Clinical decision support request

Please complete the form below

Name

Enter the name of the person requesting the CDS Rule.

First Name

Last Name

Phone

Best Contact phone number

(###)

###

####

So we can contact you for questions and/or discussion.

Brief name of proposed Clinical Decision Support (CDS) Rule

e.g. Warfarin/INR rule, or PICU Ketorolac rule

Who should see this CDS rule?

Physicians and other providers

Nurses and Medical Assistants

clerical Staff

Other

If Other selected above, Please specify

e.g. pharmacists, or respiratory therapists, as a couple of examples

To which patients does the rule apply?

Please carefully consider the target patient population for this rule (e.g. pediatric ICU patients only, or diabetics over 65, or all patients).

Please provide evidence to support the rule

Give as much detail as possible, including journal or guideline references when available (e.g. coumadin related deaths kill 1000 Americans annually, or UpToDate lists this recommendation as Category A).