Use order content types to make the patient chart match the provider order. The order description is the ordered text. The content type tabs are the chart updates.
Select every content type the order changes before moving through the order workflow.
Choose the content type
If the provider order changes | Select |
A visit, frequency, discipline, date, or visit type | Calendar |
A medication | Medications |
A diagnosis | Diagnoses |
Provider call thresholds | Vital Sign Parameters |
A wound or procedure | Procedures |
A care plan intervention or goal | Interventions & Goals |
Do not rely on the order description alone to update the chart. The selected tabs must match the order text.
Calendar visits
Use Calendar when the order adds, removes, or changes patient visits.
Select Calendar as an order content type.
Confirm the effective date. Use the start of the Medicare week or the start of the episode, depending on when the order takes effect.
Select the date on the calendar.
Select Add Visit.
Choose the Discipline and Visit Type.
Add clinical tags when they apply.
Save the visit.
Repeat the steps for each visit the order adds.
To remove or change existing visits, select the visit on the calendar and use the available edit or remove action. Confirm the calendar still matches the ordered frequency before review.
The frequency readout updates as calendar changes are made.
Medications
Use Medications when the order adds, edits, holds, or discontinues a medication.
Select Medications as an order content type.
Review the current medication list.
Select the plus button to add a new medication, or select an existing medication to edit, hold, discontinue, or remove it.
Enter the medication name, dose, route, frequency, start date, end date when applicable, and reason.
Save the medication update.
Confirm the medication appears under the changed medications list.
The medication update must match the order description.
Diagnoses
Use Diagnoses when the order adds, edits, removes, or re-sequences diagnoses.
Select Diagnoses as an order content type.
Review the active diagnosis list.
Select Add to add a diagnosis.
Search for the diagnosis code.
Select the diagnosis and save it.
Edit existing diagnoses when the order changes the diagnosis details.
Remove a diagnosis when the order directs removal.
Re-sequence diagnoses when the order changes priority or order.
Confirm the final diagnosis list matches the order.
Vital sign parameters
Use Vital Sign Parameters when the provider changes notification thresholds.
Select Vital Sign Parameters as an order content type.
Enter the ordered thresholds in the available fields.
Review each threshold before moving forward.
Enter only the parameters included in the provider order.
Wounds and procedures
Use Procedures when the order adds or updates a wound or procedure.
Select Procedures as an order content type.
Use the anatomical diagram to select the location.
Edit the location name if needed.
Select the procedure or wound type.
Select the subtype when prompted.
Change the onset date if needed.
Save the wound or procedure.
Confirm the saved wound or procedure appears in the order review.
Interventions and goals
Use Interventions & Goals when the order changes the care plan.
Select Interventions & Goals as an order content type.
Review existing interventions and goals.
Edit an existing intervention or goal when the order changes it.
Select an intervention from the library when the ordered intervention is available there.
Review the goals attached to the selected intervention.
Add, edit, or remove goals as needed.
Use a custom intervention when the library does not match the provider order.
Add the custom goal that supports the custom intervention.
The intervention and goals should meet the patient's ordered care needs.
Review the order
At Review & Complete, compare the order description to every selected content type.
Confirm that:
The description states the provider order in full.
Each selected tab matches the description.
No needed content type was missed.
No extra content type was added without an order.
Dates, frequencies, disciplines, doses, thresholds, locations, interventions, and goals are accurate.
Use Back to correct any tab before submitting the order.
If something goes wrong
The order text is correct but a content tab was missed before approval. Go back to the order and select the missing content type before submitting or approving.
The order was already approved and a content tab was missed. Use a dummy order when the signed order already authorized the chart update. See Correct an approved order.
The order wording was wrong or incomplete. Use a clarification order.
A visit was added but does not appear for scheduling. Confirm the Calendar tab was selected and the order was approved.
A wound or procedure is missing from the next visit assessment. Confirm the order included Procedures and the wound or procedure was saved with type and location.