Placing Orders - Orders This Episode
Overview
The following sections detail the behavior that users and system administrators should expect when placing new orders or order groups via the Order Entry Console.
Order Sets
The Order Entry Console supports the ability you to place order groups. The order search has been modified to include both orders and order groups in the results.
Once selected, you are presented with an order selection window. Here, you have the ability to select all of the items in the order set to be added to the Scratchpad or to select them individually. You can also change the frequency, dose, and special instructions when you click anywhere on the item in the group. Once everything is added to the Scratchpad, you have the ability to view and edit any orders prior to signing.
Taper/Titration
For pharmacy orders, the user can select to do a taper or titration on the fly rather than a single dose. Selecting this option gives the user the ability to define a series of taper or titration steps.
User are able to adjust the dose and frequency for each step in the series as well as determine if the steps should follow a calendar or 24-hour clock. The system defaults to Calendar. In this scenario, the stop and start times would follow the calendar vs. the original start time.
For example, a three-step titration each with a duration of three days started at 11:00 AM would have the following stop/start times:
- Step 1: Start @ 11:00 AM Day 1, End Day 3 @ 12:00 AM
- Step 2: Start @ 12:01 Day 3, End Day 6 @ 12:00 AM
- Step 3: Start @ 12:01 Day 6, End Day 9 @ 12:00 AM
On the other hand, should the user choose to follow a 24-hour clock, the same titrations would have the following start/stop times:
- Step 1: Start @ 11:00 AM Day 1, End Day 3 @ 11:00 AM
- Step 2: Start @ 11:00 AM Day 3, End Day 6 @ 11:00 AM
- Step 3: Start @ 11:00 AM Day 6, End Day 9 @ 11:00 AM
Once this order set is added to the Scratchpad, the user would see three individual orders with varying offsets. Please note: The individual orders from an order set are not managed together. If the user changes the details in one order or deletes an order, it does not automatically update or change the details of the other orders. Additional instructions are added to each order indicating which step of the titration or taper it is.
Free-Text Dose
For those situations where the physician is unsure of what dose to order for the client, or would like a pharmacy consultation, they can select the option to add a free-text dose. When selected, the Dose field is no longer available and the physician is required to enter additional instructions. The free-text dose should be used sparingly; however, it gives physicians the opportunity to communicate their intent or ask for a pharmacy consultation if they are unsure of the appropriate dose for the medication.
This option is not available when sending to an external pharmacy.
First Dose
When a new order is being added to the Scratchpad and a frequency with scheduled administration times is selected, the user is presented with first-dose information. The user has the ability to skip the first dose or to give the initial dose now.
If the user selects Skip 1st Dose, the start date and time of the order will be moved forward to coincide with the next scheduled administration.
Figure 1: Prior to selecting the first dose
Figure 2: After selecting Skip 1st Dose
If, on the other hand, the user chooses to Give Initial Dose Now, indication will be sent to the pharmacy (highlighted first dose field) and nurse (watermark on medication) that the physician has indicated a "Now" dose has been indicated by the provider.
Missing Required Fields
When placing an order, required order details are identified by red text. Once an order has been added to the Scratchpad, the system will check for any missing required fields. If any details exist, the user will see a red flag indicator next to the orders that are missing the required fields.
Interaction Alerts
With the console, users are presented with passive alerts during the ordering process. Alert icons display with the order details and in the Scratchpad. At any point, users have the ability to click on the icon, review the alerts and resolve the issues.
Figure 3: Within Order Details
Figure 4: From the Scratchpad
Clicking on the individual alert icons presents the user with only the alerts for that specific order. Upon signing, all unresolved alerts will be presented to the user for resolution. There is the potential for three tabs within the alert window to be displayed: Interactions, Duplicate Orders, and Dosage Range.
Interactions
The Interactions tab displays the following types of alerts:
- drug-drug
- drug-allergy
(also displays alert for lack of allergy data if the Display Warning if No Allergy Form Filed registry setting is enabled) - age-based
- patient-specific dosing
- client acuity
(interactions related to clinical alerts set up in the Clinical Alert Definition form)
The Override Reason field for Interactions is populated by the following dictionaries:
Duplicate Order
Duplicate Orders will be on their own tab.
The Override Reason field for Duplicate Order is populated by the Override Code (Age and Problem Alerts) dictionary.
Dosage Range
The Dosage Range tab displays alerts when a medication is configured to check a dosage range and an amount is entered during the ordering process that exceeds this dosage range. All pharmacy orders in Avatar Order Entry will be checked against the dosage range defined in RxConnect.
The Dose field on the ordering screen leverages RxConnect’s dosage range check to generate the alert when a medication being ordered exceeds a defined dosage range.
This alert is a warning and can be overridden by selecting an Override Reason for the dosage. In this case, the Override Reason field is populated by the values added in the user-defined dictionary Dosage Range Check Override Reason Code. You will be required to specify an override reason to proceed with the ordering of the medication. This override reason will be stored with the order and will be viewable by pharmacists in RxConnect.
Dosage Range Checking
Dosage Range Checking is currently NOT supported in the Order Entry Console (Orders This Episode section) when sending orders to OrderConnect for "external pharmacy mode".
This functionality is supported when Avatar is connected to the Truven/Micromedex CKO server through the CKO Server IP Address Or Server Name and CKO Server Port Number fields on the Order Entry Clinical Screening System Defaults form. Also, the user-defined dictionary value Dose Unit, should be set up with the relevant type of CKO Server Dose Unit.
In order for Dosage Range Checking to occur during order creation, the following must be on file. If this information is not on file, then a dosage range interaction alert will be presented for each missing item.
- Date of Birth
- Gender
- If over the age of 18 years old, height and weight vitals must be entered within one year of the date the order is being created.
- If older than 12, but less than 18 years old, height and weight vitals must be entered within the past six months of the date the order is being created.
- If older than two, but less than 12 years old, height and weight vitals must be entered within the past 30 days of the date the order is being created.
- If older than one, but less than two years old, height and weight vitals must be entered within the past seven days of the date the order is being created.
- If less than one year old, height and weight vitals must be entered on the current date that the order is being created.
Save Override
Users must address all alerts prior to signing. The Save Override and Exit button is not available until all alerts have been addressed.
SQL Tables
Information entered when overriding a dosage alert is saved to the OrderEntry.history_log_warn_dose table.
Information entered when overriding a clinical alert is saved to the OrderEntry.history_log_warn_clinical table.
Information entered when overriding an allergy alert is saved to the OrderEntry.history_log_warn_allergy table.
Information entered when overriding a dosage range alert is saved to the OrderEntry.history_log_warn_dose table.
Updating From the Scratchpad
When a user selects an order from the Scratchpad, the details will automatically populate in the order details section for editing. In order for the changes to be committed to the Scratchpad, the user must select the Update Order button. They can cancel or clear the edits without committing by choosing to cancel the update.
Order Favorites
You now have the ability to add order codes to your list of favorites so that you are not required to search and add each time. Currently, the only information retained with the favorite is the orderable itself, not any of the details that were entered by the physician. You can add to your favorites by selecting an orderable and clicking the 
button next to the orderable name. You can also add and manage your favorites by clicking the hyperlink next to the star.
