2-4-11_FINAL_CPOE Booklet.pub
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1. nc Z a Northwest Community Computerized Provider Order Entry Hospital User Manual Northwest Community Hospital CPOE User Manual Published by NCH November 2010 All rights reserved Northwest Community Hospital is accredited by the Illinois State Medical Society to sponsor Continuing Medical Education for physicians Northwest Community Hospital designates this educational activity for a maximum of 5 AMA PRA Category 1 Credits Physicians should only claim credit commensurate with the extent of their participation in the activity Introduction Computerized Provider Order Entry will close the patient safety loop improve guality of care and reduce errors by allowing care providers to enter orders directly into CareLink Why CPOE 0 Process improvement Cost conscious decision making o Clinical decision support Optimal use of physician time CPOE can actually optimize practice 0 CPOE was designed to support medical practice not subjugate your own clinical judgment The system does this with decision support tools such as InfoLinks and warnings Tools and data are dynamic creating opportunities for im proved patient care Studies on post implementation CPOE show 0 In one post implementation study time for the administration of STAT Furosemide was gt 50 faster than pre implementation making a big difference for a CHF patient Process improvement decreases fra2. Go delete 11 i Forms i Forms are interactive forms that will generate an order e To complete an i Form Launch orders Type the name of the order into the Order Completer pane Select i Form from the list Check the appropriate boxes in the i Form Click Submit Orders at the bottom of the i Form The submitted orders are displayed in blue text in the Orders pane e You may modify or delete as necessary e Complete the order entry process press done lt F8 gt e Accept and Exit Heparin Infusion for DVT or PE CPOETEST JUDY 9S Bullet indicates order is placed automatically Laboratory Orders S a gt A O Indication required C Deep Vein Thrombosis C Pulmonary Embolism CBC STAT drawn prior to heparin start X INR Protime STAT drawn prior to heparin start e PTI STAT drawn prior to heparin start Medication Orders CBC ROUTINE every other day while on heparin infusion This form is using 60 kg for the calculations Enter weightto Recalculate dose Nursing Orders PTTSTAT 6hrs after the start of the Haperin Infusion PTT STAT 6 hes after ANY DOSAGE ADJUSTMENT e PIT STAT 6 hes aiter the first PTI ratio that is within the target goal of 2 to 3 5 If two consecutive PTT results are in the target range order the PTT QAM and maintain the heparin infusion rate With each PTT ratio result nurse to adjust kaparin dose per the Weight Based Heparin Dosing Chart for DVT or PE Notify physicia
3. only be matched with ONCE and Q_H When to Start To order a OxH test vou must choose TMD PK with optional start date amp time 1 ROUTINE default 2 STAT 3 DRAW STAT 4 TMD PE or enter an allowed value or enter a start date time and priority After picking TMD PK you can enter TOD if it starts today or 0 Enter a specific time or entire date time if the order is for the future Then select an allowed frequency How often 1 ONCE default TC kn AM 00 Ol 4 EVERY OO AM 00 01 O2H PICE TMD PR s 03H PICK TMD PE MAH PICK TMD PK O6H PICK TMD PK 9 OSH PICK TMD PK How often ROUTINE can only be matched with ONCE TOMORROW AM QAM or ONCE default TOMORROW AM 00 01 EVERY OTHER AM 3 4 5 6 7 8 9 13 Medication IV Orders General Information How medication orders are displayed oral generic brand name inj generic inj brand name ped generic ped brand name If the route isnt available to administer the medication You want to order IV and it isn t displayed you have selected the WRONG form of medication e To correct this click Oops e Start over select the inj form of the medication e Complete the order entry process as usual Med Order Entry Process O On the Order Entry screen type the name of the drug in the Order Completer Pane and Enter e Select the drug from the list displayed in the Order Detail pane O Follow
4. strict vital Signs per uni standrd bip pr oxygen nasal cannula al 2 4 Ipm maintain o sat gt or io 90 call m d if lt 90 pulse oximetry g Shift td then d unable to obtain accurate output then may msert indwelling urinary Catheter may discontinure foley once on oral diuretics f then d unne output lt 350 mS hours while on iv diuretic therapy then notify md central telemetry monitoring call md for gt 10 beats of vt or symptomatic vt once md aware of non sustained vt cal only if sustained or symptomatic patient education institute reinforce heart failure teaching protocol apn consuh heart failure notification of comsult to be made by nursing unit x7363 invision 840351 dietary consult for chf dietary instruction do not hold drugs wahout a physician s order for hypotension or 10 Linked orders appear in blue text in the Orders pane New orders Nov 08 13 30 do not hold medication iv without physician order for hypotension or bradvcardia stari on 11 8 at 15 30 Nav OE 13 30 r gist r d dietitian to instruct diet for chf dietary instruction start on 11 8 at 15 30 Sov 08 13 30 apn cossult epoe beart Gilure notification of omsuli to be made by nursing unit wih invistom F093 lt stari am IUS ar 15 30 ov OF 15 30 paient education instituto rejslorce heart failure teaching protocol start om ILS at 15 20 ov OF 15 30 centra telemetry monitoriag call md for gt 10
5. supporting physicians midlevel providers and NCH clinicians as well as Roaming Trainers CareLink Hotline 847 618 4830 Option 6 for CPOE assistance CPOE Support Page Click the 2nd link on the CareLink log in page below the message of the day
6. AM and Q 24 H frequencies will not start until tomorrow at 9 AM e STAT e The med order will come to Pharmacy with the start time the pro vider entered the order STAT NOW in Pharmacy e START TODAY e Is the frequency to be used when you want a medication to start today If you select START TODAY on a med that is given once a day i e DAILY QAM Q1PM or Q24 hrs and it s past the time to give the dose the first dose will be administered today 1 NEXT SCH default 2 STAT 3 START TODAY or enter an allowed value or enter a start date time and priority or press ENTER NEXT SCH 15 Medication IV Orders Medication Rules To hold a dose Open Orders and select the medication you want to hold and send a Pharmacy Communication order Enter the date time of the dose to be held in the comments section of the Pharmacy Communications order Pharmacy to dose med orders Enter 0 MG as the dose and enter Pharmacy to dose in the comments The exception is Coumadin You MUST order the first dose then add Pharmacy to dose in the comments IV_DISPLAY ISSUES Some IV medicated drips will display in the PRN section instead of the IV section of the Orders pane ADC VAAN DISML view Pharmacy to Adjust Dose The provider will order Pharmacy to adjust dose with a specific dose already in the dose field Incorrect Dose is Ordered by the Provider Pharmacy will add the comment Dose adjusted per MD o
7. POFRX FORTY MBA BODODOLITIN Patient Type inpatient Age 87 Y Adeutted 10 1910 16 30 kasatian 10M 0 192 07 Ener orders for a cunenty admitted patent A second security box displays If you have the correct patient click OK Y LA HEU Launcher Launch tonli mation Patent CPOERX FORTY MAN BDO Age Gr Y ls patient has the following valid active encounters available for orders H the selected encounter in bold is incorrect click Cancel and navigate to the correct encounter orje Patient Typa LOS Location na Attending Phy S Semi gap JE E392 MCGILLEN JOHN Private oz J A second confirmation box displays click OK to launch the Order Entry i07 iay in 16 30 0 This action launches the Order Entry application The Order Entry Screen KU Horizon Expert Orders Order Entry S91201 CPOETEST JUDY 8000012390 40years F CPOE Medical Floors Top Orderables Outline A ADC VAAN DISML display 1 mandatory admit orders Admission 2 diet weight 60 000kg 132 31b Sep 29 11 28 al 4 b na 5 card 6 cbc without diff 7 cbc with diff 8 collect culture aerobic routine includes smear 9 collect culture urine severe sepsis shock Sep 29 11 26 Condition Select an item from the list vital signs cpoe q vital signs cpoe ongoing scvo2 cvc with continuous scvo2 in vivo calibration initially and g 24h or if cable is o edi disconnected from ca
8. beats of vt or symptomatic vt once md aware of non sustained vt call ashy HW sustained or symptomatic start on LL at 13 30 Mor OE 15 30 GE thes if urimo output lt 3 mls boers while om iv digretic therapy thos notifv md start om 11 8 at 15 30 Mor OE 15 10 GE then if unable to obtaim accurate output thes mav insert indwelling urinary catheter may discontinare foley once om oral dimretics start on 118 at 15 30 Nov O8 15 10 pulse oximetry nursing spot check q shift start on 118 at 15 30 Nov O8 15 30 oxygen nasal cannula at 2 4 lpm maintain oF sat gt or to 90 call m d ni lt 4 z start on LUS at 15 30 Sov OF 15 30 vital signs cepec per umit standrd bip tyr start on ING at 15 30 Mov 08 15 30 intake and output strici start on 11 5 at 15 30 Nov O8 15 30 daily weaght start am 1l ai 15 30 Nov E 15 10 ambulate entourage early ambalanen a soon as patent is able start om 11 8 ar 15 20 Nov O8 15 30 diagnosis heart failure siari om 11 8 at 15 30 Previous orders Nov 12 06200 cbe rubont diff ted pk xl times oov 15 06 00 Nov 12 06200 cbe rubont diff ted pk xl times Nev 12 00 00 Modify or Delete Linked Orders To modify or remove one of the linked orders click the item in blue text and O Select Modify or Delete Complete the Order Entry process Press done lt F8 gt ACCEPLANG EXI Nov 08 15 30 intake and output strict start on 11 8 at 15 30 Go modify
9. er Entry process e Click on the order element you want to modify and enter the modification e Select done lt F8 gt e Accept and Exit Note You can modify some saved orders If you click the order and the modify option appears the order can be modified AFTER the Order Is Saved you can modify most medication orders e Select a patient and open Order Entry e Left click the medication in black text e Select Modify e You will be returned to the Order Entry process e Click on the order element you want to modify and enter the modification e Select done lt F8 gt e Accept and Exit Delete an Order e Select a patient and open Order Entry e Left click the order s blue text in the Current Order Pane e Select Delete You can only delete an order before it is accepted e The order disappears from the Current Orders pane e Select done lt F8 gt e Accept and Exit lt A S A A A O The Order Entry Process continued Discontinue a Single Order Click a saved order on the Orders pane Click Discontinue in the pop up box DO NOT use Discontinue for cleanup the department is not notified Click done lt F8 gt Accept and Exit Discontinue Multiple Orders Select a patient and open Order Entry Click D C lt F3 gt on the toolbar A list of orders that can be discontinued displays Check the box boxes before the orders you want to discontinue Click the Discontinue orders button The ord
10. ers disappear from the Current Orders pane Click done lt F8 gt when finished Accept and Exit Renew Orders Select a patient and access Orders Entry Click the Renew button if it is highlighted in fuchsia on the Order Entry toolbar e Check the box next to the order you wish to renew e Click Renew Selected Orders Click done lt F8 gt Accept and Exit Co Sign Orders Select a patient and access Orders Entry Click the Co sign button if it is highlighted in red on the Order Entry toolbar e Check the box next to the order you wish to cosign that appear in the My Orders box e Click Acknowledge Selected Orders at the bottom of the box to co sign the orders Click done lt F8 gt Accept and Exit Order Entry Continued Order Sets An order set or order outline contains multiple orders that are characteristi cally ordered together for example Chest pain R O Coronary Syndrome Order sets are denoted by gt gt following the order name 2 heart failure orders 12 08 cpoe Linked Orders A linked order is denoted by a a sign in front of the test name e By clicking the numbered order above the list all linked orders move to the Orders pane at the same time e You enter multiple orders with one click of the mouse 1 mandatory admit orders x LINKED ORDERS 2 diagnosrs heart failure ambulate encourage early ambulation as soon as patient is able daily weight mlake and output
11. gmentation of the pro vider s time e Decrease in the number of lost orders e Decrease the number of inquiries for ambiguous orders e Clinical decision support tools like InfoLinks and alerts improve workflow and minimize disruption e Evidence based information is built into the system Log in to the CareLink Website Portal to Enter Orders Viewing all your patient orders You will have to check the chart for orders that have been written on paper until all providers are CPOE trained You should also check MedsViewer OrderViewer e The Meds Viewer Tab o This tab located between the Document Viewer Tab and the Order Viewer Tab allows physicians to view all medications and V s ordered and administered e The Order Viewer Tab Is located next to the Order Entry Tab and displays all non med orders written on the patient during this admission 0 You may sort orders by status order group or those written in the last n days The Chronological view in the Orders pane in Order Entry Displays all orders from newest to oldest Provides a quick review of recent orders if you have been away for a few days or are new to the patient Provider Order Entry Process Log in to CareLink Select your patient and open the chart o Click the Order Entry tab The first security box displays Insure that you have the correct patient e Click Enter Orders MA E CM MED Lagncher Patbani C
12. ient Information View All Orders View Patient Demographics O Downtime Procedures Write orders on paper and use telephone orders O Special i Forms Type in i Form gt Pneumonia Diabetes 8 Il Heparin Diet Blood Bank PCA Thrombosis Risk Assessment Consents 21 Set your default view on your My Census tab to the Data Monitor View e You are able to access new labs rad results and in the future co sign CareLink orders from this tab ti M Custom Patient List Patient Type Inpatient w St Census Type My Patients w lefresh Click on Refresh to refresh the Datamonitor view with up to date alerts indicators Censu Patients 5 atus sh Census List How to set the default view on the My Census Tab to the Data Monitor Click the edit button on the My Census view page Scroll down the page and change the Default view to Data Monitor Scroll to the bottom of the page Click Save Additional Resources CareLink Support Page O Click the link on the CareLink Website Portal login page under the Message of the Day CPOE Training materials Fast Track Learning topics Tips Medication Rules IV Info Essential Computer Skills Review 22 Notes 23 nC Northwest Community Hospital CPOE SUPPORT Unit based Support See placard by unit computers Support to include Clinical Resources out of staff clinicians dedicated to
13. n for platelet count lt 100 000 mm3 siens and symptoms of bleeding ora PTT ratio gt 4 Heparin Infusion 900 units hour 15 units ke hr rounded to nearest 50 Use caution with IM injections while on Heparin Concentration 25 000 units Heparin 500 mL DSW Heparin Dosing Chart for DVT or Pulmonary Embolism InfoLink HeparinBotus 000 units IV Push 60 units ke rounded to nearest 1000 NO HEPARIN BOLUS PTT Ratio Drip Rate Changes Give bolus of 60 units kg and Increase infusion rate by 4 units kg hour Give bolus of 30 units kg and Increase infusion rate by 2 units kg hour Therapeutic Range NO CHANGE in infusion rate draw next PTT 6 hours after the last PTT then again with moming labs Decrease infusion rate by 2 units kg hour Hold Infusion for hour then decrease infusion rate by 3 units kg hour and notify the physician Exit Without Ordering NOTE You cannot modify or discontinue a diet generated from a diet i Form but you can delete the order before it is accepted Merely complete another i Form to order a new diet Other i Forms can be modified when the orders are displayed in blue text in the Orders pane InfoLinks 0 InfoLinks are web pages that contain reference information o They can be found on i Forms or on order outlines 12 LAB PRIORITY AND FREGUENCY MUST BE ENTERED CORRECTLY OR THE LAB WILL NOT BE DRAWN AT THE TIME IT APPEARS TO BE ORDERED TIMED PK can
14. nes such as influenza or pneumonia vaccines e The attending MD is responsible for signing any Standing Orders You will sign these orders after the patient is discharged on the Chart Completion Tab of the CareLink Portal 18 Transfer Orders Type transfer in the Order Completer Pane 9 When to Start Routine is the default e You can modify if necessary When to start with optional start date X time 1 ROUTINE default 2 STAT 3 TIMED or enter an allowed value or enter a start date time and priority or press ENTER ROUTINE 9 Select from 0 4 values Transfer To 1 x Critical Care 2 CSU 3 Oncology 4 Orthopedics 3 Post Surgical 6 Medical Renal 7 Medical Pulmonary 8 Medical Surgical 9 Neuro 10 Pediatrics 11 Pediatric Acute Care 12 POP 13 Labor and Delivery 14 Mother Babv 15 Admitting Nursery 16 NICU 17 Newborn Nursery 18 Mental Health Voluntary 19 Mental Health Involuntary 20 MOU 21 Medical Unit 22 Interventional Unit 23 PPPU 24 Surgical Heart Unit 25 Short Stay HF Unit Select from 0 to 4 values Press ENTER when finished O Enter comments if needed O Complete the order entry process as usual 19 Select No 1 Transfer patient from the list in the Order Detail pane Discharge Orders O Type discharge into the Order Completer Pane O Select the appropriate discharge order set 1 discharge orde
15. ng through ADC VAAN DISML Current Orders 8 Chronological views D C lt F3 gt Displays a list of your orders that may be discontinued renew Turns fuchsia when orders are within 24 hours of expiration cosign Turns red when there are telephone or verbal orders to acknowledge co sign Outlines lt F4 gt Brings up a list of order outlines Oops lt F5 gt Takes you back one step in the order entry process like a back button help lt F6 gt Help files complain lt F7 gt Suggestion button opens email that is sent to our Process Build team Please enter helpful suggestions done lt F8 gt When you are finished entering orders prepares to leave the system CareLink Order Entry Process e Open a patients chart and select the Enter Orders tab in the CareLink Website e Type the order in the Order Completer pane and press Enter e Select the order from the list o Follow the prompts in the Expanded Information pane Select a Priority When to start o Frequency How often O Select a Duration For how long e Provide any additional information reguired or enter Comments if necessary e Press Enter You can enter more orders or e Click done lt F8 gt e Accept and Exit CARELINK ORDER ENTRY PROCESS Modify an Order BEFORE Saving and Accepting the Order e Select a patient and open Order Entry e Left click the order s blue text in the Current Order Pane e Select Modify e You will be returned to the Ord
16. rder so the RN will know that Pharmacy has clarified and adjusted the order Weight based Dose Some drugs have weight based formulas built into the dose field i e immunoglobulin Pharmacy can round doses per policy Per policy will be visible in the Comments so the RN will know why the dose is different from the provider order One Time medication orders should NOT be modified Blanket orders Hold all sedatives are not acceptable To renew a medication when the toolbar button is fuchsia you must renew the EXACT SAME order If you want to modify the original order you must either modify the original order or create a new order 16 Medication IV Orders 0 Chained Orders allow providers to taper medication doses Enter taper in the comments field and Pharmacy will enter addi tional orders if necessary e The Medrol dose pack is a good example of tapering doses Non formulary meds If you don t find a med in your search it may be non formulary If the NCH alternative is not acceptable enter Misc to search for the drug For example Zantac is non formulary but you would find it under Misc IV Orders 1 iv fluids nicu To find common IVs 2 iv fluids adult a 3 Iv fluids pediatrics x e Type IV fluids in the search pane 4 bolus iv fluids Select from the list of IV Fluid order set To order an IV click IV fluids in the ADC VAAN DISML e Select from the li
17. rs by attending physician cpoe 2 discharge orders by consulting physician cpoe O The defaults for the discharge order are Routine and Once O Select the Discharge Conditions Discharge Conditions 1 no need to call consultants 2 If okay with surgeon 3 _ if okay with ID consltnt 4 _ if ok w consltnts list in commnts Select from 1 to 3 values Press ENTER when finished Complete Discharge To Discharge To a HOME b HOME WITH HOME CARE c HOME WITH HOSPICE d ECF SNF e HOSPITAL TO HOSPITAL fF INPATIENT HOSPICE z ACUTE REHAB h LTC HOSPITAL i AMA or enter an allowed value Complete Additional prescriptions Activity Diet Follow up Other instructions Comments O Complete the Order Entry process 20 What s Still on Paper Consents or signed documents Epidurals Chemo orders Some critical care orders i e Xygris Code Blue documents Transitional IV insulin protocol orders Conditional orders i e DC Lanoxin if OK MET Alert documents with Dr Jones TPN Restraint Orders Home Care Orders O ADC VAAN DISML view of the Orders pane e Find radiology orders under Other Investigations e Discontinued orders fall off the ADC VAAN DISML orders view O To view all orders entered into CareLink click the Patient Banner at the top of the Orders pane 590101 CPOETEST JUDY 38000012390 40 years F CPOE HEO Message Order Entry AM Pat
18. st of available IV fluids IV fluids There are switch orders on most IV fluid orders This allows you to switch an IV to a saline flush when appropriate switch to sodium chloride 0 9 flush Discontinue the IV fluid Click the order on the Orders pane Select discontinue You will have the ability to order the saline flush Complete the order entry process 17 O One per Patient warning Some orders are built to be ordered only once on a patient The system stops the process if it believes you are attempting to enter a duplicate order O Mandatory Admit Outline You must enter admission status O Conditional Orders If OK with are strongly discouraged These types of orders must be written on paper O Viewing Orders Providers must view all orders in the Orders Viewer and or Meds Viewer to see changes You can also check the most recent orders in the Chronological view of the Orders pane Inthe Hybrid World Providers must check for orders written in the paper chart until all CPOE implementation phases are complete O Standing Orders e Dr s Standing Orders will be used to order the 5 NCH Standing Orders 5 STANDING ORDERS na Adult Medical Surgical Standing Orders m Tm Cardiac CT Angiography Pre Procedure Standing Orders Hypersensitivity Reaction to Chemotherapy Standing Orders Za VenoLs Access Device Maintenance Flushing Standing Orders e Drs Standing Orders will also be used to order vacci
19. the prompts in the Expanded Information pane O Enter comments if needed O Press done lt F8 gt O Click Accept the order and Exit Modify a Med Order Click the blue text of the order in the Orders pane O Select Modify Complete the order entry process Accepted meds may be modified if the modify option is displayed O Follow the above procedure O Pharmacy Communication Order Used to make changes to existing medication orders when e Holding a single dose e Temporarily stopping a medication or dose around a procedure or surgery e Particular medication needs Patient may use own meds On the Order Entry screen type Pharmacy Comm in the Order Completer Pane and Enter O Enter the change in comments i O Complete order entry process Cancel and re enter medication orders if you need to change a DOSE FREGUENCY and or ROUTE Medication Schedules O There is a difference between ordering a med as QnH and GnHR in the system e A QnH frequency will order the medication at NCH standard times e A QnHR frequency means the medication will be administered immediately amp at n hours from the time of entry Used for antibiotics e BEST PRACTICE for most meds is QnH When to Start e NEXT SCH e The med order will come to Pharmacy with a start time of the next scheduled dose based on the frequency and time the provider entered the order e After 9AM the DAILY Q
20. theter Sep 29 11 26 re Activity limitations activity progression protocol Oct 12 09 33 bedrest ongoing Oct 06 12 54 Intranet Allergies allergy to drug nka Sep 09 00 01 BE nn da Deven om p am me m m de P P L The Orders Pane e Occupies the entire left side of the screen e Displays all active orders entered into CareLink e 3views ADC VAAN DISML default provider view Chronological lists all orders in chronological view from newest to oldest and Current Orders default non provider view The Order Detail Pane e Returns a list of items matching the search terms you entered in the Order Completer pane e Select an item from the list When you begin to build the order the details display in this screen The Expanded Information Pane e Prompts your next actions in the order entry process The Order Completer Pane The area where you will type in your search term like a Google search Launches a search engine that retrieves tests treatments etc that mach your entered search term Where you will type responses to the prompts in the Expanded Information pane The Toolbar Buttons e Click the button to initiate the action e lt F gt indicates that you can also use the function key on your keyboard to initiate the action print lt F1 gt Initiates printing display lt F2 gt Changes the Orders pane view cycli
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