Banner Bar: DNR on File

On March 4, 2019, you will be able to identify if a patient has an Out of hospital DNR or an In Hospital DNR on file on the banner bar in PowerChart.

If a patient does not have a DNR on file for either Out of Hospital or In Hospital, it will reflect ‘None’ in the banner bar. Note: If the field is blank, click refresh.

Out of Hospital DNR/In Hospital DNR on File

If a patient has an Out of Hospital DNR and/or an In Hospital DNR (Applies to patients who are admitted to inpatient or placed in observation), the document will be scanned into the AD Out of Hospital DNR Order bucket and/or the AD Consent for DNR bucket. Once the document is scanned, the banner bar will reflect ‘Review’ on the banner bar.

This provides indication that the patient has a current or previous Out of Hospital DNR and/or In Hospital DNR on file (This is NOT an indication that the DNR is valid – this is only an indication that the chart should be reviewed for what is on file)

**The source of truth will always be the scanned document**

If the patient revokes their Out of Hospital DNR and/or In Hospital DNR, the scanned DNR will be rescanned with VOID marked across the page.

Accessing the DNR on File

In order to quickly access the DNR on file, navigate to the Summary View or the Workflow Page (for those on Dynamic Documentation). Click on the blue hyperlink and you will navigate directly to the scanned document.

Changing the Code Status

To change the code status order:

1. DO NOT discontinue!
2. Find the existing Code Status and right click to Modify.

Click HERE for handout tutorial

Tamiflu Dosing Reminder

Tamiflu (Oseltamivir) Dosing Reminder

Reminder per UMC Medication Management Team, Clinical IT

Upon review of the EHR dose-range checking alerts, there are still a significant amount of alerts firing in the EHR surrounding dose-range checking for Oseltamivir:

Per manufacturer and pharmacy recommendations, Tamiflu should be adjusted for renal impairment.

Flu Season is upon us and with so many providers prescribing Tamiflu, it is important to remember that this drug needs to be renally dosed.

Influenza Treatment

•  Adults with renal impairment (Moderate, CrCl greater than 30 up to 60 mL/min): 30 mg orally twice daily for 5 days
• Adults with renal impairment (Severe, CrCl greater than 10 up to 30 mL/min): 30 mg orally once daily for 5 days
• Adults with ESRD on hemodialysis (CrCl 10 mL/min or less): 30 mg orally immediately, then 30 mg after every hemodialysis cycle; treatment duration not to exceed 5 days from the time of the initial dose 
• Adults with ESRD on continuous ambulatory peritoneal dialysis (CrCl 10 mL/min or less): Single 30-mg oral dose immediately 
• Adults with ESRD not on dialysis, influenza treatment: Use not recommended

Influenza Prophylaxis

• Adults with renal impairment (Moderate, CrCl greater than 30 up to 60 mL/min): 30 mg orally once daily 
• Adults with renal impairment (Severe, CrCl greater than 10 up to 30 mL/min): 30 mg orally every other day
• Adults with ESRD on hemodialysis (CrCl 10 mL/min or less): 30 mg orally immediately, then 30 mg after alternate hemodialysis cycles 
• Adults with ESRD on continuous ambulatory peritoneal dialysis (CrCl 10 mL/min or less): 30 mg orally immediately, then 30 once weekly 
• Adults with ESRD not on dialysis, influenza prophylaxis: Use not recommended

Source: Micromedex

(Disclaimer: These are recommendations set forth by Micromedex and the manufacturers of Oseltamivir only; double check and use clinical judgment as it applies)

Cerner Change: Encounter Focus

During the CPOE conversion there was a new filter set to “Focus” which will only look at the orders on the current encounter. This was a recommended change by Cerner in order not to confuse providers when going about their day-to day business, for the most part.

We will be making the change back to “All” orders associated with the patient.

This change will take place on February 25,2019.

With this change you might need assistance with your exisiting filters.  There are videos and articles on PUTTER that will assist you if needed.

/tutorials/using-filters-and-order-view-customization.html

You can also reach out to the help desk @ 806-743-4357 or emrhelpdesklubbock@ttuhsc.edu

PowerChart Scheduled Maintenance

Dynamic Documentation: Public Autotext Changes

All Public Phrases built for procedures have been renamed to start with ( ;proc ).  Going forward this will be the standard naming convention for any procedure auto-text created for the public.

The ICU family conference note has been renamed to display as: ( ;ICU_family_conference_note )

Clinical Opioid Withdrawal Screen Powerform

Documenting Cologuard FIT-DNA Results

Blood Pressure Screening Requirements Documentation

Powerforms for Regulatory Documentation

Heparin-Induced Thrombocytopenia Antibody Process

A new lab order, Heparin-Induced Thrombocytopenia Antibody (HIT AB) will be available January 2, 2019. This order will provide decision support for providers: 1) Is HIT AB test necessary for my patient? 2) Results from HIT AB will reflex Serotonin Release Assay (SRA) when needed.

When completed, the HIT Powerform shown below will result with a 4Ts Score of 0-8. This will  be the first step to provide probability of HIT diagnosis. When signing the order, a 4Ts score of less than 3 shows a probability of 1.9%. With low probability for HIT, there is the option to Cancel or Override the order for HIT AB.  When the 4Ts score is more than 3, the order for HIT AB is placed after signing.

Below are the probabilities of HIT given each HIT AB negative result along with each possible 4Ts score from the PowerForm and each positive result for HIT AB along with the possible 4Ts Score. When HIT AB is detected, the probability of HIT diagnosis increases and Serotonin Release Assay (SRA) will reflex to confirm.

2019 Radiology Order Updates

Look for new Radiology orders January 2019 per CMS requirements:

• o   CT Asp Needle w/ Guidance, 1st Lesion
• o   MRI Asp Needle w/ Guidance, 1st Lesion
• o   MRI Breast Unilat w/o
• o   MRI Breast Unilat w/wo with CAD
• o   MRI Breast Bilateral
• o   MRI Breast w/ CAD Bilat
• o   MRI Functional Brain
• o   SP Asp Needle w/ Guidance, 1st Lesion
• o   SP Renal Dilation Existing Tract
• o   SP Renal Dilation New Access
• o   US Asp Needle w/ Guidance, 1st Lesion
• o   US Parenchyma

Fecal Microbiota Transplant Process

Fecal Microbiota Transplant Orders, Forms and PowerPlans

This process will go-live on January 23, 2019

The current Fecal Microbiota Transplant Plan will be inactivated and unavailable for use.

The 3 new powerplans will be searchable by FMT and Fecal. These plans are route specific.

The provider will place the appropriate FMT plan and the first phase (Fecal Specimen Processing) will be initiated pending, while the other three phases are planned pending. This means that the first phase will be initiated by the provider when they sign the orders. The next three phases will be initiated by the nurse on the day of the FMT. You will note that both orders in the first phase (Fecal Specimen Processing) are prechecked/required and the route is defaulted to the appropriate route.

When the provider clicks on ORDERS FOR SIGNATURE the Fecal Microbiota Transplant Inclusion/Exclusion Criteria form will pop up and must be completed to order the FMT.

The Inclusion/Exclusion Form, three questions

After completion of the Inclusion/Exclusion form the screen will look like this, note the blue orb indicating a missing detail.

You must enter the date of the FMT into the Fecal Specimen Processing order. This will tell the lab when to start preparing the specimen. After completion of this detail the plan will be signed and the first phase initiated.

On the FMT Rectal Plan the Fecal Specimen Processing order has two order sentences and one must be chosen.

On the FMT Colonoscopy Plan the first phase has an additional order, Schedule Endoscopy Procedure.

There are three additional phases that will be initiated by the nurse on the day of the FMT.

The Policy and procedure for Inpatient FMT is available in two places on the powerplan.

Right click on the plan in the Orders View window and click Evidence.

Or click on the sheet of paper icon to the left of the Fecal Specimen Processing Order.

NPO Diet Field Additions

The NPO Diet order will now have 2 additional fields.  This is to differentiate and clarify why the patient will be NPO. 

The options of GI Dysfunction, Medical Condition, Procedure, and Swallow Dysfunction will now be available under the new field NPO Reason.  One of the options will be required to be chosen.

Except for Tube Feedings requiring a yes or no answer has also been added.