Orders

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Dynamic Documentation: Changes to Ambulatory CP and VL Orders

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Changes to Ambulatory Cardiopulmonary and Vascular Lab orders:

Due to the upcoming changes with Dynamic Documentation, the first five services lines converting will notice a small difference when ordering either Vascular Lab or Cardiopulmonary orders.

The folders will look the same; the difference will be that most of them are no longer caresets. The Schedule Heart Station Procedure order has been removed. That order will be placed automatically for you via a rule in the system. The nurse/scheduling staff will still receive the task and PowerForm as before.

When placing the non-careset orders, you will no longer receive the pop-up screen (Figure 1).

As always, please call any of the HELP desks for questions.

Educational Handout

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Oncology PowerPlans - Removal of "Activate All" Functionality

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There have been issues identified with the "Activate All" functionality and the Oncology PowerPlans. The decision has been made to turn this functionality off. 

We will remove this from all inpatient plans so that the nurse will activate individual days of treatment instead of activating all. This will help with the rescheduling of medications and days of treatment. The nurse will activate the day of treatment as she is ready to. This will follow the workflow of nursing in the outpatient setting. This will furthermore allow the outpatient chemotherapy plans we currently have built to be used in the inpatient setting.

This is the current look to the Oncology Inpatient PowerPlans. The nurse clicks “Activate All” and all of the days of treatment are activated.

This is how it will display for the nurses. The nurses will no longer have the option to “Activate All”. They will click on the triangle next to “Actions” and click on “Activate”. This will activate the individual treatment day. In doing this, this will also allow the nurse to clearly see what day of treatment the patient should be on, especially since most of the time the same nurse does not have the same patient every day of the patient’s treatment.

Once the “Activate” button is clicked the process is the same. The day of treatment goes into an “Initiated Pending” state. The nurses will click “Orders For Signature”

 

The nurses will then review the orders and click “Sign” to finish the activation process.

 

After signing, they should “Refresh” the screen. Day of treatment 1 is now in an “Initiated” status while the other days of treatment remain in a “Future” status to be activated when needed.

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Rhogam Process Implementation

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Per decisions made in the OB Collaborative:

There will be a new RhoGAM process implemented on Wednesday, October 3rd around 0900 (inpatient only). 

When a mother has a documented delivery on the active visit (encounter) and her blood type is negative, an order for the RhoGAM workup will be placed automatically if no RhoGAM workup exist. Once the blood bank completes their workup and determines the mother is to receive a RhoGAM injection, the blood bank will then receive an order to send the RhoGAM to the floor.

As a final step, at the time of delivery and mom has a positive Rh factor and there is an active RhoGAM workup order, the system will cancel the RhoGAM workup order.

This process will not replace existing workflows such as ordering the type and screen and RhoGAM workup at the same time but will help to place orders when orders are not present.

Always double-check that a mother receives/doesn't receive RhoGAM injections as appropriate.

 

For questions regarding this process, please call FBC or UMC Clinical IT

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New Alert for C. diff by PCR Orders

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In the next few weeks, there will be a new alert added that will aid in the prevention of ordering unnecessary C. diff by PCR testing.

As approved by the Use & Standards governance committee, the alert will impact inpatient ordering only.

There will be an alert that will prevent ordering C. diff by PCR if a previous C. diff has been ordered within 7 days.  

According to Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA), it is recommending to not repeat Clostridium difficile testing (within 7 days) during the same episode of diarrhea.  As a result, all Stool C difficile toxin by PCR orders placed within 7 days of the previous order will be rejected.

IDSA Clinical Practice Guidelines

BB Send Blood Product Order Updates

Changes made to the three BB Send Blood Orders and the BB Blood product Cancel order.

Removed the existing order sentences from the 4 orders (BB Send, Pediatric BB Send, NICU BB Send and BB Blood product cancel.) Added a drop down with the needed options.

Current and Future State:

Current:

When you place the above orders you receive this pop up screen with prebuilt order sentences.

 

Future State:

The 4 orders will now have no prebuilt order sentences but have a drop down with the 5 selections and only allow for 1 selection to be made.


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Changes To NICU Blood Orders

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The NICU blood orders listed below will no longer have the Lab Alert or Override Reason Form pop-ups when the orders are placed and the patient is in the NICU. The change was requested by the NICU because the Lab Alert and Override Reasons do not apply to the patient population within the NICU. The order has been updated to require a reason for administration of the blood product.

 

Example – No alerts because the patient is in the NICU location.

New required field – Reason for Cryo Order with NICU specific options.

When the orders are placed and the patient is outside the NICU the Lab Alert and Override Reason Form pop-up will continue to open as they do today.

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Additional Significant Events Component Update

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An additional line has been added to the Additional Significant Events component. The component will now notify you if a new admission has been created within 30 days of the previous one.

Current workflow allowed for an alert based only off the EC Readmit Alert/Order. It tracked only potential 30-day readmit Medicare patients.

This new line will appear any time there is a readmit within 30 days regardless of Medicare or the EC Readmit Order.

New Order/Update to Fall Policy

Attention Providers:  New Order/Update to the Fall Policy

The UMC fall policy has been updated to state that “any patient that is a high fall risk and is requesting to leave the unit, must have a provider order on the chart and they must be accompanied by a family member or caregiver”.

Due to this change a new order has been created to be used in this situation and is available now.

The order name is “patient may leave Unit/Floor accompanied by family/caregiver”.

The easiest way to search for this order is by typing in “patient may” in the orders search bar.

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Radiology: New Central Line Placement Orders

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FYI:

Central line placements performed in Special Procedures will now be more clinically orientated. By searching “SP CVL” in Powerchart, new orders can easily be found. See below:

  • o   SP CVL Non-Tunneled Cath Placement
  • o   SP CVL HD Non-Tunneled Cath Placement
  • o   SP CVL Tunneled Cath Placement
  • o   SP CVL Tunneled HD Cath Placement
  • o   SP CVL Trifusion Cath Placement
  • o   SP CVL Portacatheter Placement
  • o   SP CVL PICC Placement < 5 yo
  • o   SP CVL PICC Placement
  • o   SP CVL Portacth Repair
  • o   SP Central Line Placement
  • o   SP CVL Tunneled Replacement
  • o   SP CVL PICC Replacement
  • o   SP CVL Tunneled Cath Removal
  • o   SP CVL Portacath Removal
  • o   SP CVL Portacath Stripping
  • o   SP CVL Cath Reposition
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Deceased Patient Alert

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Beginning May 8th, when end users attempt to place orders on patients that are marked as ’Deceased’ in the banner Bar, they will receive an alert preventing them from signing the order.

If an end user misses the banner bar message, and place an order a deceased patient, after they click Sign on the order they will receive a prompt stating that the patient has been identified as Deceased and the order will be cancelled.


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Lipid Panel Changes

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Updated Direct LDL Order Education: 7.2.18

As per education provided in June 2018, the UMC lab and financial departments identified that they were receiving no reimbursement for Direct LDLs with Triglycerides less than 400. Based on this, subject matter experts were consulted and a new set of Lipid Panel orders were developed.

You will now find Lipid Panel and Lipid with Cardiac Risk panel for your use.

Contents:

Lipid Panel:

Non-HDL Cholesterol

Triglycerides

VLDL

LDL Calculated

HDL

Cholesterol

 

Lipid with Cardiac Risk:

Non-HDL Cholesterol

Chol/HDL

Triglycerides

VLDL

LDL Calc/HDL

HDL

Cholesterol

 

BOTH panels will have a calculated LDL and reflex Direct LDL when Triglycerides are over 400.

If the triglycerides are over 400, LDL Direct will reflex

If the LDL cannot be calculated you will see this comment.


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Admission PowerPlan: Oncology Patient

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When admitting a patient for Oncology (typically 4E) we must use the ONC General Inpatient Plan. You can find this plan by searching the word General just like you would the General Medicine Plan.

Once in the plan you will notice several differences that is important to oncology patient care. In Patient Care you have the Access Implanted Port, and Perform Neurological Checks.

In the ONC General Inpatient Plan there is also a medication section. This section includes biotene mouthwash, lidocain-prilocains topical (lidocaine-prilocain 25%), and heparin flush.

The final difference in the plan is under Consult MD. You will see in this field a required order, Consult MD. This allows you to choose to choose what service to notify. You can notify either Oncology or Hematology.


Lung Cancer Screening Workflow

Lung Cancer Screening

Based on the results of the 2011 study from the New England Journal of Medicine on low dose CT screenings, UMC now offers lung cancer screening through the Southwest Cancer Center. 

This service is covered by Medicare as health maintenance if the following guidelines are met:

  1. The patient must have a documented shared decision making visit at a Screening Center
  2. The patient must meet the USPSTF requirements for screening
    1. Ages 55 to 80
    2. Smoking history of 30 years or more (an average of one pack a day for 30 years)
    3. Currently smoking or have quit within the last 15 years
    4. No current cancer symptoms requiring a diagnostic workup
    5. Counseling must be provided on the importance of maintaining cigarette smoking abstinence if the patient is a former smoker; or the importance of smoking cessation if the patient is a current smoker and they must be furnished with information about tobacco cessation interventions, if appropriate.
    6. The patient must be entered into the National Lung Cancer Screening Registry through the American College of Radiology

Patients referred to the Lung Cancer Screening program will have a shared decision meeting scheduled with either Dr. Yepes or Dr. Islam.  Our pulmonologists will order the screening CT and provide follow-up on the results of the scan; e.g. regular visits for observation of a nodule, biopsy of a nodule, yearly follow-up for surveillance of a negative CT. 

To order your patient’s lung cancer screening, please select the Consult/Referral SWCC Lung Screening order in PowerChart.  Please educate your patients, they will be receiving a phone call from the SWCC Lung Cancer Screening Program Patient Navigator for scheduling of the initial screening appointment, which will take place at the SWCC, and scheduling of the Low Dose Screening CT of the chest. 

Laryngectomee Speech Consult Order

A new order is available for use on patient’s that have had a laryngectomy.  The order is called “Laryngectomee Speech Consult”.  When placed, this order will consult Speech/Language for evaluation and treatment and also for care of the patient.  If a speech therapist is not available, it references the policy and procedure for nurses to follow on how to care for a patient with a laryngectomy.  This order should be considered for use on a patient that is status post laryngectomy, has a permanent tracheostomy, or history of laryngeal cancer. 

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Diagnosis Requirement on All Outpatient lab orders

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Announcement per UMC Clinical IT:

As of 8:00 AM Monday, February 19th, 2018 all Outpatient Lab Orders (orders placed from a clinic encounter in a future state) will require a diagnoses associated with it.  As shown below, the diagnosis tab will show the blue ball/white “X” indicating the need for a diagnosis code to be added. This workflow is the same as the current radiology order process.  

This change will require all ordering clinicians to associate the appropriate diagnosis at the time the outpatient order is placed. 

NOTE: All EXISTING Future Lab Orders that are still active will require the diagnosis to be added to the order when activated in the lab. This means any orders placed from the clinics prior to Monday, awaiting your patient to get their labs drawn, will require the UMC laboratory registration staff to try and identify a patient’s diagnosis for that visit from the chart. If there is no diagnosis associated, then additional steps will be required to perform the order; including possibly calling the ordering provider/clinic, and ultimately canceling the order if no diagnosis can be found or ordering provider approval cannot be reached (UMC Laboratory is solidifying this workflow).

This change is being implemented to improve the amount of rejected lab charges declined due to the lack of diagnoses.