Download - OMRS13 Order Entry
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Order Entry
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Metoprolol 50 mg PO twice dailyCD4 CountFull Hemogram in amX-Ray left arm for traumaLow Sodium DietUp In Chair for 10 min four times dailyCall for pulse > 120
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Metoprolol 50 mg PO twice dailyCD4 CountFull Hemogram in amX-Ray left arm for traumaLow Sodium DietUp In Chair for 10 min four times dailyCall for pulse > 120
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Definitions
OrderableA concept that can be ordered.
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Definitions
OrderA request from a provider to do something to/for a patient.
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Definitions
Order TypeDefines the major category of the order.drug, test, referral, diet, activity, nursing, call orders, letter, handout
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Definitions
UrgencyWhen an order should be done
STAT, routine, scheduled, conditional
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Definitions
Order NumberAn identifier used to track the life of an order (in HL7, it’s the “placer” number), which may be sent to external systems as a reference to the order.
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Definitions
Order ActionThe action being taken on the order.new, revise, continue, renew, discontinue, supplement, hold
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Definitions
Active OrdersOrders that have not been discontinued or expired.
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Definitions
Structured Dosing (Drugs)Codified dosing instructions, where individual components are captured: dose, dosage form, route, frequency, duration, duration units, PRN condition, additional instructions
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Definitions
Complex Dosing (Drugs)When dosing instructions cannot be fully codified and must be captured as free text.
eg: “2 tabs QAM and 1 tab QPM” “as directed”
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Definitions
Order TemplateThe definition of an order, which may be used to aid in the creation of an order.
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Definitions
Order SetA collection of order templates that defines a useful set of orders (regimen, convenience sets, etc.).
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Definitions
Order GroupTies together orders that were placed together (e.g., as part of a regimen or convenience set) – e.g., a record of the order set used.
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Orders 1.9
order_idpatient_idencounter_idurgency
concept_idinstructionsstart_dateauto_expire_datediscontinueddate_discontinueddiscontinued_reason
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Orders
order_idorder_typeorder_numberprevious_order_idpatient_idencounter_idorder_group_idurgencyorder_action
concept_idindicationinstructionsstart_dateauto_expire_datediscontinueddate_discontinueddiscontinued_reasonordererfulfilled ± fulfilled_by/accession_number vs. status?comment_to_fulfiller
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Drug Orders
order_iddrug_idstructured_dosingdosedose_unitsroutefrequency
durationduration_unitsas_neededas_needed_conditionadministration_instructionsquantityquantity_unitsnum_refills
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Test Orders
order_idspecimen_sourcelateralityclinical_history
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Order Group
order_group_idpatient_idorder_set_id
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Order Set
order_set_idorder_set_statusnamedescriptiontitlecommentoperator
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Order Set Member
order_set_member_idparent_order_set_idsort_weighttitlecommentorder_set_member_typeconcept_idorder_templateorder_set_id
concept_classconcept_set
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IMPLEMENTATION GUIDANCE FOR THE NHS DOSE SYNTAX