CPOE-Inpatient

Transcription

CPOE-Inpatient
Computerized Provider Order
Entry - Inpatient Provider
Basics
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
VIEW
(MENU)
Order Profile
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
Find box
Filter
Order Type
Diagnosis
Problems
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
Medications
o Sub-Phases
– ETC.
Order Set Components Cont...
• Check the
orders you wish
to include in the
Order Set




• More Details are
available by
clicking the down
arrow



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 SubPhase 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
Weight Based Medications Cont...
• 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

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
Alerts will fire for the same Orderable name
• Review the Orders and click the
appropriate action button below
• When finished, click the “OK” button to
complete the signing process
Keep
New Order
Remove
New Order
Change
New Order
Duplicate Order Alert Window Cont...
Alerts will also fire when an active Order exists
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...
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 struckthrough
• 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
Discharge Order Set Details Cont...
• Now click the Orders
For Signature button
to continue the
process...
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
Discontinuing the Order Set Cont...
• 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
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.
For further information about this module please contact
Cinda Cowen at 226-5366
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