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Physician Reference
Guide
June 4, 2012
Important Numbers
http://www.clarian.com/informatics/active/
physician_education/ v2/index.php
2
Table of Contents
Overview....................................................................... 9
Introduction ...................................................... 9
Cerner Password ............................................... 9
Security ............................................................. 9
Log On and Off........................................................... 10
Introduction .................................................... 10
Remote Log On Procedure.............................. 10
Downtime Procedures .................................... 11
Log On Procedure ........................................... 13
Log Off Procedure ........................................... 13
Change Your Password............................................... 14
Introduction .................................................... 14
Procedure........................................................ 14
Access Other Clinical Systems ................................... 15
Introduction .................................................... 15
Available Systems............................................ 15
View Surgical Schedules ............................................ 16
Procedure........................................................ 16
Utilize Message Center ............................................... 17
Introduction .................................................... 17
Sign Single Telephone and Verbal Orders....... 17
Sign a Group of Telephone and Verbal Orders17
Forward Orders for Signature......................... 18
Refuse Orders for Signature ........................... 19
Cosign a Note .................................................. 19
3
Create and Maintain Patient Lists ............................... 20
Introduction .................................................... 20
Lists Used ........................................................ 20
Create a Relationship List ............................... 20
Add Patient to Relationship List...................... 23
Remove Patient from Relationship List .......... 23
Create a Query List (Report) ........................... 24
Modify a Query List......................................... 25
Safeguard Printed Patient Information .......... 26
Search for a Patient ..................................................... 27
Introduction .................................................... 27
Procedure........................................................ 27
Multiple Encounters........................................ 27
Locate the Correct Patient Encounter ............ 28
Document Chart Access.............................................. 30
Introduction .................................................... 30
Procedure........................................................ 30
View and Add Allergies.............................................. 31
View Allergies.................................................. 31
Add Allergies ................................................... 31
Navigate to Sections of the Chart ............................... 33
Introduction .................................................... 33
Manage Search Criteria on the Results Review Band 36
Move Forward or Back by One Day ................ 36
Navigate to Results ......................................... 36
View Result Details ......................................... 36
Set View Format for Current Session.............. 37
View Clinical Documentation..................................... 38
4
Four Bands ...................................................... 38
Procedure........................................................ 38
Navigate Scanned Documents ........................ 39
Create a Free-Text Clinical Note ................................ 40
Write Notes ................................................................. 41
Set Up Personal Document Types as Defaults 41
Suggested Content.......................................... 41
Procedure........................................................ 41
Create New PowerNote .................................. 43
PowerNote Views............................................ 46
Modify PowerNotes ........................................ 47
Advanced PowerNote Functions .................... 50
Computerized Provider Order Entry (CPOE) ............. 59
Customize Views ............................................. 59
The Orders Window........................................ 67
Order Entry Basics...................................................... 69
Specialty Clinical Folders................................. 69
Set Your Clinical Specialty Folder as Your Home
Folder .............................................................. 69
Basic Order Search .......................................... 70
Search for Orders............................................ 70
Enter Single Orders ......................................... 71
Modify Orders................................................. 73
Favorites Folders............................................. 74
Medication Order Frequencies ....................... 77
Standard Schedules for IU Health................... 78
Order Entry Tools ....................................................... 79
Order Sets ....................................................... 79
5
PowerPlans...................................................... 79
Medication Order Entry .............................................. 87
IV: Titratable Drip............................................ 88
IV – Heparin Nomogram and Thrombo-
stabilizer Infusions .......................................... 89
IV – TPN Adult ................................................. 89
IV – TPN Pediatric and Neonatal..................... 94
Medications: Dose Range Orders ................... 96
Medications: Hold a Single Dose.................... 97
Medications: Irrigation Orders ....................... 98
Medications: Multiple PRN Reasons............... 98
Medications: Multiple Route Orders .............. 98
Medications: Non-Formulary/ ........................ 99
Substitution..................................................... 99
Alerts ............................................................... 99
Medications: One-time STAT Doses.............. 101
Medications: STAT Doses with Ongoing Orders
....................................................................... 101
Medications: Patches.................................... 102
Medications: Taper Doses............................. 102
Medications: Taper Dose, No Existing Taper
Order ............................................................. 103
Medications: Prescriptions ........................... 104
Dosage Calculator..................................................... 112
Introduction .................................................. 112
Where to Find the Dosage Calculator........... 112
Calculation Options by Weight ..................... 113
Calculate Standard Doses ............................. 113
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Pediatric Antimicrobial Stewardship ........................ 116
Introduction .................................................. 116
Orders ........................................................... 116
Program Goals............................................... 116
PowerPlans.................................................... 117
Organization of Antimicrobial Agents........... 117
Place Orders from a Subphase...................... 118
Locate an Antimicrobial Agent PowerPlan ... 122
Restricted Agents.......................................... 123
Medical Student Orders ............................................ 126
Overview: Medical Student Orders .............. 126
Medical Students: Order Processes.............. 126
Other Order Entry Processes..................................... 136
DNR Orders ................................................... 136
Medication Special Alerts/............................ 140
Communication............................................. 140
Transfer Order Review Note ......................... 141
Discharge Instructions (eDI).......................... 142
Glossary .................................................................... 154
Frequently Used Phone Numbers ............................. 156
IU Health Ball Memorial................................ 156
IU Health Methodist ..................................... 156
Riley Hospital for Children at IU Health ........ 157
IU Health University...................................... 158
Richard L. Roudebush VA Hospital................ 159
Wishard Memorial Hospital .......................... 160
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8
Overview
Security There are strict regulations that govern the use and
protection of patient information. Certain measures have
been put into place at IU Health that protects patient data
in the EMR.
• Cerner automatically logs out after 15 minutes of no
activity; however depending on the location, certain
areas may have a different automatic logout time
• Do not share passwords
• Do not allow another person access under your ID and
password
• Log out of the EMR when walking away from the
computer
9
Log On and Off
Remote Log
On Step Action
Procedure
1. Open your web browser.
2. In the address locator bar, enter
https://sragate.clarian.org
3. Click Yes to install Juniper on your system.
4. Enter your IU Health Network ID and
password.
5. Click Enter or Sign In.
Available roles in the secure gateway display.
10
Log On and Off, continued
11
Log On and Off, continued
12
Log On and Off, continued
Log On
Procedure Step Action
1. Double-click on your computer desktop.
2.
Click displayed in the Applications
window.
3. Enter your user ID (usually your dictation
number) and password into the respective
fields.
4. Click OK.
Log Off
Procedure
Step Action
1. Close all open patient charts.
2. Click to immediately disconnect from
the server.
The Exit Application window displays.
3. Select Exit and shut down the application.
Note: To suppress this message in the future,
place a checkmark in the box.
13
Change Your Password
Introduction You can change your password at any time using the
following procedure.
Procedure
Step Action
1. When logged onto Cerner, click Task on the
toolbar.
2. Select Change Password from the drop-down
menu.
14
Access Other Clinical Systems
Introduction Within Cerner, you can access other clinical systems used
at IU Health.
Available
Systems System Description
INPC Data repository that includes:
• Labs and documentation created
prior to the Cerner implementation
• Current information from other
health care sites around the state of
Indiana
ClinDoc • Electronic nursing flowsheet contains
data entered by nursing
• Data flows into Cerner
• It can be viewed from either ClinDoc
or Cerner
ClinSuite Tool used to facilitate the patient
handoff process between physicians
UpToDate IU Health’s source for evidence-based
clinical information
15
View Surgical Schedules
Procedure
Step Action
1. Click in the links within Cerner.
2. Click the appropriate surgical area.
16
Utilize Message Center
Sign Single
Telephone Step Action
and Verbal
1. Click the Orders, Cosign Orders or Med
Orders
Student Orders folder.
2. Review order details for accuracy.
3. Right-click the order.
4. Select Approve from the menu.
Sign a Group
of Telephone Step Action
and Verbal
1. Click the Orders, Cosign Orders or Med
Orders
Student Orders folder.
2. Review order details for accuracy.
3. Hold the Control key down while clicking on
multiple orders.
4. Right-click anywhere WITHIN the highlighted
orders.
5. Select Approve from the menu.
17
Utilize Message Center, continued
Forward
Orders for Step Action
Signature
1. Select the order(s).
2. Click Forward Only.
3. Select Sign from the Additional Forward Action
list.
4. Find the provider by:
• Typing the name of the intended recipient
provider, or
• Click Search and look for the provider
5. Enter comments (up to 120 characters,
including spaces) if necessary.
Note: Comments become part of the
permanent patient medical record.
6. Click OK.
18
Utilize Message Center, continued
Refuse
Orders for Step Action
Signature
1. Click the Message Center Orders, Cosign
Orders or Med Student Orders folder.
2. Double-click the order you wish to refuse.
3. Click Refuse.
4. Select a reason.
5. Type a comment (up to 120 characters) if
needed.
6. Click OK or click OK and Next if you need to
refuse additional orders.
The order is routed to the refusal admin.
Cosign a
Note Step Action
1. Click the Documents folder.
2. Double-click the note requiring cosignature.
3. Review the note for accuracy.
4. Click OK to sign the note.
19
Create and Maintain Patient Lists
20
Create and Maintain Patient Lists, continued
Create a
Relationship
List, cont.
Step Action
4. Click Next.
5. Click + to the left of Visit Relationships.
6. Click Next.
7. Place a checkmark in the box to the left of
the appropriate type of physician
relationship(s).
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Create and Maintain Patient Lists, continued
Create a
Relationship Step Action
List, cont.
12. Place a checkmark in the box to the left of
each location.
Add Patient
to Step Action
Relationship
1. Click the patient list tab where you need to
List
add the patient.
2. Click (Add Patient).
3. Enter the patient’s last name or MRN (medical
record number).
4. Click Search.
5. Select your patient from the search results list.
6. Select the appropriate encounter from the
lower pane.
7. Click OK.
8. Click to refresh.
Remove
Patient from
Relationship
Step Action
List 1. Click the specific patient list tab where you
need to remove the patient.
2. Click the patient’s name.
3. Click (Remove Patient).
4. Click Yes to confirm.
If you have only one relationship with the
patient, the patient drops off your list. But if
you have more than one relationship with the
patient, the patient does not drop off.
5. Select the appropriate relationship.
6. Click OK.
7. Click to refresh.
23
Create and Maintain Patient Lists, continued
8. Click Next.
9. Type the first few letters of the physician’s
name to move quickly to that area of the
physician list.
10. Place a checkmark in the box to the left of the
desired physician’s name.
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Create and Maintain Patient Lists, continued
Create a
Query List Step Action
(Report),
15. Highlight the new list in the Available lists
cont.
pane.
Modify a
Query List Step Action
1. Click .
2. Click (Modify Parameters).
3. Modify the parameters for a query list (add or
remove a physician or location).
4. Click OK.
5. Click (Execute Query) to implement
your changes.
25
Create and Maintain Patient Lists, continued
26
Search for a Patient
Procedure
Step Action
By Name
1. Type the last name of the patient in the Name
search field.
By MRN
1. Click the arrow to the left of the patient search
field.
2. Select MRN.
3. Enter the MRN into the search field.
Multiple • You may find that the patient has multiple encounters
Encounters that are displayed in the lower pane. Certain types of
patients may have multiple Active encounters.
• You must identify and select the correct patient
encounter. If the improper encounter is selected, your
orders and documentation will not follow the
appropriate workflow and will need to be corrected.
Locate the
Correct Step Action
Patient 1. Carefully view the patient encounters in the
Encounter lower pane of the Patient Search window.
2. Search for an encounter near or on today’s
date.
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Search for a Patient, continued
Locate the
Correct Step Action
Patient
7. Review the patient header to ensure that you
Encounter,
cont. have accessed the correct encounter.
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Document Chart Access
Introduction If you access a patient chart for any reason other than
direct patient care (e.g., research, administrative, or
accidental access) you must document why you accessed
the patient chart.
Procedure
Step Action
1. Open a patient chart.
2. If a relationship window displays, select a
relationship.
3. Click Chart on the toolbar at the top of the
screen.
4. Scroll to the bottom and select Chart
Accessed By.
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View and Add Allergies
View If allergies have been entered into the patient chart, the
Allergies name of each allergy displays in the patient demographic
bar. The list may be truncated.
Add
Allergies Step Action
1. Click (Allergy link) in
the patient header to access allergy details.
Note: Alternatively, you can click
(Allergies band) to enter allergies.
2. Click + Add.
3. Click the + to the left of the appropriate allergy
category folder.
31
View and Add Allergies, continued
Add
Allergies, Step Action
cont.
4. Double-click the correct allergy name.
32
Navigate to Sections of the Chart
Band Function
Results Displays lab results, vital signs, significant events, and
Review other pertinent information for your patient
In Patient Allows access to most of the patient data displayed in
Summary the patient chart. You can take action directly from this
band, such as adding problems, diagnoses, and orders,
and viewing physician notes and test results.
33
Navigate to Sections of the Chart, continued
Band Function
Rounds Displays an online view of data similar to the printed
rounds report
I/O / I • Provides advanced graphing functionality
Flowsheet • Is useful for viewing data trends over a period of time
• Displays volumes in split-screen format (flowsheet
and graph); optional split-screen display
• Default setting displays previous 24-hour totals
Allergies • Displays all allergies entered into the system
• Allows for additional allergies and reactions to be
documented
MAR Summarized medication administration over 24 hour
Summary timeframes during current encounter
Medication A record of all meds ordered for a patient, either by
List history, through online prescription ordering, or by
PowerChart order entry. Also allows for new medication
orders to be added.
Orders Provides the Order Profile for a patient—existing orders
as well as order statuses and detail information. Allows
for new orders to be entered.
2 Year
Clinical Contains notes from today to 2 years prior
Notes
72 Hr Defaults to display only notes for the past 72 hours.
Clinical Types of online documents include:
Notes • Interfaced notes dictated from other systems
• Scanned documents (display under admission date)
• Direct-entered notes (PowerNotes, intra-operative
documentation, etc.)
34
Navigate to Sections of the Chart, continued
Band Function
2 Year
Displays notes by physicians and mid-level providers and is
Physician
a sub-set of clinical notes
Notes
PowerNote Allows for the use of templates to create structured notes.
Use the PowerNote band to document your online notes.
Problems
Displays problems and diagnoses entered into the system,
and
also allows for adding or editing information.
Diagnoses
Patient Info Contains demographic and case-related information
organized under sub-tabs, including list of procedures,
problems, immunizations, and visits, as well as growth
chart information, and a provider list through which you
can manage physician relationships.
Dictation Displays a combined view of Documentation and Lab &
View Diagnostic Results to assist physicians with the pertinent
data they need to complete a Dictation (for example, to
help facilitate the dictation of a Discharge Summary).
Chart Displays summarized information in window-frame layout.
Summary Includes information regarding special alerts, providers,
patient data (e.g. reason for visit, surgical cases, etc.),
medications and IVs, and patient care and ancillary orders.
Discharge Secure electronic form used for documenting custom
Instructions patient discharge instructions.
Chart Is a search engine that allows users to search for patient
Search data within the patient’s medical record. It will search for
words, phrases, and clinical concepts. It can match and
rank documents so that the most important documents
move to the top of the results list. Chart Search does NOT
include:
• Orders • Allergies
• Problems • Lab panels (currently must search
• Procedures for individual components)
35
Manage Search Criteria on the Results Review
Band
View Result Double-click any result to see more detail (reports, result
Details history, specimen information, etc.).
36
Manage Search Criteria on the Results Review
Band, continued
Group
Group format arranges results by:
• Test descriptions across the top of the screen
• Category (e.g., Vital Signs) and dates/times within the
category on the left side of the screen
List
List format arranges results in a linear list format by event
date and time.
37
View Clinical Documentation
Procedure
Step Action
1. Depending on the timeframe you need to view,
click either the 2 Year Clinical Notes band or
the 72 Hr Clinical Notes band.
2. Click one of the radio buttons to sort the index
by one of the following options:
• Type
• Status
• Date
• Performed By
• Encounter
3. Double-click the needed folder to open.
4. If there are sub-folders, click the + to see more
folders or documents.
5. Double-click to open a document.
6. Use the large blue arrows to move
quickly from one document to the next or to
move between note types.
38
View Clinical Documentation, continued
39
Create a Free-Text Clinical Note
Procedure
Step Action
1. Click either the 2 Year Clinical Notes band or the
72 Hr Clinical Notes band.
2. Click (New Note).
3. Select the correct note Type.
4. Change date and time if necessary.
Note: Clinical documentation always reflects the
date and time that the note was created. If the
documentation pertains to the prior day, you
must change the date and time of the note prior
to signing the note.
5. Enter the Subject of the note.
6. Type your note.
7. Click Sign, Save, Save & Close or Cancel.
Option Function
Sign • Enters your note into the
patient’s permanent record
• Changes to the note must be
made by addending the note
Save • Saves your note before signing
• Changes can be made to the
note
Save & • Saves your note before signing
Close • Closes it so that you may
complete it at a later time
Cancel Deletes your note with no saved
record of the note
40
Write Notes
Set Up Before you enter your first PowerNote, you must set up
Personal your personal document types as defaults for your
Document specialty and author status: Staff, Resident, Fellow, or
Types as
Medical Student. All note types listed represent both
Defaults
Adult and Pediatric specialties.
Note: Medical students will not have document types by
specialty.
Procedure
Step Action
1. Open the patient chart.
2. Select PowerNote +Add from the menu.
41
Write Notes, continued
Procedure,
cont. Step Action
3. Select View from the uppermost task bar.
6. Click to uncheck
it.
7. Select Personal Note Type List from the
Default List Type.
9. Click OK.
44
Write Notes, continued
45
Write Notes, continued
Step Action
1. Click the contributor icon to view the note in
report format.
Step Action
1. Click in the upper left corner of
the note to expand the note view to full
screen.
2. Click in the upper right corner to
reduce the screen size.
46
Write Notes, continued
Step Action
1. Click the Clinical Notes band.
2. Double-click to open the note that you need
to addend.
3. Click (Modify) or right-click in the body
of the note and select Modify.
4. Enter the additional text below *Insert
Addendum Here:.
Modify a Note
You may occasionally need to strike out incorrect
information within your note and enter the correct
information.
Step Action
1. Click the Clinical Notes band.
2. Double-click the appropriate note to open it.
3. Click or right-click the body of the note
and select Modify.
47
Write Notes, continued
5. Click (Strikethrough).
6. Enter the corrected text below *Insert
Addendum Here:.
In Error Note
You may find that you have entered incorrect
information on a patient or written a note on the wrong
patient. Use the following In Error process to strike the in
error note from view in the EMR.
48
Write Notes, continued
5. Click OK.
6. Either return to the PowerNotes or Physician
Notes band to write your replacement note
or select the correct patient to begin entering
your documentation.
49
Write Notes, continued
Step Action
1. Make sure that the note you need to copy into
is open.
2. Click to minimize the new note.
3. Double-click to open the note that you need to
copy from.
4. Highlight the appropriate text that you need to
copy from the existing note.
5. Press ctrl>C on the keyboard to place the text
on the electronic clipboard.
6. Click to maximize the new note.
7. Click the area of the note where you need to
paste the new text.
8. Press ctrl>V on the keyboard to paste the text.
50
Write Notes, continued
Step Action
1. Click + Add in PowerNote band.
2. Click the Existing tab.
3. Click to highlight the appropriate note to copy
forward in the bottom pane.
4. Place a checkmark in the Copy to New Note
box.
5. Select the appropriate Document Type.
.
6. Type an appropriate Title.
7. Click OK.
8. Select paragraphs to copy.
9. Check and uncheck the appropriate items in
the Auto Populate window.
51
Write Notes, continued
Step Action
1. In the selected structured note, select terms
as positive or negative as needed for your
macro.
2. Right-click the appropriate paragraph or
sentence header at the level in which you
need to save your macro.
Note: You can save a macro at either the
paragraph or sentence level (e.g., Review of
Symptoms or Constitutional).
3. Select Save Macro As from the pop-up menu.
52
Write Notes, continued
Insert a Macro
Step Action
1. Click the M in the section of the document
where you have created the macro.
53
Write Notes, continued
You can also save any free-text that you have typed as an
Auto-Text as follows:
Step Action
1. Type the free-text.
2. Highlight the appropriate text and right-click it.
3. Select Save as Auto Text.
4. Enter an abbreviation.
Note: Start all your abbreviations with a leading
period. This is important to ensure that you are
not interrupted with a display of your auto-text
when you are typing your note (e.g., “.pyelo”).
5. Enter a description.
55
Write Notes, continued
Drawings
You can draw on body images, annotate the images, and
insert the drawings into your PowerNote.
Step Action
1. Click next to the appropriate section.
2. Click the appropriate drawing location.
56
Write Notes, continued
Step Action
1. Create a PowerNote but do not sign.
2. Click Documentation in the toolbar and select
Save as Precompleted Note.
57
Write Notes, continued
Advanced Symbols
PowerNote Understanding the symbols that are available in
Functions, PowerNotes can help you document in more detail.
cont.
Symbol Function
(= = =) Allows you to enter numeric values such as
BP or pulse
* • Automatically repeats the affiliated
terms to allow for documentation of
differences between two sides, etc.
• If no * is present, you can manually
repeat selection of terms where there
may be a discrepancy between two sides
or two locations by right-clicking on a
term header (i.e., Capillary Refill) and
selecting Repeat
(…) • Provides additional descriptive choices
for a term in a separate display window
• Items selected from an ellipses (…) do
not immediately display but will be
included in your final note
Note: You can see your added
descriptions in the Contributor View.
+ • Signifies that additional information for
that term exists
• Additional terms can be accessed by
clicking on the symbol
58
Computerized Provider Order Entry (CPOE)
Step Action
1. Open the patient chart.
2. Click the Orders band.
3. Click the Options menu at the top of the
screen.
4. Click Enable Pop-up Windows for Selecting
Orderables to remove the checkmark.
Note: The last filter setting that you used will be displayed
the next time you log in. If you change your filter view,
remember to change it back to your default setting so that
you do not accidentally overlook critical information.
59
Computerized Provider Order Entry (CPOE),
continued
Step Action
1. From the Orders band, click the Displayed:
hyperlink to access the Advanced Filters
window.
Step Action
2. In the Display drop-down list, click one of the
options that begins with * (asterisk) and
contains Med Student to set the filter to
display inpatient orders only. (continued)
Note: Home medications MUST be removed
from the inpatient medication list. The filters in
the Display list marked with an asterisk were
designed to remove home medications from
the Orders view.
Warning: DO NOT modify the radio buttons or
checkboxes in the Advanced Filter window.
This is only used to modify the Display option.
Changing these buttons may result in missed
orders.
3. From the Current menu, select Customize
View.
61
Computerized Provider Order Entry (CPOE),
continued
62
Computerized Provider Order Entry (CPOE),
continued
Step Action
1. Open the patient chart and click the Medication
List band.
2. Click the Displayed: hyperlink to access the
Advanced Filters window.
64
Computerized Provider Order Entry (CPOE),
continued
65
Computerized Provider Order Entry (CPOE),
continued
66
Computerized Provider Order Entry (CPOE),
continued
Step Action
To enlarge the Order details pane…
1. Hover your mouse over the upper border of
the order details pane until a symbol
appears.
67
Computerized Provider Order Entry (CPOE),
continued
68
Order Entry Basics
Basic Order You can search for a single order, PowerPlan, or Orders
Search Set by the first word of the order name or by a specific
word contained in the order name. PowerPlans and Order
Sets are covered in further detail starting on page 79.
70
Order Entry Basics, continued
Enter Single
Orders, Step Action
cont.
4. If displays, there are missing order
details. Click to move from
one missing detail to the next.
5. Highlight the Order detail, then complete or
change the corresponding Detail value.
7. Click Sign.
8. Click to refresh the screen.
Signed orders file into the corresponding clinical
category.
72
Order Entry Basics, continued
73
Order Entry Basics, continued
Favorites You can create your own Favorites folders where you can
Folders store and access orders that you use frequently or orders
that are difficult to locate.
Step Action
1. Click the Orders band.
2. Click + Add.
3. Click the arrow by the Favorites icon.
4. Select Organize Favorites.
Step Action
1. To move a folder to a different parent folder,
highlight the folder you need to move.
2. Click Move to Folder.
3. Select the appropriate parent folder.
4. Click OK.
Step Action
1. Highlight the appropriate folder.
2. Click to move the folder up or down.
Step Action
1. Highlight the folder.
2. Click Delete.
3. Confirm Deletion and click Yes.
4. When you are done managing folders, click
Close.
75
Order Entry Basics, continued
Step Action
1. Click the Orders band.
2. Search for the appropriate order.
3. Complete the order details.
4. Right-click the correct order.
5. Select Add to Favorites.
6. Highlight the folder where you need to save
the order.
7. Click OK.
76
Order Entry Basics, continued
Medication
Order
Frequencies
Frequency Standard Administration Times
Daily 0900
QAM/ 0900/2100
QPM
At 2100
Bedtime
BID 0900, 2100
TID 0900, 1500, 2100
Four times 0900, 1300, 1700, 2100
daily
Q2 02, 04, 06, 08, 10, 12, 14, 16, 18, 20, 22,
24
Q4 0200, 0600, 1000, 1400, 1800, 2200
Q6 0600, 1200, 1800, 2400
Q8 0600, 1400, 2200
Q12 0900, 2100
Q_H The next hour after the order is written
and at the specified interval thereafter.
77
Order Entry Basics, continued
78
Order Entry Tools
Order Sets Order Sets are orders that are grouped together by
common use, disease, or process for ease of use.
An order set is denoted by .
Step Action
1. Select the appropriate orders within the order
set by placing a checkmark next to the order(s).
2. When all orders have been selected, click OK.
3. Sign the orders.
4. Click to refresh the screen.
Locate a PowerPlan
Step Action
1. Click + Add on the Orders band.
2. In the Search window, search for the
appropriate Plan.
Step Action
1. Click a PowerPlan to open it.
2. Select/deselect orders from the Plan by
placing/removing a checkmark in the box next
to the order name.
Note: Order details can be completed in
several ways. To proceed with this, ensure
that the box next to the appropriate order is
checked.
3. When an order has alternate order options, a
down arrow displays. Proceed as follows:
a. Click the arrow to select alternate order
details such as dose, frequency or rates
for your orders.
b. Click the appropriate details from the
drop-down list that displays.
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Order Entry Tools, continued
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Order Entry Tools, continued
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Order Entry Tools, continued
2. Click .
3. Click Orders for Signature.
4. Click Sign.
5. Click to refresh.
Step Action
1. Select the PowerPlan by clicking the initiated
PowerPlan name in the view pane.
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Order Entry Tools, continued
86
Medication Order Entry
Order an
Immunization Step Action
/PPD
1. Select the order sentence with a frequency of
ONCE.
2. Change the Requested Start Date/Time to
tomorrow’s date at 0900, unless you have
reason to schedule otherwise.
IV – Fixed
Rate Step Action
1. Click + Add in the Orders band.
2. Type the first few letters of the fluid to be
ordered. (i.e., "Sod" for Sodium Chloride,
"Dext" for Dextrose, "Lacta" for Lactated
Ringers).
Note: You may also search using the
synonyms: D5, LR, D10, NS, ½ NS.
3. Select the correct order from list.
4. Select the correct order sentence.
5. Verify the correct diluent (e.g., Dextrose 5%)
and additive (Potassium Chloride).
6. Enter or change any missing order details.
Note: When you select the rate, the Infuse
Over detail calculates automatically.
IV – Step Action
Heparin 1. Click the Orders band.
Nomogram
and
2. Click + Add.
Thrombo- 3. Type "Hep".
stabilizer 4. Select the appropriate Heparin Nomogram
Infusions /Thrombostabilizer PowerPlan.
5. Check or uncheck orders as you would any
other PowerPlan.
6. Review the Heparin drip order.
Note: The rate defaults as Per Nomogram.
7. Click Initiate and then Orders for Signature.
8. Click Sign and Refresh.
Step Action
1. Click + Add in the Orders band.
2. Enter “TPN” in the Search window.
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Medication Order Entry, continued
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Medication Order Entry, continued
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Medication Order Entry, continued
Step Action
1. When entering ongoing daily TPN orders,
search for “TPN”.
2. Select the appropriate single TPN order and
NOT the PowerPlan or Order Set.
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Medication Order Entry, continued
IV – TPN After completing the initial TPN PowerForm using the TPN-
Pediatric Neonatal or TPN-Peds order, subsequent TPN PowerForms
and prepopulate with the previously selected values for the
Neonatal
additive fields.
Step Action
1. When entering a TPN order, search for “TPN”.
2. Select the appropriate single TPN order, TPN-
Neonatal or TPN-Peds, and NOT a PowerPlan or
Order Set.
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Medication Order Entry, continued
IV – TPN
Pediatric Step Action
and
4. A PowerForm opens to complete the details for
Neonatal,
cont. the TPN order. All highlighted fields must be
completed before you will be able to sign the
PowerForm.
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Medication Order Entry, continued
Medications:
Dose Range Step Action
Orders
1. Click + Add in the Orders band.
2. Search for the medication name.
3. Select the medication order.
4. Enter the highest dose.
5. Enter the shortest frequency.
6. Open the Order Comments Tab.
7. Enter the dose range (e.g., DOSE RANGE 1-
2mg q2-4 hours).
8. Click Sign.
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Medication Order Entry, continued
Step Action
1. Click + Add in the Orders band.
2. Search for Hold Medication Dose.
The Order details window opens with the
instruction: Must Complete Order Comments.
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Medication Order Entry, continued
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Medication Order Entry, continued
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Medication Order Entry, continued
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Medication Order Entry, continued
Medications:
One-time Step Action
STAT Doses 1. Click + Add in the Orders band.
2. Search for a medication to be ordered STAT.
3. On the Order Details tab, click Pharmacy
Order Priority (on the left) and select STAT
from the Detail values list (on the right).
Medications:
Patches Step Action
1. Click + Add in the Orders band.
2. Search for the medication name.
3. Select the appropriate medication patch
order set.
Note: Medication patches are built into the
system as order sets because the patch
order needs to be paired with a patch
removal order. The patch removal order is
automatically checked, so it will always be
ordered.
4. Select the appropriate patch strength and
complete the order details.
Note: The patch removal order serves as a
reminder to the nurse to remove the
previous patch before placing a new one.
Medications:
Taper Doses Step Action
1. Click + Add in the Orders band.
2. Search for the medication name and select
the orderable with the term "taper" after
the order (e.g., Prednisone taper).
Order Details opens with the instructions:
Must Complete Order Comments.
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Medication Order Entry, continued
Medications:
Taper Doses, Step Action
cont.
3. In the Order Comments tab, enter your
tapering regimen (e.g., Prednisone 60mg po
daily x 6 doses, 40mg po daily x 6 doses,
etc.).
4. Click Sign.
Medications: If the medication you are ordering does not have a taper
Taper Dose, order in the system when you search for the drug name:
No Existing
Taper Order
Step Action
1. Enter "Pharmacy taper”.
Order Details opens with instructions: Must
Complete Order Comments.
2. In the Order Comments tab, in addition to
the tapering regimen, you MUST also enter
the name of the medication.
3. Click Sign.
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Medication Order Entry, continued
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Medication Order Entry, continued
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Medication Order Entry, continued
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Medication Order Entry, continued
Step Action
1. Click + Add and select prescriptions from
the Type drop-down.
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Medication Order Entry, continued
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Medication Order Entry, continued
Step Action
1. Click the ellipses to the right of the Send To
box.
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Medication Order Entry, continued
111
Dosage Calculator
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Dosage Calculator, continued
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Dosage Calculator, continued
Calculate
Standard Step Action
Doses,
2. Using the drop-down menu, evaluate the
cont.
Rounding Rule for this medication and patient
weight.
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Dosage Calculator, continued
Calculate
Standard Step Action
Doses
4. If the available dosing options are not
(continued)
appropriate, then type the appropriate dose in
the Final Dose field.
The mg/kg automatically calculates and the
Rounding Rule updates to Manually Entered.
5. Click Apply Dose.
115
Pediatric Antimicrobial Stewardship
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Pediatric Antimicrobial Stewardship, continued
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Pediatric Antimicrobial Stewardship, continued
Step Action
1. Select the appropriate subphase by placing a
checkmark in the box next to it.
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Pediatric Antimicrobial Stewardship, continued
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Pediatric Antimicrobial Stewardship, continued
Place
Orders from Step Action
a Subphase,
7. If a new IV antimicrobial order is being entered
cont.
within 24 hours of the patient’s admission, this
PowerForm displays. In order to complete the
antimicrobial order, provide documentation of
the prior administered doses including doses
administered at a prior hospital, en route, in
the ED, etc.
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Pediatric Antimicrobial Stewardship, continued
Place
Orders Step Action
from a
9. Enter a Separate PowerPlan for a Missing
Subphase,
cont. Antimicrobial
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Pediatric Antimicrobial Stewardship, continued
Step Action
1. Once inside the Antimicrobial PowerPlan, select
and deselect orders as you normally would.
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Pediatric Antimicrobial Stewardship, continued
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Pediatric Antimicrobial Stewardship, continued
125
Medical Student Orders
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Medical Student Orders, continued
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Medical Student Orders, continued
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Medical Student Orders, continued
Step Action
1. While in Message Center, select Med
Student Orders from the Inbox Summary.
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Medical Student Orders, continued
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Medical Student Orders, continued
Step Action
1. While in Message Center, select Med
Student Orders from the Inbox Summary.
2. Double-click the appropriate order and
review the details.
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Medical Student Orders, continued
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Medical Student Orders, continued
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Medical Student Orders, continued
135
Other Order Entry Processes
Step Action
1. Select the DNR order in the order entry field.
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
Step Action
1. Within the Documents folder located in the
Message Center, identify any documents
requiring cosignature.
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Other Order Entry Processes, continued
Medication
Special Alerts/ Step Action
Communication
1. To enter exception orders (i.e., No
Heparin, No IM Injections, No ACE
Inhibitors, No Aspirin, etc.), search for the
MEDICATION SPECIAL ALERTS Order Set in
the catalog.
2. Select the appropriate exception order(s)
from the list displayed.
3. Verify start date and time in the Details
tab.
4. Click OK.
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
Discharge
Instructions Step Action
(eDI), cont.
1. Click the band to access
the eDI form.
2. Scroll down to complete the following sections
or click each link to move to the desired
section of the form.
• Patient Data
• Physicians to contact for
• Discharge Instructions Distribution
• Follow Up Visits
• Follow Up Tests
• Activity Limitations or Restrictions
• Treatment/Procedure/ Equipment
• Dietary Requirements
• Additional instructions
• Vaccinations & TB Testing
• Allergies & Sensitivities
• Final Release Info
3. Click + Add or + Edit to initially enter or edit
information.
A window pops up to allow you to enter data.
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Other Order Entry Processes, continued
Discharge
Instructions Step Action
(eDI), cont.
4. After you have entered or edited data, click
Save prior to moving to the next screen.
5. If a change must be made to an existing
section, click to make changes to the
information.
6. If you place orders for tests or labs, you must
click eSign to electronically
sign the orders.
7. If you need to add more than one test order,
click Save and Add for efficiency.
Caution: If orders for future tests or services
are placed in eDI, they will NOT result in the
scheduling of the tests or studies.
A requisition prints for each lab order when
the Final Sign & Print is completed.
Medication List
The medication list tab is used to evaluate and reconcile
current home and inpatient medications in order to create
a complete list of home medications for the patient after
discharge. When completed and printed, medications
listed on the patient instructions will be grouped into the
following categories:
• Take these medicines at home
• STOP taking these medicines
• DO NOT TAKE these medicines until instructed by your
Doctor
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
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Other Order Entry Processes, continued
Add Favorites
Step Action
1. Click .
2. Enter the appropriate information in the
form.
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Other Order Entry Processes, continued
Delete a Favorite
To delete a Favorite, click beside the Favorite name..
Replace a Favorite
To replace a Favorite that was entered into the
Discharge Instructions, select Replace.
Select Favorites
To select more than one Favorite choice, select Append.
153
Glossary
155
Frequently Used Phone Numbers
156
Riley Site Description Number
Hospital General Main # 317-944-5000
for Bed Control 317-944-3903
Children Central Dictation 317-962-8401
at IU Dictation Help 317-962-8501
Health ED 317-944-3936
IMACS OneCall 317-944-5000
IUH 24/7 Transfer Center- Adult 877-247-1177
IUH 24/7 Transfer Center-Neo/Peds 877-447-4539
Lab (Main) 317-491-6000
Pharmacy (Inpt) 317-948-8762
OR Main OR 317-944-8222
PACU 317-944-9943
PreOp 317-944-8634
Rad IR 317-948-6328
Reading Rooms 317-948-6343
Reading- Plain Film 317-948-6315
Reading- CT 317-948-6300
Reading -MRI 317-948-6331
Reading- US 317-948-6300
Techs 317-948-6336
Telemetry 317-962-3211
157
IU Health Site Description Number
University General Main # 317-944-5000
Bed Control 317-944-3903
Central Dictation 317-962-8401
Dictation Help 317-962-8501
ED 317-944-4705
IMACS OneCall 317-944-5000
IUH 24/7 Transfer Center- Adult 877-247-1177
IUH 24/7 Transfer Center- Neo/Peds 877-447-4539
Lab (Main) 317-491-6000
Pharmacy (Inpt) 317-944-0362
OR Main OR desk 317-944-4001
Pre-Op 317-948-5400
PACU 317-944-4088
Simon OR desk 317-948-7493
Simon Pre-Op 317-948-7100
Simon PACU 317-948-7522
Rad IR 317-944-1828
Reading- Chest 317-948-8483
Reading- Abdomen 317-944-1831
Reading- MRI 317-944-3692
Reading- Neuro 317-944-3692
Reading- US 317-948-8219
Techs 317-944-3351
Telemetry 317-944-0362
158
Richard L. Site Description Number
Roudebush General Main # 317-554-0000
VA Bed Control 317-988-2536
Hospital ED 317-988-3059
Dictate 317-988-2047
Lab Main Lab 317-988-2545
OR Main OR 317-988-2350
Pre-Op 317-988-3190
PACU 317-988-2237
Pharmacy Inpatient 317-988-2583
Radiology Techs 317-988-3173
Reading Rooms 317-988-2806
Abdomen 317-988-2806 x1
Chest 317-988-2806 x2
GI 317-988-2806 x3
IR 317-988-2806 x4
Msk 317-988-2806 x5
Neuro 317-988-2806 x6
Nuclear 317-988-2806 x7
Diagnostic 317-988-2806 x8
Telemetry 317-988-3659
159
Wishard Site Description Number
Memorial General Main # 317-639-6671
Hospital Bed Control 317-630-2233
ED 317-630-6243
Dictation 800-454-9106
Labs Main Lab 317-630-7442 x1
OR Main OR 317-630-7205
Pre-Op 317-630-8179
PACU 317-630-7030
Radiology Xray Techs 317-630-6570
Chest 317-630-6231
Abdomen 317-630-7911
Neuro 317-630-6998
160