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CPOE Reference Manual

TABLE OF CONTENTS

1. Admission, Transfer, Discharge Processes pg 3

Direct Admit pg 3

Admits from the Emergency Department pg 3

Newborn Admission pg 3

Transfer in Level of Care (Med- Surg to Critical Care, pg 3 Critical Care to Med-Surg, Acute care to F/G100, F/G200, F/G300 and vice versa)

Discharge Planning Orders pg 3

Discharge to TCU, Rehab or C-200 pg 4

Discharge to another facility pg 4

Discharge to home pg 4

2. Orders

Add On Lab Orders pg 4

Blood Product Orders pg 4

Verbal Orders and Order Communication Type pg 4

Radiology Orders pg 5

Downtime Orders pg 5

Paper Orders pg 5

Which Orders are paper and which are electronic pg 6

Diet Orders o Diet Instructions Nursing pg 7 o Diet Advancement Powerplan pg 7

Communication Orders pg 7 o Peak and trough or other drug level orders pg 7

PICC Lines pg 7

VTE Prophylaxis pg 7

3. Powerplans and Caresets pg 8

Powerplan: o Multiphase Powerplans pg 8 o Decision Alerts pg 8 o Planned Powerplans pg 8 o PA/NP ordering of narcotics pg 8 o Reference Text pg 9 o Unit Collect pg 9

4. Operative Workflow

Outpatient Scheduled Surgery pg 9

PACU ORDERS pg 9

Patients in Pre-admission pg 10

Inpatients going to the OR: pg 10

Patients boarding in PACU: pg 10

Emergency Department (ED) Patient Surgical Patient pg 10

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5. Nursing Staff Workflow

Order detail form pg 10

Nurse Review of Orders pg 10

Report Process pg 11

Task Management pg 11 Scheduled tasks Continuous tasks PRN tasks Documenting and completing tasks

Workflow for PCA pg 11

Workflow for Unit Secretary pg 12

Workflow for Nurse pg 12 Appendix I Completing Sub-Phase PowerPlan pg 13

Appendix II Adding Order to Your Favorites pg 14

Appendix III Adding Pre-Completed Orders to Your Favorites pg 15

Appendix IV Creating Favorites Folders pg 16

Appendix V Customizing and Saving and Order pg 17-18

Appendix VI Customizing Orders Page pg 19

Appendix VII Ordering Time Study Labs pg 20

Appendix VIII Orders Helpful Hints pg 21

Appendix IX Dose Range Checking pg 22

Appendix X Food Allergies pg 23

Appendix XI IV Titratable pg 24-25

Appendix XII Modify versus Cancel/Reorder pg 26

Appendix XII NP & PA Control Substance pg 27

Appendix XIII PCA HandHeld pg 28

Appendix XIV Reviewing Schedule pg 29

Appendix XV Tube Feeding pg 30

Appendix XVI Medication Reference Guide pg 31-35

Appendix XVII Nursing Workflow pg 36-38

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CPOE Reference Manual Orders, Powerplans and Workflow

Admission, Transfer, Discharge Processes Direct Admit

May use current process of calling orders to Telefax

May place planned orders on any Springfield Hospital Admission Admits from the Emergency Department

Admission order given verbally to ED nurse or entered in Cerner

Orders for care on nursing unit may be entered as a “planned powerplan,” given verbally to the nurse on the nursing unit after the patient is admitted, or placed as “initiated orders” after the patient is on the nursing unit and in the correct location in Cerner.

If patient will not be able to be admitted upstairs in a ____amount of time, if possible the patient will be transferred to the Clinical Decision Unit and the previously planned orders will be initiated. If there are no planned orders, the physician will be contacted for orders

Newborn Admission

The current process will be continued with the nurse initiating the Newborn Admission Powerplan with the communication type “physician signature required.” The orders will go to the physician in-box for signature.

Transfer in Level of Care (Med- Surg to Critical Care, Critical Care to Med-Surg, Acute Care to F/G100, F/G200, and F/G300 and vice versa)

Transferring physician will complete transfer med reconciliation

The transferring provider will modify or discontinue active orders as needed. Medication reconciliation will also be completed at transfer of level of care.

Discharge Planning Orders

Case Management Staff arrange for most post discharge care.

Below is a table providing information on how to order post-discharge care.

Details for these orders should be put into the order comments

Post Discharge Care Needed Order to be used

Assisted Living Arrangements Social Worker

Hospital to Hospital Transfer Social Worker

In-Patient Psych Admission/Transfer Social Worker

Long Term Acute Care Social Worker

Nursing Home Placement Social Worker

Rehab Evaluation Social Worker

Skilled Nursing Evaluation Social Worker

Home Equipment Care Coordinator

Home Health Care Eval and Treatment Care Coordinator

Home Infusions/Home Parental Care Coordinator

Hospice Care Care Coordinator

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Discharge to TCU, Rehab or C-200

The transferring physician will use the appropriate admission powerplan and place these orders in a “planned phase”.

The receiving physician will use the same powerplan and add their additional orders. The powerplan is initiated after the patient is in the correct bed in TCU or Rehab.

Medication Reconciliation should be completed by the discharging physician. Discharge to another facility

Use the paper facility to facility form

Complete Discharge Medication Reconciliation Discharge to home

Place the discharge order, completing the powerform. The information on this form will go directly to the Discharge Patient Summary.

Additional comments can be placed in the “order comments” field. These comments will not go directly to the Discharge Patient Summary, but can be added to the summary by the nurse. Quick Tip: If you use the same instructions on several patients, these instructions can be placed in the order comment field and saved to your favorites.

Orders Add On Lab Orders

If a provider wants to add a test to a specimen already sent to the lab, place a new order and state in the comments “lab has blood”.

Blood Product Orders

The ordering of blood products is a two step process. Providers will place both a Product Order Request and a Transfusion Order (if a transfusion is needed).

To simplify the ordering process we have created a Blood Product Orders Careset which includes the various products, type & screen and the option to order the transfusion all in one conversation. The transfusion may also be ordered separately by selecting the Transfuse order.

The paper form process for releasing blood from the blood bank will remain the same.

Verbal/Telephone Orders and Order Communication Types

Verbal/Telephone orders are discouraged.

Verbal orders may be accepted if: Verbal orders are to be limited to urgent situations where immediate written or electronic communication is not feasible. Use of verbal orders will be monitored. If a physician is noted to be an outlier, the MEC will be notified, and the physician may be requested to appear before the MEC to explain his/her verbal ordering practices. Excessive use of verbal orders may result in disciplinary action including suspension of privileges. Verbal orders are not allowed when the prescriber is present and the patient’s chart is available, except during a sterile procedure or in an emergency situation, in which case a repeat-back is acceptable. Verbal orders must be signed electronically within 48 hours.

Verbal/Telephone orders may also be accepted at night when the physician is not in the building or their office.

Because providers will now have the ability to place orders from any computer, the need for verbal/telephone orders will be decreased. If it becomes necessary to

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accept a verbal order from a provider, follow the basic order entry process. The provider must be on the phone with the nurse when taking telephone orders.

Drug interaction and duplicate checking alerts may display and the nurse can not override without the providers input.

When prompted to select an ordering provider, pay careful attention to select the correct provider and communication type. This will drive how the order is routed for co-signature.

Verbal – Goes to Provider Inbox for signature Written – Does NOT go to Provider Inbox o Written means you have a signed order on paper. Electronic – Any time you initiate an order set that has

been signed by the Provider, choose the communication type “Electronic”. Conditional: Does NOT go to Provider inbox. o Conditional means there is an electronic

communication order giving the nurse instructions to place an order if a condition is met, such as draw peak & trough prior to 4th dose.

Per Protocol – Does NOT go to Provider Inbox o Per Protocol means that the order is being placed

because there is a written approved protocol/guideline that allows it to be done.

Requires physician signature: Does go to Provider Inbox for signature. o Requires physician signature is used for orders that

can be placed by nursing or ancillary staff, are not verbal orders, and require a physician signature.

Note: The functionality of this Ordering Physician dialog box requires a name of the provider giving the order for the patient regardless of what communication type is selected.

Radiology Orders

Many radiology exams require preps.

If a prep is required, the prep will be attached as reference text to the order.

Pregnancy tests will be ordered by nursing as needed as a protocol order.

Creatinine orders will be placed automatically by the system as appropriate for in-patients who have not had a creatinine level within 48 hours.

If the patient has had a barium procedure within 7 days of many CT abdominal or pelvic exams, the patient should have a bowel prep. You can use the ”Radiology Bowel Prep“ powerplan to place the bowel prep order.

If the patient has had a previous contrast allergy, the “Radiology Contrast Allergy Orders“powerplan may be used to order pre-medications for the patient.

Downtime Orders

Paper orders will be used during computer downtime following the same current procedure.

Once the downtime is over, ancillary departments will enter their orders, and nursing will enter their orders.

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Paper Orders

The following order sets will be ordered using paper orders

Some orders may be on paper or may be electronic. (see table next page)

Paper or Electronic Orders Chart for Aug 23

Workflow Paper Electronic

Admissions

Admission - Direct x x

Admission from ED x x

Pre-admission x, use same process

Pre-OP/Procedure patient in SDS x, use same process

Admit -Medication Reconciliation Orders x

Procedure - Surgical Patients

Pre-Op/Pre-Procedure Inpatient Orders x

Intra-Op/Intra-Procedure Orders x

Anesthesia Pre-Admit/Pre-Op Orders (Outpatient) x

Anesthesia Pre-Admit/Pre-Op Orders (Inpatient)

x

Anesthesia PACU orders

x

In-Patient Surgeon PACU orders x

Outpatient PACU Surgeon Orders x

Post-Op/Procedure Inpatient Orders x

Post-Op/Procedure Outpatient (SDS) orders x

Anesthesia SDS orders x Labor and Delivery Patients

Observation x x

Planned C-Section Pre-op/Pre-admit x Planned C-Section Post-op x

Planned Induction - pre x x

Planned Induction - post x

Present in Labor x x

Discharge

Inpatient/Observation to home x

Inpatient/Observation to TCU, Rehab, Senior Adult Psych (C200) x

Inpatient/Observation to non-Cox Facility Facility to facility form X (discharge order)

SDS x, use same process

Discharge Medication Reconciliation x

Inpatient Orders other than above Chemotherapy

Epidural Orders

Order Sets for Research

TPN x

Downtime x

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DIET ORDERS

Diet Instructions Nursing

Use this order for advance diet orders, NPO at specific time, or any other type of diet instructions.

Diet Advancement Powerplan

Use this order for gradual diet advancement. Communication Orders

Communication orders should be used to give instructions to the nurse for patient care that cannot be ordered using other orders. They can also be used to give conditional orders. (e.g. “Obtain blood culture if patient’s temperature is above 101.5).

Most communication orders are constant; however, some communication orders have frequencies that allow the nurse to schedule specific tasks.

Communication order allows nursing to schedule tasks that are unique to patient care.

If appropriate, discontinue communication orders when they are completed e.g. “MD to nurse; Call me when patient arrives.”

Peak and trough or other drug level orders-

When a peak/trough or other dose related drug level is needed the provider will order this using a communication order instructing the nurse when to order the level.

The nurse will then enter the actual laboratory order. PICC Lines

The provider can enter the order for PICC placement with the “PICC LINE ORDERS” powerplan. When the order is signed the PICC team will receive an automatic e-mail.

PICC lines can also be placed by IR (Interventional Radiology) when the HPS is unable or unavailable to place the line. These should be ordered using the SP PICC Line Insertion by Radiology Order. Once this occurs and IR places the PICC line the intent is that they'll follow the same process as the PICC team and will enter the order for the maintenance and care of the PICC line. If this is not done, the nurse or primary care provider will need to place the PICC Line Management Powerplan.

VTE Prophylaxis

VTE risk assessment no longer needs to be completed, except for pre-op orders and OP Surgery patients.

There is a brief reminder assessment attached to the VTE Prophylaxis Powerplan as a reference text.

VTE prophylaxis powerplan is included in most admission orders.

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Powerplans vs. Caresets A Powerplan is a tool in the orders tab. It is different from a Careset:

This tool allows a provider to enter orders in a phased process.

Plans can be multiphase, such as pre-op and post-op phases. This improves the provider ordering efficiency.

There is an option to leave orders in a planned/pending state until the provider chooses to initiate the plan.

Once the Powerplan is signed and initiated by the provider the order then becomes active.

Powerplans can be discontinued all at once whereas, a Careset requires discontinuing one order at a time. If a communication order(s) comes from a Careset as opposed to a Powerplan, the communication orders will need to be individually discontinued by the providers when the Careset is discontinued.

Decision Support Alerts

Decision support alerts fire upon planning and initiation of a Powerplan. o These alerts include duplicate checking of orders and drug interaction

checking. o Powerplan need to be initiated by a licensed prescriber or by a nurse. If

new medication alerts fire when the plan is initiated by a nurse, or when entering verbal orders, then the physician must be contacted to address the alerts.

Planned Powerplans

Plan powerplans - when patients are not yet in a bed on a nursing unit. (For example: patient in ED, post-op orders, direct admission orders)

Planned orders may be entered on any Springfield Hospital encounter, including discharged encounters.

Orders will be initiated by admitting nurse when patient has arrived on the nursing unit and is in the correct bed in Cerner.

Any medication alerts generated by the powerplan will be addressed with the physician.

Planned orders may be entered as verbal orders but must also be initiated as verbal orders.

Orders added to “planned” powerplans must be added using “add to phase”, or they will not go to the correct encounter and will be lost.

PA/NP ordering Narcotics

If a PA/NP is placing a planned powerplan, they cannot order narcotics using the orders in the powerplan. The following process should be used: Choose “add to Phase” Select the narcotic medication you wish to order R click on the order and select “ordering provider”

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Select the physician’s name providing the verbal order for the narcotic and select “verbal order” as the communication type.

Continue placing the rest of the powerplan order. Reference Text

Many paper order sets had information such as table for calculations and additional information tor ordering.

This information has been attached as reference text to the powerplan. The reference text icon can be seen and opened on the order, or at the top of the powerplan after it has been chosen to order

Unit Collect

Orders with the order entry detail for unit collect to yes will create a task on the nurse’s task list to collect the specimen when a lab is ordered.

Unit collect “yes” should be used for urine specimens and for blood specimens collected by the nurse instead of a lab phlebotomist.

Operative Workflow Outpatient Scheduled Surgery

.

Outpatient Pre-op and post-op orders remain on paper

If patient switches and will become an Inpatient or Observation, admission orders will be placed electronically when it is decided to admit the patient instead of discharging home.

If patient starts in SDS, then is admitted after surgery, the post-op orders will be entered electronically. These can be entered as planned orders immediately after surgery.

PACU ORDERS

Anesthesia and Surgeon PACU orders will be entered electronically

Anesthesia PACU orders will be discontinued when patient is discharged from PACU

Surgeon PACU orders WILL NOT be discontinued when patient is discharged from PACU, and will continue on the nursing unit.

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Patients in Pre-admission

All pre-admission orders will remain on paper for outpatients following the same workflow from the physician office

Inpatients going to the OR:

Pre-Op, PACU and Post-op orders will be entered electronically Post-op the surgeon will review all current orders and discontinue any

inappropriate orders.

Patients boarding in PACU:

Once the anesthesia recovery phase is completed and the PACU orders have been discontinued, the post operative orders will be followed.

Emergency Department (ED) Patient going to OR

Direct to OR and then to be admitted o Paper/Current process for the ED until after surgery o Choose appropriate Powerplan and initiate after surgery

Nursing Staff Workflow Order Entry Detail Powerform

The Order Entry Detail (OED) Powerform interfaces with radiology orders.

This form will be part of Admission 2, and the twice daily plan of care review. The details from this form will supply the following details to radiology orders:

isolation status, presence of an IV, presence of O2, and transport mode. Nurse Review of Orders

All new orders and any changes to orders will be routed to nurses for review. The eyeglass icon in the New Orders column of the PAL will indicate to the nurse that a review needs to be performed. Double click on the icon to see the list of new orders. Select the orders you wish to review and click the Apply button. Check details for accuracy and completeness and click the Review button.

The Nurse Review process provides three important steps; 1) cites the nurse’s validation of the review, 2) increases awareness of the orders, and 3) enhances the accuracy of orders.

Orders can be nurse reviewed from the orders tab. Orders reviewed from the orders tab will still have a clipboard icon on the PAL

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Report Process

It is the expectation that the nursing report process be done at the computer.

The Off-going nursing staff is required to be signed into Powerchart during the report process. Both nurses are to review the Off-going nurse’s orders/Plan of Care and task list.

This is a patient safety process. Task Management

There are 3 categories of tasks:

o Scheduled tasks These are tasks with frequencies You may reschedule these tasks

o Continuous tasks These are tasks that are constant and will not go into overdue The continuous task is there to help you remember what patient care

may be needed that you might have forgotten. Review the continuous task list periodically or at the end of your shift to

see if you forgot to document on something

o PRN tasks These are task ordered as PRN

Task are only completed when they are documented from the PAL or Task list

Note: Orders placed will generate tasks to the next rounded scheduled times. Example, order placed after 09:01 will not post a task scheduled for 09:00 but will only post for the following day. In this case, use ad hoc

Use the PAL or Tasklist to manage patient tasks and documentation

Complete a task Schedule Continuous PRN

Chart Done/Not Done

Reschedule a task

Create an admin NOTE: One change with electronic orders is that there will now be times when medication tasks are created for areas that are not on e-mar (Radiology, Cath Lab, Endoscopy, OR Holding, SDS.) The Med-Surg areas will need to “chart not done” on these tasks, with the comment, “documented on paper.” Most of these medications will say to administer these medications in the procedural area/OR. Workflow for PCA

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PCA workflow should not change that much other then they will have more tasks on the PAL.

Most tasks have Powerforms already attached. If task documentation is completed via Ad Hoc folder system then the task on the PAL will not drop off and remain incomplete.

Workflow for Unit Secretary

The unit secretary will monitor the PAL for new orders, and stat orders. The unit secretary will be responsible to notify nurse of any new stat orders. It is the expectation that nursing is checking their PAL on a regular basis also.

The unit secretary will continue to be responsible for taking off paper orders that HAVE BEEN WRITTEN BY A PROVIDER, that have diagnostic exams, and patient care orders. The unit secretary will be able to enter those orders into the computer if there is a provider signature.

Pharmacy orders on written paper orders will be faxed to pharmacy for order entry. This includes paper medication reconciliation orders.

Workflow for Nurse

It is the expectation that nursing is checking their PAL on a regular basis.

For the majority of orders, nurses will no longer need to do “chart checks” because it will be the provider who is entering the order electronically.

The nurse must still and always review any new orders.

There will be some orders that remain on paper due to their complexity.

Following the report process is vital to the safety of our patients.

Questions? Please email [email protected]

Completing Sub-Phase PowerPlans

Some sub-phases will require you to complete them before you can Sign the PowerPlan.

As an example we will look at the “VTE Prophylaxis” which is in many PowerPlans.

The first thing you look for to know that it’s a Sub-Phase is to look for the linked PowerPlan icons.

To complete the Sub-Phase PowerPlan look to the left side of your page in the “View” area.

You will notice below the Master PowerPlan, in this example “Admission Adult” you will see the Sub-PowerPlan like the “VTE Prophylaxis”

Left Click on the VTE Prophylaxis. It will highlight blue and you will then see the VTE Prophylaxis PowerPlan.

Select the items you wish to use from the sub-phase PowerPlan by placing a check mark in the box next to the item.

Once you have completed the Sub-Phase PowerPlan left click on the “Return to….” and it will return you to the master PowerPlan.


To add an order to your Favorites list first, search for desired orderable.

Adding Orders to Your Favorites

1. Right click the orderable in the Add Order window .

2. The “Add to Favorites” button will appear.

3. Left Click on it to add the orderable to your Favorites.

4. The Add Favorite window will open and then click “OK”

5. To view your Favorites in the Add Order window, click the “Star” on your tool bar.


Adding Pre-Completed Orders to Your Favorites

1. Search for the orderable like you normally would.

2. Complete the order by filling in the details..

3. Right click on the Order line.

4. Then click “Add To Favorites”

5. The Add Favorites window will open.

6. Click “OK”

Even a Pre-Completed order may possibly need additional information depending on the order. In this example of the CBC order “Unit Collect” will need to be answered every time. All of the other details will fill in like you saved it.


Creating Favorites Folders

To help organize your Favorites list you can create subfolders in your favorites area.

You do this by:

1. Left click on the downward triangle.

2. Then left click on “Organize Favorites” button.

3. The Organize Favorites window will open.

4. To create a new folder click “Create Folder”

5. A new folder will be created. Note that the name is high lighted allowing you to type in a new name.

In this example we called it “Custom Labs”

1. To move the lab into a folder just left click the lab and then click “Move to folder.”

2. “Browse for Folder” window will open.

3. Left click on the folder.

4. Then click “OK” and the lab has been moved.


Customizing and Saving an Order

In this example we will create a “Communication Order” that is not part of a PowerPlan but you may need to order on a regular basis.

1. First search for “Communication Order.”

2. Left click on the Order.

3. Close the Order search window by clicking the “Done” button on the right bottom of the window.

4. The only required field is “PRN” yes or no. We will select “No”.

5. Then we will want to change the “Constant Indicator” the Yes.

6. Then left click on the “Order Comments” tab. (See Star)

7. On the “Order Comments” tab you can type out your instructions you wish to communicate.


8. Once you have completed all required fields and added any additional comments Right click on the Order Line,

9. Left click on “Add To Favorites”

10. The “Add Favorite” window will open, click “OK”.

From then on you will be able to reorder this Communication Order without typing that information again.

1. Click the “+Add” button.

2. Click the “Star” icon.

3. You will see your favorites orders in this location.

4. Notice you can see all the details that you saved with the order.

PRN and Constant Indicator

In general when creating Communication Orders you will what to select PRN “No”, and Constant Indicator “Yes”. This keeps the order from happening just one time and then the task just disappearing.


Customizing Orders Page

This Tidbit will help you setup your Orders page to see just “Today” or “Tomorrows” orders, or any combination of dates.

1. Open the Orders page.

2. Click on “Customize View”

3. Click on “Group Order by:” change from “Clinical Category” to “Date”

4. Now you can filter what orders you wish to see.

5. You do this by adding or removing check marks next to the categories.

6. To return to the Normal default view just reverse the process by clicking “Customize View” and change from “Data” to “Clinical Category”.


Ordering Times Study Labs

If you need to order a lab to be draw multiple times here is how you do it. For this example we are going order three Troponin.

1. Search for the order under

the “+Add” button. This example is Troponin.

2. Select Collection Priority as “Time Study”.

3. Collect Date/Time, you will place the date and time you wish the first lab draw to be taken from the patient.

4. Next click on “Frequency” note in this example I have selected “LabQ6Hr”

5. Next Click on “Duration” this is a free text box that only takes numbers. I want three lab results so I placed 18 in the text box. (Free Text Box Not Shown.)

6. Next click on “Duration Unit” and select “hr” for hours.

So now this order for Troponin will be drawn every 6 hours starting on 8/26/2011 at 7am., and will last for 18 hours.

This will cause three Troponin lab test to be performed on the patient.


Laboratory

Tissue Request:

Specimen Received Date & Time

Specimen Received by – You can type in the user name of the physician or “Nurse”.

Specimen Description - Type in up to 60 characters to describe the specimen

Copy Report - complete for physicians that will need copies.

Collect Date/Time - Enter Date and time specimen was taken.

Body Site – select from list.

Pre/Post Op Diag, Clinical Imp, etc.

Cultures - start with a “c” followed by a space. Example “c blood”.

Radiology Groupings

CT = CT scans

MA = Mammography

NM = Nuclear Medicine

SP = Special Procedures

US = Ultrasound

MR = MRI

Therapy Groupings

AUD = Audiology

BEH = Behavioral Health

OCC = Occupational Therapy

P/O = Prosthetics/Orthotics

PHY =Physical Therapy

RHB = Rehab

REC = Recreational Therapy

SPE = Speech Therapy

Therapy Abbreviations

WBAT = Weight Bearing as

Tolerated

NWB = Non Weight

Bearing

PWB = Partial Weight

Bearing

TDWB = Touch Down

Weight Bearing

Reason for Exam Fields (on any exam) including all Radiology test.

Enter an accurate reason for the exam being ordered. Use only Cox approved abbreviations.

Completing Detail Values

Orders – Helpful Hints

Questions Please email [email protected]

Dose Range CheckingOrdering dose “Ranges” are changing.

Now you will order the maximum dose you want your patient to receive with further dosing information in the order comments.

If the dose is in a PowerPlan it will be prebuilt but on individual orders you will need to script the comment yourself.

Here are examples:

Dose Range Checking Alert

When you order a medication it will be checked for appropriate dosing.If you have ordered an inappropriate dose for your specific patient you will get this warning.

At that time you will be able to:• Cancel order• Ignore alert• Modify order

This is an example of what it will look like in a PowerPlan .• Notice how the dose is 10mg

in the order line.

• The information on how it can be given is then stated in the “Order comment” window.

This is an example of an individual order that you create outside a PowerPlan.• Notice how you have ordered 10mg, IV, Q4H.

• Then on the “Order Comments” tab you will need to free text (Type) the dosing comment. In this example “May give 4-10 mg”


Adding Food Allergies

It is imperative that we add food allergies to the patient allergies list.

1. Click “Allergies” in the demographics banner.

2. Once the “Review” window

opens click the “+ Add” button.

3. Once the Allergies window opens you can enter the food allergy one of two ways.

4. First way is to click the Catalog tab.

5. Then select the food from the list provided.

6. Remember to change the “Category” to “Food”.

7. Second way is to “Free” text the food if it is not on the list provided

8. To do this first click in the “Free Text” box. (see #1)

9. Then type in the food item in the “Substance” line. In this example “Banana” is the food.(see #2)

10. Remember to change the “Category” to “Food”.(see #3)

#1#2

#3

Remember food Allergies are

critically important for dietary and

it’s up to you to enter them!

There are two ways to do this.


IV Titratable for Pre-mixed Medication

Clevidipine Diltiazem Dobutamine

Dopamine Eptifibatide Esmolol

Heparin Lidocaine Milrinone

Nicardipine Nitroglycerin NorepinephrinePropofol Magnesium Sulfate Conivaptan(Vaprisol)

The List of Pre-mix Medications:

You can find administration instructions one of three different ways.

1st If you review your Medication from the eye glasses you will see the information in the review window. (See Below in the Highlighted area)

You can also review them from the HandHeld.

1. Find the drug in this example Dopamine.

2. Take your stylet and hold it down on the drug.

3. Then tap “Order Details”.

4. Once the order details open. Click on the “Comments” tab.

5. This will allow you to review the administration instructions for the medication

2nd


IV Titratable for Pre-mixed Medication (Cont)

3rd

The third way is if you are reviewing the medication from the HandHeld .

1. When you get the request on the HandHeld to do the Nurse Review you will say “Yes”

2. Once again tap the “Comments” tab to review how the medications should be given.

Completing the order

1. You will start this like any other IV by tapping the “Add IV Event” and the select “Begin Bag”

2. Fill in the “Site” location of the IV insertion.

3. You have to fill in the “Dose” & “Dose unit” and the rate will automatically fill in.

Questions Please email [email protected]

Modify versus Cancel/Reorder

1st All Lab orders will have to be Cancel/Reorder. You are unable to modify any lab order once it has been signed.

As you can see “Cancel/Reorder” is your only option with lab orders.

The question has come up, “when is it best to modify versus canceling and reordering?”

The following order categories have different areas that you can modify.

Remember these are examples and not every order in a category will react the same.

2nd Radiological orders at this time will allow you to modify all areas except “Exam Date/Time”.

3rd Drug Orders allow you to modify some details, but not all details.

Areas you can modify are bold, and areas that you can not are light gray.

4th IV Orders allow you to modify rate or infuse time.

Even though the “Rate” and “Infusion Over” are grayed out if you click in the area you can then edit the entry.

For workflow purposes for all patient care providers if you can “Modify” an order that is generally best.

If the order detail you wish to change can be modified then please choose “Modify”. If the order details you wish to change cannot be changed by modifying then choose

“cancel/re-order”.

Other areas you can modify are:

Strength dose Strength dose unit Volume dose Volume dose unit Freetext dose Drug Form PRN

PRN reason Next dose date and time Stop date and time Freetext rate Rate Rate unit Infuse over

Infuse over unit Special Instructions Last Dose Date/Time Normalized Rate Normalized Rate Unit

Remember not all drug orders will have all these areas.

You will have to sign all orders that you Modify or Cancel/Reorder.


Nursing Practitioner & Physician Assistant Controlled Substance PowerPlan.

To direct the NP’s & PA’s controlled substance orders to their collaborative physicians in box so they can be cosigned a new PowerPlan is being put in place.

1. NP & PA will need to deselect all the controlled substances in PowerPlanswhen placing them.

2. You deselect them by clicking the check mark.

3. NP & PA will now order all their control drugs from this new PowerPlan and will place them as verbal orders.

Nursing

This is critically important that anytime you see Control Substances (NP?PA) PowerPlan that you sign it as Verbal!

1. When the patient arrives on your floor/unit you will need to “Initiate” onlyControl Substances (NP?PA) PowerPlan as a verbal order.

2. Then sign it but as a Verbal order.

If the Control Substance NP/PA PowerPlan has just been Signed (Placed in a Planned State) but not Initiated nursing will need to do the following:


PCA Orders with CPOE

With CPOE your PCA orders will no longer be available on paper for you to reference so you can do it from the HandHeld.

The two ways you can see the information are:

1st Nurse Review from the HandHeld.

1. Once you tap that you wish to review order you will see the following information.

2. To see all the information you will need to scroll down the page by using the scroll bar.

If you have already reviewed the PCA order from the eye glasses on the Patient Access List (PAL) you will use this method.

1. Once you have scanned the medication this window opens.

2. In this window you can find the information.

3. You will need to scroll down by using the arrows.

2nd

Questions email Nursing Informaticist @ CoxHealth.com

When ordering medication if the “Review Schedule” appears you will need to check the order schedule to insure that the medication will be given

at the correct time.

Reviewing Schedule Medication Times

From the order window once you have selected a Frequency you will see the “!Review Schedule”.

You will only see this depending on frequency and the time of day that you are placing the order.

This window will open on the right side of the order window.

You can do two things in this window.1. Change start date

and time.2. Skip the next

dose.

To skip the next dose just click the box next to “Skip administration”

Note the next dose dithers out once you have selected this box.

Complete the remaining required fields and sign the order as you normally would.

Click on “!Review Schedule”

Questions email Nursing Informaticist @ CoxHealth.com

Tube Feedings

To order a tube feeding go to the Orders/Plan of Care page in Cerner.

Click the “Add” button.

Search for the nutritional product you wish to order.

Notice that you can order either:“Continuous”

or “Bolus/intermittent”

Select the product by left clicking it.

If you select “Bolus/intermittent” option you will have two options to select from.

If you select “mL, Feeding tube” you will be required to fill in the “Volume dose” and “Frequency”.

If you select “mL, Feeding tube at bedtime, hr” you will need fill in the “Volume dose.”

If you select continuous you will see this window that resembles the IV window.

Like the IV you will need to fill in one of the two yellow fields. The second will auto populate once you click away from the first box

Medication Reference Guide

To add an Order click the button.

Search for the order you need to place. (In this example “Lasix” is being ordered.)

Slower:If you select “(None)” you will have to answer required fields before you can sign the order.

Fast and Easy:The easiest way is to use the order sentences. Even if the sentences is not exactly what you wish to order select it and modify.

Order Sentences

Page 1

Tip

You can search for and add additional orders before you close this window. When you have chosen all the orders you want close this window by clicking done.

At times a medication “Decision Support” window will open and you will need to select the appropriate answer from this drop down.

After you have selected the override reason click, “checkmark”. “Apply To All” if there is more than one alert in the window.

Click “OK”

Dosage Calculator

The dosage calculator will open.1. Actual weight should be filled in. (This

information is entered by the pharmacy.)If the “Actual weight” is missing you can fill it in yourself.

2. Final Dose can be adjusted or rounded to the dose you wish to give to the patient. The gray box to the right will automatically calculate the mg/kg.

1

2


Page 2

Rounding Dose


Dosage Calculator

The dosage calculator will open.1. Actual weight should be filled in. (This

information is entered by the pharmacy.)If the “Actual weight” is missing you can fill it in yourself.

2. Final Dose can be adjusted to the exact dose you wish to give to the patient.

3. The gray box to the right will automatically calculate the mg/kg dose.

4. Take the automatically calculated dose and place in this field.

Exact Dose

2

1

3

4

Example of the Exact Dose Order

Note the target dose line matches the block 4 above.

Example of the Rounding Dose Order (Page 2)

Note the target dose line matches the order sentence.

Page 3


1

2

Detail values area will give you the ability to select options for each area selected in block 2.

Order details area allows you to modify each line on the order.

Order details:

Dose: You can enter a custom dose or select from a standard dose listed.Drug Form : This should not be used. The pharmacy will modify as needed.Route of administration: You can enter a custom route or select from standard route list.Frequency: This allows you to select how often the medication is to be given. PRN: This allows you to set a reason why a medication may be

given PRN.

Pharmacy order priority:

Now: Priority orders. These orders take precedence over routine orders. They are to be administered within 60 minutes.

Routine: Orders that require no special response. These orders will be processed routinely (generally within 2 hours).

STAT: Drugs being used to treat life-threatening situations. These orders need immediate responses.

Requested start date and time: Allows you to adjust start date and time unless you have indicated a “Now” or “Stat” order priority.

Next dose date and time: You can skip this dose if it is not appropriate to be given at this standard administration time, or you can change the dose time.

Duration: Will default to 42 days. (The exception is narcotics.) This area will allow you to set the number of doses you wish to give

Stop date and time: This will change depending on what you have set in your duration field.

The remainder of the fields will not be normally used.

Tip

An example would be if you have a once daily medication and you only want to order three doses set duration to 3 days.

Page 4

1

2

Tip

If you are uncertain when a medication will need to be given. (i.e., Lasix between PRBC.) You will need to order as unscheduled.

Using Order Comments

If you need to give additional instructions or information to the pharmacy you will want to place that information on the order comments tab.


Page 5

Reminders:If you order Gentamicin or Vancomycin you have a “Communication Order” in your folder.

In both of these orders the “Special Instructions” have a predefined statement to order a drug level. You can add additional information at the end of this statement to tell the nurse to order after third dose or after a certain time.

DO NOT put information here that does not relate to administering meds. (i.e., no orders for drug levels.)

Appendix iv

Nursing- Stop/Start/Continue Workflow

Process Start Stop Continue Shift Report: RN to RN, RN to PCA

On and Off going RN to review: PAL for overdue tasks, eMAR, Orders and Patient Care Summary. Clarify questions on tasks that are overdue. Verbal report for significant events and priority plan.

Report from one unit to another for patient transfer

Each RN to simultaneously review PAL, eMAR, Orders. Clarify tasks that need to be on the receiving unit. Be sure to review active orders to ensure they are clear,

Waiting to view patient chart until the patient arrives on the new nursing unit.

Verbal report for significant events and priority plan. Some units have paper forms for specialty care and they should continue to be used. Calling providers if there are questions about the orders.

New Orders Review Using the PAL to see new orders icon to indicate new patient order.

Paper chart review and/or seeing the physician on the unit writing the order

Reviewing orders and asking questions if the order does not make sense.

Refer to the PAL at least every hour to ensure you are up to date with new orders and results.

Referring to the paper orders.

The unit secretary will also review the PAL on a regular basis and will also notify the nurse when there are new orders, immediately if there are stat orders.

Blood Order verification Two nurses co-signing written order

Critical Results Document notification of critical results to physician in a course of events

Documenting notification of critical results on paper physician order page

Transfer Orders The RN will see new or changed orders to review.

Sending provider to review all orders and discontinue or modify as needed. RN to call provider if questions arise about the orders.

Process Start Stop Continue Planned Orders Initiate “planned” orders when

patient is in correct bed after admitted

Review orders for stats and plan of care.

24 hour chart check Reviewing all active orders on power chart. The exceptions are: TPN, chemotherapy and some protocol orders - that will remain on paper.

Night shift 24 hour chart check. Active orders are continuously reviewed.

To review the limited paper orders and sign off. If a stray written order is found, and enter it into power chart.

Emergent or Code Orders Paper or verbal orders for "stat" interventions are appropriate in these situations (when the event is over, paper orders can be written). The unit secretary can enter the order into power chart for the provider in these situations if the provider has written, EXCEPT FOR MEDICATIONS. Medication orders should be faxed to pharmacy.

Paper orders for emergent or code events should be written immediately after the event. Medication orders that need to be on the eMAR must be faxed to the pharmacy for entry into eMAR. Orders for ancillary services (lab, rad, blood gas) must also be written.

Stat Orders Looking for the red exclamation icon on the PAL indicating a stat order.

Check the PAL frequently during the shift for new orders.

The unit secretary will also see the stat order icon and notify the RN when they see this.

The unit secretary will let the RN know of new stat orders on the PAL.

Verbal Orders Entering verbal orders into Cerner with “verbal” communication type.

Taking verbal orders unless the provider is physically unable to access a computer, or is woken in the night for orders

PACU / Anesthesia Orders

Anesthesia will initiate the PACU power plan. The PACU RN will discontinue the PACU power plan when the patient either leaves the unit or stops requiring PACU level of care.

Using paper orders.

Discharge The form on the discharge order will feed to the patient summary, instead of the nurse transcribing most of the information.

Completing the patient instructions for the patient discharge form, if the physician has completed it with the discharge order. Completing facility to facility orders for patients discharged to TCU, Rehab, and Senior Adult Psych

Completing facility to facility order form and nursing assessment for patients discharge to another facility. Completing the nursing update on the facility to facility form for patients discharged to TCU, Rehab, and Senior Adult Psych.

Process Start Stop Continue

DNR / DNI Viewing orders in power chart and see code status. order

Looking for attending physician co-signature on the paper form.

Blood Products Blood Products care set to be completed by the provider. This is a multi-step process.

The paper form for "releasing" blood from the blood bank remains the same.

Blood Gas Order Provider to place ABG Request. This generates a task for the HUC and RN to enter the ABG Analysis order at the same time the ABG specimen is drawn. The order will complete when the results are entered by ABG tech.

No paper or verbal orders.

Blood specimen to be obtained either by the RN or ABG tech.

Calorie Count Provider to enter the calorie count order into power chart. This order is linked to a printed calorie count form. The RN or HUC can print the form and place on the patient door.

Stop faxing the order or calling dietary for the form.

Placing the calorie count form on the patient door.

Dietary (or designee) will be notified of the order and come up to obtain the calorie count forms and consult as needed.

No change to current practice.

Peak and Trough or Timed Lab orders related to Procedure/Transfusion

This is a 2 step process. Provider to enter a "communication" order with comments to draw peak and trough.

Computer Problems? Call the HELP Desk 69-3153 Physicians: Call 69-docs

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