SigmaCare Care Management

Transcription

1 This document will walk a physician or nurse through the process of creating a physician order in SigmaCare. Creating a Physician Order Do this Step 1. From the Resident Summary page, click the Orders tab. Step 2. Click +Add New. Step 3. Type the first part of the medication name in the Search field. See this Step 4. Click Search. Step 5. Locate the desired order in the list of search results ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 1

2 Step 5 Validate whether there is a DUR alert. This is the icon just to the left of the formulary status icon. If there is no DUR alert, proceed to step 6. If there is a DUR alert click on the DUR icon If physician approved, click - Custom Medication, DUR determined by pharmacy - Severe Alert - Contraindication Alert - Informational Alert - Moderate Alert When there is a DUR Alert, click the DUR icon: If approved by physician, click Next and go to step 7. If not approved by the physician, then click Back, then return to step 3 OR click the ALT link to view and select an alternative medication. Note: Typically with an alert of severe or higher, the physician will provide an alternative medication. Click the Alt link to the far right of the row for that medication. Step 5 Validate the formulary status icons just to the left of the medication name. - On Formulary - Preferred - Preferred if prescribed generically - Not on formulary - In Stock - Formulary Status Unknown - Restricted -Excluded - Prior Authorization Required Note: Follow your facilities policies on formulary and alternative medication selection. To see a list of alternative medications, click the ALT link to the far right of the row for that medication Note: If the medication has a DUR alert of then contact the pharmacy to verify the DUR status. Step 5C. Determine if there is a Controlled Substance notification next to the medication name in the order details. Controlled Substances must be submitted through DrFirst / EPCS Gold when your facility uses eprescribing Other icons you will see: Click the to show additional drug information Click to the right of the medication name to show an alternate medication list Click to show order details If the medication is linked to an order set, the order set name will appear along with a which will allow you to select the order set and/or view the details of the order set The first indicates the medication has already been ordered for the resident, and the further to the right allows the user to discontinue the medication 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 2

3 Step 6. Click the medication name link for the desired medication. Step 7. Verify the appropriate medication order opened in the upper right of the physician order writer. Step 8. Select a SIG from the list of common SIGs for that medication Note: this will enter the direction selected into the box above the list of SIGs 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 3

4 Step 9. Make any changes to the SIG selected by using the drop-down menus and fields below the list of common SIGs. Note: Most often, selecting the common SIG will populate the Method, Route, Quantity, Measure, and Frequency. If a duration was included in the common SIG that will populate as well. To add a PRN use the PRN Type drop-down. To add a STAT dose, use the Priority drop-down. To add a duration, use the Duration drop-down to select a type and then click the box to the left of the drop-down to enter the number for the duration. To add additional instructions not included in any of the drop-downs, use the Addl Text field. The following fields are available for all customers but required when using eprescribing: MDD: Maximum Daily Dose MDD Measure: will Default to the measure indicated in the order, may be edited if necessary. Note: The Dispense Quantity and Refills Allowed fields will be visible if enabled for your facility. Click into either of these fields to provide this information. For simple orders the Dispense Quantity will be automatically calculated from the quantity, frequency and duration. Note: The Create Retail Script? Checkbox will be checked by default for facilities using eprescribing when a controlled substance is being ordered. If unchecked no script will be created. If a script is needed, but the box was unchecked, a script will need to be manually created by using the Reorder Medication link on the orders tab of the resident summary ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 4

5 Step 10. Click the schedule tab. If there is a prepopulated schedule and it is correct, continue to step 11. If there is a schedule but it is incorrect, click the remove link to the right of the selected schedule. If there is no schedule or if you have removed the schedule erroneously, you m ay either select an existing schedule or build a new one: Notice the Select a Schedule radio button is already selected. If you see the schedule you wish to add, click on it to select it. If not then follow the instructions. Click the Build a schedule radio button. Select a type from the Schedule Type drop-down. Select the frequency from the Rotation drop-down. Complete the additional required fields that will appear based on the rotation selected. Click Add Schedule. C. If a compound schedule is required, additional data can be entered. In the example a schedule has been added for a medication to be given twice daily for two days and then an additional schedule is being added to give the same dose only once daily for two additional days. Click Add Schedule C. Note: A schedule may need to be confirmed if there is a yellow circle next to the Sched tab. To confirm a schedule, click on Click to Confirm Schedule 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 5

6 Step 11. Click the Protocol tab. Note: This field should be entered if the physician has provided any parameter for this order. To add a protocol, type the information into the Text box or select from the common protocols by clicking the Description of the desired protocol. To edit protocol, click into the text box and edit the field. Step 12. If Clinical Monitoring is desired or requested by the physician, Select the Clinical Monitoring radio button, be sure to follow any facility policies and procedures for required clinical monitoring. Select the Type of clinical monitoring from the drop-down menu. Click the Before, Follow-up or Both radio button to trigger when clinical monitoring should occur. C. Select the desired comment field display setting from the Show Comment drop-down. If follow up is selected, you will need to indicate how long after administration the monitoring should occur. D. The PRN Only? Checkbox should be checked if there is a routine and a PRN schedule for this order and only the PRN component of this order should have monitoring follow up. E. Click Add when finished ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 6

7 Step 13. Click the Dx tab. Click the ICD-10 or Clinical Findings radio button. Select the desired Select By radio button, to indicate whether you wish to search by: a. Resident Hx to select a diagnosis from the resident s history. b. Drug To search for a diagnosis that the drug is commonly used for. c. Search to search for the diagnosis by name. d. You may also search the Alphabetic/Tabular Search to use the indexes. C. Click the appropriate diagnosis Description to select it. D. Notice once selected the diagnosis appears in the top panel. C. D. Step 14. Click on the Summary tab. There are various functions that can be performed on the summary tab: Change the Designation, this is where you wish for the order to appear. Enter a Start Date or start Time for the order. C. Enter a Stop Date, the stop date controls the date of the auto discontinue, either calculated from the duration from the Sched tab. D. Require/add a row to the administration record for the Dose, Site and/or Comment. Step 15. To add additional orders click Add New in the left hand panel above the orders and repeat Steps OR If no additional orders are needed continue to step 16. C. D ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 7

8 Step 16. To complete the order: Click the Auth box to indicate that this order has been given by a physician, Read Back to indicate that you have read the order back to the physician. Click Complete ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 8