered on your behalf for the patient. The Orders page is divided into two sections: the Navigator and the Profile View NAVIGATOR PROFILE VIEW 5/9/2011 15

The Navigator The Navigator is located on the left side of the Orders page. It is organized into a directory tree. The main categories of the tree include: Orders for Signature, Plans, Suggested Plans, Orders and Reconciliation History. Clicking on the category name will display that category in the Profile View. Orders are organized into Clinical Categories. Categories in bold font contain active orders. A check in the box next to the category name indicates the category is included in the Profile View on the right side of the window. Unchecking the box will temporarily exclude it from the Profile View. Recheck the box to include it in the Profile View. Clicking on the name of a category will focus the Profile View on the right to that category. The Navigator may be collapsed to allow for additional display area in the Profile View on the right. Click the left facing arrow icon located in the upper right corner of the Navigator to collapse. Re-expand the Navigator by clicking the right facing arrow icon collapsed. that appears when the Navigator is 5/9/2011 16

The Profile View The Profile View is located on the right side of the Orders page. It is also organized by Clinical Categories. The categories are indicated by the light blue dividers. Orders can be sorted within the Clinical Categories by clicking on a column header; for example click on Order Name to sort alphabetically or Status to sort by Ordered, Suspended, Discontinued; etc. TIP: Use the Display drop down to change the type of order status(es) that display. TIP: indicates there is reference text associated with the order. Click the icon to view. 5/9/2011 17

Details with an ellipsis ( ) contain additional information that cannot be displayed in the allotted space. Hover over the order details to view the additional information. Additional Display Options & Customize View Click on the ellipsis button to change or select additional order display filters. Click New to create, name and save a custom filter based on the available selections. 5/9/2011 18

Customizing the Orders View The Orders View can be customized to control: how the columns appear in the Order Profile the order in which the columns display how orders are grouped and/or sorted click the link in the upper right corner above the Order Profile. TIP: Be sure that the Type column is always selected and is the first column (at the top of the list). This displays the icon which indicates Inpatient versus Documented Home Medications. 5/9/2011 19

Orders Buttons and Icons Active and Inactive Orders - A check mark indicates that the order is currently active. Click the check mark to discontinue. Completed or Discontinued orders do not display check marks because they are no longer active. Add - Add an order. Add to Phase Add a single order to a pre-existing Order Set. Clinical Calculator Either button launches a calculator with available conversion formulas. Discontinue/Cancel Discontinue an Order Set. Dose Calculator - Launches the dose calculator for medication dosing. Excluded In an Order Set, an order that is currently excluded or not selected, but may be included or selected by clicking the check box. Expand and Collapse - A plus sign indicates that the item can be expanded to view additional sub-categories. The minus sign means that the item is expanded and can be collapsed. Expand and Collapse (Navigator, Details) Use the arrows to expand or collapse the Navigator (left and right) or the Order Details section (up and down). Included In an Order Set, an order that is currently included or selected, but may be excluded or deselected by clicking the check box. Initiate An Order Set needs to be Initiated before it is Signed to activate the orders and tasks. Signing an Order Set before Initiating places it into a Planned status. Merge View In an Order Set, merges pre-existing orders with those in the Order Set to avoid duplication of orders. Missing Required Details - Required details that have not been completed can be easily viewed and accessed by clicking on the Missing Required Details button. Keeps a running count as details are completed. Nurse Review - Indicates that Nurse Review of the order is required. Order Details Not Complete - Indicates that there are required order details that have not been completed for the orderable. These must be addressed before the order can be signed. Order Set - Indicates an Order Set or an Order that is part of an Order Set. Orders for Nurse Review The recommended location for nurses to review orders. Orders for Signature Displays a list of the current orders in the Order Profile window that need to be signed. Physician Cosign - Indicates that physician cosign is required for the order. Physician Cosign Refusal - Indicates that the physician has refused to cosign the order. 5/9/2011 20

Reference Text - Indicates there is reference text associated to the order. Renew Indicator - Hard Stop Policy Indicates the order will be stopped when its expiration time is reached. A user must intervene to continue this order. Required In an Order Set, an order that cannot be excluded or deselected. Denoted by the gray or dithered background of the check box. Rx Refusal Indicator - Indicates that a pharmacist has rejected the order. Rx Verify Indicator - Indicates the order is subject to pharmacy review and has not yet been reviewed by a pharmacist. Sign - Signs all orders currently displayed in the Order Profile window and sends them from Order status to Processing status. Sliding Scale - Opens the Sliding Scale dialog box. Taper Dosing- Opens the Taper Dose Tool. View Excluded Components In an Order Set, shows the orders that were not included or selected ( ) when the Order Set was Initiated and Signed. Order Statuses Order the order needs to be completed and signed Processing an order is Processing until it is updated by clicking on the Refresh button Ordered the order is entered, signed and updated (by clicking the refresh button) Completed an order has reached the defined stop time/date or the necessary tasks/procedures have been completed Pending Complete when one or more of the orders (but not all) in an Order Set have been completed or the Order Set has reached its defined stop date and time but still has tasks that have not been completed. Discontinued An order with a frequency or interval associated with it can be discontinued after the procedure or medication has been administered at least once. The Multum drug interaction checking continues for Discontinued orders for their defined time frame. Canceled orders can be canceled to stop them immediately. Some orders may change to discontinued depending on certain conditions. Planned A status of Future is applied to orders with a start date and time that is in the future. Preadmit orders not yet assigned to an encounter are given an order status of Future. Suspended orders with frequencies can be suspended then resumed. If the stop date/time have passed the order must be reentered. 5/9/2011 21

Order Sets An Order Set is a group of orders, which may include medication orders, relating to a condition or course of treatment. Order Sets are more convenient to order, opposed to individual order entry, and can be customized based on the needs of the patient. Searching for and Selecting Order Sets and Orders Order Sets and individual orders are searched for using the same methods. Order Set/Order entry may be initiated through the +Add button on the Inpatient Summary, the Orders page or the +Add button on the Menu. This will launch the Add Order window. The left side of the Add Order window includes the Diagnosis for the patient s encounter and Problems that have been entered on the patient. Diagnosis and Problems can also be entered from this window. The right side of the window is the area for searching for and placing Order Sets/Orders. Begin by typing the name of the Order Set/Order in the Find field. Order Sets are named according to the service and paper order set they replaced. They are indicated by the yellow Order Set icon. TIP: Order Sets use naming conventions such as ED, CARD, ORTHO, OBGYN, etc. 5/9/2011 22

It is important to note whether the search criteria is set to Starts With or Contains. Starts With = finds any Order Set /Order that begins with the letter(s) typed into the field. This provides a narrower search, but is the preferred way to search for orders and Order Sets. Contains = finds any Order Set/Orders that includes the letter(s) typed into the field. This provides a broader search. Select the Order Set/Order by SINGLE clicking on the name of the order in the list. TIP: The search criteria filter (Starts With versus Contains) will default to the last selection used the next time a user logs in. 5/9/2011 23

After SINGLE clicking on the Order Set/order name it displays as bold and blue. Multiple Order Sets/Orders can be searched for and selected consecutively. Once one order is selected, type the next order name into the search field then select from the list. Once all orders have been searched for and selected, click the right corner of the Add Order window. button in the lower Selecting Orders within an Order Set The Profile View will focus to the selected Order Set. Orders within the Order Set are either: Gray check box with checkmark Required: cannot be excluded from Order Set (example below Vital Signs) White check box with checkmark Included: can be excluded from Order Set by unchecking (example below Intake and Output) White check box without checkmark Excluded: can be included in Order Set by checking (example below Acetaminophen) 5/9/2011 24

Sub-Phases Sub-Phases may be contained within an Order Set and are indicated by the icon. Click on the name of the Sub-Phase to open it and include, exclude or make changes to order details. Click the Return to.. button to go back to the Order Set. Sub-Phases are also listed in the directory tree under the main Order Set s name. Adding a Single Order to an Order Set Individual orders may be added to an order set by clicking the +Add to Phase button in the upper left corner. Select Add Order, search for and select the order(s). Order Sentences/Details Orders with the icon have required details that must be addressed before signing. These may be satisfied by selecting an order sentence or entering order details on the line. Order sentences may be selected for any order with the button. Click on the arrow to display available order sentences. Identical to single orders, order details may also be added by double clicking on the details line. 5/9/2011 25

Merging Views Clicking the Merge View button in the upper left corner will merge the orders in the Order Set with orders that are already ordered and active. Orders under the light blue divider and preceded by the smaller check box ( ) are those that are part of the Order set. Orders already ordered are under the dark blue divider and preceded by the larger, pre-checked check box ( ). Individual orders may be discontinued at this time by either right clicking the order and selecting Cancel/DC from the menu or unchecking the box on the order line. Discontinuing an Individual Order in an Order Set Individual orders in an Order Set may be discontinued by either right clicking the order and selecting Cancel/DC from the menu or unchecking the box on the order line. Duplicate Orders Attempting to place an order that is already active in the patient s profile may prompt the Duplicate Order Alert. Range Orders for medications may also appear. For each duplicate order set select either: Order Anyway places the new order Remove deletes the new order Cancel/DC select the current active order to Cancel/DC Modify allows the Order Details to be changed before placing the new order TIP: It may not always be necessary to remove duplicate orders; some duplicates may be relevant to the care of the patient. 5/9/2011 26

Completing the Ordering Process for an Order Set The following steps must be completed to order and activate the Order Set. 1. Initiate Once all orders have been selected/included/excluded/added and details completed the Order Set must be initiated. The Initiate button is located in the lower right corner. After clicking on the Initiate button all orders included in the Order Set will now display the icon. TIP: Signing an Order Set without Initiating it first places the Order Set in a Planned status. It may be Initiated at a later time. 2. Orders for Signature Display all orders available for signature by clicking the Orders for Signature button. This step removes all unchecked orders from the Order Set and only displays the orders that were selected. 3. Sign Sign the orders by clicking the Sign button. TIP: Any required Order Details that have not been completed must be addressed before signing. TIP: Duplicate orders must also be addressed at this time. TIP: Signing medication orders as part of an Order Set prompts for biometric verification. 5/9/2011 27

4. Refresh After clicking the Sign button, the following message appears: Click the Refresh minutes ago button to complete the ordering process. The status of the Order Set is (Initiated) and the individual orders are Ordered. Orders that were placed as part of an Order Set are indicated by the View. icon in the Profile Placing an Order Set in a Planned Status To place an Order Set in a Planned status for Initiation at a later time - click Orders for Signature Sign Refresh. TIP: Do Not click the Initiate button or the Order Set will be initiated immediately. 5/9/2011 28

Initiating a Planned Order Set To initiate a Planned Order Set, follow steps 1-4 for Completing the Ordering Process for an Order Set. Viewing and Ordering Excluded Orders in an Order Set To view orders that were originally excluded from the Order Set, click the View Excluded Components icon in the upper left corner. Orders that were initially excluded from the Order Set will display with a orders may now be included by clicking the check box(es) and signing. check box. These TIP: This is a toggle switch; click it again to turn this feature off. 5/9/2011 29

Discontinuing an Order Set Right click on the Order Set name in the Directory Tree and select Discontinue. A reason for discontinuing the Order Set may be selected from the drop down. Complete by clicking,, and. TIP: You can keep individual orders by checking the Keep check box. Voiding an Order Set An Order Set may be voided (similar to Unchart) by right clicking the name in the navigator and selecting Void. 5/9/2011 30

Favorites Folders Adding Order Sets and Orders to Favorites Folders Frequently placed Order Sets/Orders can be added to Favorites folders. Folders created by individuals are specific to that user. Search for an Order Set/Order in the Add Order/Find window. Right click on the order and select Add to Favorites. Click the New Folder button to create and name additional folders. After naming the folder click OK. 5/9/2011 31

The order will be saved into the folder which is highlighted. In this example, the Ambulate order will be saved into the Activity folder. To add an order to an existing folder, right click on the order name in the search window, select add to favorites, click on the folder name then select OK. Accessing Favorites Folders In the Add Order window, click on the Favorites icon to access the Favorites folders. Select orders in the same manner described in the Selecting Orders section. Organizing Favorites Folders The Favorites folder organizing tool is accessed through the Down Arrow button of the Favorites icon. to the right From the organize favorites window choose from the following: Create folder makes a new folder. Rename click the rename button to rename an item. It will automatically be resorted if Sort Favorites Alphabetically is selected. Move to Folder to move orders from folder to folder either manually drag and drop or select the Move to Folder button. Delete select a folder to remove it and all of its contents or select an individual order to delete. Sort Favorites Alphabetically (checkbox) sorts the folders alphabetically. Deselecting will set them back to the original order. Up/Down Arrow icons resequence folders or orders within folders. This option is not available if Sort Favorites Alphabetically is selected. 5/9/2011 32

Deleting Orders from Favorites Folders Open the Favorites folder with the icon in the Add Order window. Open the folder containing the order. Right click the order name and select Remove from Favorites. Patient Care Orders Searching for and Selecting Orders Patient care orders are searched for using the same methods used to seach for and select Order Sets. TIP: See Searching for and Selecting Order Sets & Orders in the Order Set section. Order Sentences If Order Sentences are available for an order, they may be selected from the Order Sentences window. If none of the Order Sentences apply to the order, (None) should be selected. Additional or different Order Details may be entered later. Once all orders have been searched for and selected, click the right corner of the Add Order window. button in the lower 5/9/2011 33

Order Details Tab Some orders have required details, indicated by the Required Details icon. These must be completed before the order can be signed. Double click the Order Details to access the Order Details tab or right click and select Modify Planned Order. The left side is a list of available Order Details. Required details are highlighted in yellow. The right side lists the Detail Values associated with the selected Order Detail. TIP: Use the arrows to navigate through the order details. Required order details are highlighted in yellow. Any required details that have not been completed can be easily viewed and accessed by clicking on the Missing Required Details button in the lower left. TIP: Use the up & down arrows to expand or collapse the Order Detail entry area. 5/9/2011 34

Signing Orders Once all Order Details (required or otherwise) have been entered, click the Sign button in the lower right corner. If any required details were missed, the following alert box will appear: Click the First Detail button to be taken to the first missing required order detail. A signed order is in a Processing status and inactive until the screen is refreshed. Clicking the Refresh button in the upper right corner Ordered and the order is now active. changes the status to Canceling/Discontinuing Orders To cancel an order, right click the order and choose Cancel/DC or click the check box on the order line. If the cancel option is not available, all or part of the order has been completed. TIP: Cancel multiple orders at one time by holding down the Ctrl key on the keyboard and selecting the orders. Right click on a selected order and choose Cancel/DC. Click the Orders for Signature button order details were omitted the alert window will appear. then the Sign button. If any required Click the Refresh button to complete the cancellation process. 5/9/2011 35

Viewing Order Details/Information Order Details may be viewed in the Profile View under the Details column. Details too large to fit in the column are indicated by an ellipsis ( ) and can be viewed by hovering over the Details with the cursor. Order Information may be viewed by clicking on the name of the order in the Profile View or right clicking on the order and selecting Order Information from the menu. Details displays the current details for the order. Ingredients Comments displays order comments and/or MAR notes entered for the selected order with the most recent listed first. Validation indicates who reviewed and cosigned the order Additional Info displays the order name, start time, stop time, order ID number and status. History displays each action taken on an order in reverse chronological order. The initial order action displays the order details. Subsequent modifications show Before and After detail information for comparison. Results displays Results Review for easy reference. Click the Exit button when finished. Individual orders may be discontinued at this time by either right clicking the order and selecting Cancel/DC from the menu or unchecking the box on the order line. Medication Orders Medication Orders are placed in the same manner as patient care orders and can be added through the Orders page or the Medication List page. = Inpatient Order = Documented Home Medication = Prescription (discharge) TIP: indicates a Nurse Review of the order is required. 5/9/2011 36

TIP: Allergy information must be documented on the patient before entering any medication orders (including those in Order Sets, home medications and medication reconciliation.) If this information is not documented an alert boxe will pop up. TIP: If a medication is to be given on a frequency as well as available on a PRN basis, two separate orders must be entered. TIP: Range orders (ex. 1-2 tablets) must be entered separately. Search for and select the medication. Select an Order Sentence if appropriate. Order Sentence Details can be changed before signing the order. TIP: Signing medication orders prompts for biometric verification. TIP: indicates the need for pharmacy verification. Medication Orders are to be verified by Pharmacy BEFORE administering the medication to the patient; unverified med orders generate a warning box. Select units will have auto verification of medication orders. 5/9/2011 37

Alerts appear if interactions exist between the medication being ordered and documented allergies, other ordered medications, dosing, etc. Address alerts as clinically appropriate. TIP: An override reason may be selected for each interaction or applied to all interactions. TIP: Selecting Yes to Scheduled / PRN will organize the order under the PRN section on the MAR Summary and will require a nurse to document a PRN Reason. 5/9/2011 38

Orders for Nurse Review Orders requiring nurse review are indicated by the eyeglasses icon: Pharmacy Verify Pharmacy verification of medication orders is required before a nurse may administer the medication(s) to the patient. The icon indicates the need for pharmacy verification. TIP: An unverified medication will prompt a warning box when attempting to administer. Physician Cosignature Physicians are required to co-sign orders entered on their behalf. The need for a physician cosignature. icon indicates the Telephone and verbal orders can be signed by a physician from within a patient s chart by clicking on Orders for Cosignature 5/9/2011 39

A pop up window will appear allowing the physician to view the order actions requiring cosignature and the physician can sign off on them by clicking cosign Check or uncheck the Select All box to control which orders are being co-signed Transfer Medication Reconciliation Transfer Medication Reconciliation works in the same way as an Admission Medication Reconciliation. The physician must address all medications (home and inpatient medications are listed) and decide whether to continue the order or not upon a change in the level of care. 5/9/2011 40

Home medications that were continued upon admission are shown as Suspended, but with their associated inpatient order. The left side lists the medications prior to the reconciliation; the right side lists those that will be continued after transfer. TIP: Signing a Transfer Medication Reconciliation prompts for biometric verification. Reconciliation History Clinicians may view Medication Reconciliations through the directory tree in the Orders Navigator. The Reconcile History displays in the Profile View on the right for the chosen medication reconciliation. TIP: This is helpful to clinicians for patients that have multiple transfers. 5/9/2011 41

Depart Process The Depart Process includes Discharge Diagnosis, the electronic Discharge Medication Reconciliation, Orders and Follow-up. Click on the Depart Process icon Depart Process. located on the action toolbar to launch the The icons next to each Action indicate: = No Action Taken = Action Taken = Action Complete Open each Action with the icon. Actions highlighted in yellow are required and must be completed before Signing. Nursing will complete the Nursing DischargeSummary and Sign/Print the report for the patient. Some actions without a definite finishing point for example, Diagnosis and Orders, need to be manually completed by clicking on the circle icon. 5/9/2011 42

Discharge Diagnosis Selecting the Diagnosis Action in the Depart Process gives the physician access to the Diagnosis and Problems entry window. A Discharge Diagnosis should be documented by the physician at this time. Please note the defaults for Diagnosis Type = Discharge, Confirmation = Confirmed and Classification = Medical. Once the discharge diagnosis has been addressed click on the cirle to indicate that this area has been completed. TIP: For detailed instructions see the Problems and Diagnoses section. 5/9/2011 43

Discharge Medication Reconciliation The Discharge Medication Reconciliation addresses all medications (home and inpatient) individually. For each medication order select one of the following: Continue After Discharge Home medications will automatically resume and Continue After Discharge (it is assumed that the patient already has a prescription for this medication). Selecting this option for an Inpatient Medication will automatically convert it to Create New Rx (it is assumed that the patient will need a prescription for this new medication). Create New Rx 1. Select this option to print a prescription for the patient to leave with. Do Not Continue After Discharge 2. This option will not resume the home medication or convert the inpatient medication to a prescription. Home Medications automatically default to a Continue After Discharge status and are considered addressed so they do not display the orange icon. 5/9/2011 44

Prescription Writer TIP: Prescriptions must be called into a pharmacy if the Discharge Medication Reconciliation is completed by an RN on behalf of the Physician or is completed remotely by the Physician. Medications that are given as a new prescription are indicated on the right side of the screen with a icon. Order details must be addressed for these medications. TIP: Use the Missing Required Details Details for prescriptions. button to open the Order The order values (dose, frequency, etc.) default into the fields and may be changed as necessary. TIP: The Dispense quantity calculates based on the dose, frequency and selection of 30 (or 90) day prescription. Select a Send To option by clicking Select Routing; this field is mandatory. 5/9/2011 45

The available printer(s) are listed as well as the option(s) not to print (Do Not Send). Remember, if a nurse is completing the Discharge Medication Reconciliation on behalf of the physician, the physician must call prescriptions in to the pharmacy. Continuing IV Medications Post Discharge If a patient is being discharged to another facility (other then home) it may be necessary to add IV medications to the Discharge Medication Reconciliation. 1. Click on the +Add button in the upper left corner 2. Search for the IV medication 3. Address required prescription details by double clicking on the new IV medication 4. Select the approptiate Dose, Route, Frequency, Duration, Dispense and Refill fields 5. Review the rest of the prescription details and modify as appropriate, i.e. adjust the Start & Stop date/time accordingly 6. Click on the Send To drop down to display printing options 7. Select Do Not Send: Other so a prescription will not print 5/9/2011 46

Once all medications have been addressed and the Reconcile and Sign button has been clicked, the Discharge Medication Reconciliation is complete which is indicated by the checkmark icon. The Discharge Medication Reconciliation will print on the Patient Summary in easy to understand categories: New Medications Medications to Continue Taking That Have Changed (which includes dose and frequency changes and which medications to START and which medication to STOP) Medications to Continue With No Changes No Longer Take the Following Medications Orders The next step in the Depart Process is to submit the discharge order. Selecting the Orders Action gives the physician access to the Add Orders window as well as the Orders Page (Navigator and Profile View). Discharge Order Search for the word Discharge Single click on the Discharge Patient order Click Done 5/9/2011 47

The required details request the entry of a Start Date & Time for the Discharge: If you want to discharge the patient immediately type a T for Today in the date field and N for Now in the time field. If you wish to discharge the patient at a later date enter the date and time accordingly. If you wish to discharge the patient after the results of an exam or after consulting another physician free text the information into the special instruction area of the order detail values. Additional orders for discharge and medications may be placed directly within the Depart Process. Click on Special Instruction: Type the instructions in the Detail values area TIP: See the Orders section for detailed instructions TIP: The order Type defaults to Discharge Meds as Rx, however the Type may be changed to Inpatient allowing patient care orders to be placed. TIP: If interactions for medication orders are present, an alert will appear. 5/9/2011 48

Follow-up Add followup physicians by utilizing the Provider search box. Enter the physicians last name and click on the magnifying binoculars. Selest the appropriate physician. The names and addresses will display under the Selected Follow up box. You may also click on one or more of the Quick Picks and/or Predefined Comments to be added to the follow up instructions. If you have specific comments to make you can use the Edit Comments box. Click Sign when done. 5/9/2011 49

The physician components are now complete. Fill in the circles and close this view by clicking on the gray box in the upper right corner. Do not click on the RED box as this will close your CarePoints session. What you have just entered in the Depart Process will appear on the Patient Summary screen which will be finalized by nursing and printed out for the patient to take home. 5/9/2011 50