Computerized Provider Order Entry(CPOE)

Transcription

1 Computerized Provider Order Entry(CPOE)

2 From your Inpatient List, click the patient or check the box next to the selected patient and click the Order button at the bottom of the screen.

3 This will bring you into the Order Summary screen. You can view individual orders by clicking the + to the left of each category header. The Order Sets, Orders and Meds/Fluids buttons will be used for order entry.

4 For Order Sets, such as VTE Prophylaxis, click the Order Sets button. These are arranged by category. You may click on the category or do a type-ahead search. Check the box beside the desired order set (you may choose more than one) and click Done.

5 Click the + beside the order set name. This will open the details of the order set and allow you to select the individual orders that are appropriate for your patient. A red pencil icon indicates that more information is required before the order set can be filed.

6 Order sets are evidence-based and reflect the current standard of care. Click the view the related evidence. Click the ribbon icon to view how an individual order meets a quality measure. to

7 For individual orders, click Orders, then do a type-ahead search to narrow the list. It will find the order if the word is contained anywhere in the order description. You may have to page down to find the desired order. Highlight the order and click Select. You will return to the search page to enter additional orders.

8 Since PT can mean PHYSICAL THERAPY or PROTHROMBIN, it is important to choose the appropriate category.

9 When you have selected all orders, click Done at the bottom of the screen. You will be brought into the Preview/Edit screen. The priority (Pri) defaults to Routine. The Start/Service defaults to today. These fields can be edited as needed. Series can be used if an order is to be repeated at specific intervals. Clicking the dark grey column header will change the priority or service date for all orders. Clicking the light grey field will only change the directions for the corresponding order. The Req under Details indicates that additional information is required before the order can be filed.

10 Click the Meds/Fluids button, then do a type ahead search. You may search by either generic or trade names. Click the + beside the medication to choose the route.

11 Once you choose the route, you will be brought into a screen to select dosage and frequency. You may have to page down to find the desired order string. If you do not have any further instructions for this medication, click Done to return to the search screen.

12 Additional instructions can be added, such as number of doses or parameters for administration. You may choose a specific number of doses OR the date/time to stop the medication. Only one of these fields will be accepted.

13 There are default times associated with each direction (daily is 0900, Q6H is ). If you are ordering a daily medication after 0900, you will see a First Dose Warning. You must answer whether to give the first dose now or wait until the next scheduled time. This only applies to the first dose, each subsequent dose will be given at the default times.

14 When entering medications, you may see pop-up conflict messages. Some examples include allergies, drug interactions, and duplicate orders. You must address each message before proceeding. If you wish to continue with order (Override), you will be prompted to give a reason.

15 For IV Fluids, click the Fluids tab on the medication search main screen. This will be used for plain fluids only. Any fluids with additives (potassium, MVI, etc.) should be ordered under Medications. Do a type-ahead search, then select the fluid by volume.

16 You may choose a rate from the list or change to another rate. If you are choosing a different rate, click one of the order strings. This will fill in several of the fields for you. Click Rate > Other. You can then edit the rate.

17 Within the rate change box, you may also choose stop parameters. Only one of the stop fields will be accepted. If you are choosing a prepopulated IV rate, you may edit stop parameters using the Stop field, just as you would for medications.

18 After you have entered all orders, click Done until you return to the Order Summary screen. You may Undo any erroneous orders or add new orders. Click Submit when you are ready to file. If any required information is missing, you will be prompted to answer at that time.

19 To discontinue an order that has already been submitted, highlight the order and click the DC button. If you wish to cancel an erroneous order, use the DC button and ask the staff to call the appropriate department.

20 To order home medications, click Cont from AMB from order summary screen. This should only be done on admission.

21 This will open the home medication list. Click the check mark in the grey box to order all formulary medications, or you may order each medication individually. For non-formulary medications, you may allow the pharmacy to substitute, choose your preferred substitution, or allow the patient to use their own supply from home. Check the box to open the options.

22 You will see the medication details along the top. If you wish to choose a substitute, do a type-ahead search. For the other options, click the Non-Formulary button.

23 Fields with * are required. If the patient will be using home medication, a reason must be given. Preferred practice is to allow pharmacy substitution. A patient s home supply should only be used if a suitable alternative is not available, such as HIV antiviral medications.

24 To view or change home medications and inpatient medications, click Reconcile Meds.

25 To discontinue an inpatient medication, click Stop. To change dosage or frequency, click Edit.

26 If you choose to edit, you will be brought into this screen to make the desired changes using the drop-down options.

27 To transfer a patient to a different level of care, click Transfer.

28 Do a lookup in the Transfer to: field.

29 Choose the orders you wish to continue upon transfer. If everything is to continue, click the dark grey Cont at the top of the column. All orders default to Stop.