Policy Statement

Physician’s Orders section in Pointclickcare  manages directives from medical professionals regarding Residents and communicates requisition to external entities such as the pharmacies.This component works to reduce errors by allowing you to work corroboratively on MAR and TAR with your drug and medication providers while managing physician orders for lab, radiology, dietary orders, consults, therapy and Advance Directives

 

All orders will be entered by the prescriber or agent. Designated Agents include nursing staff, dietary staff, occupational therapist, speech therapist and physical therapists

The Order Entry popup allows you to enter in all orders necessary on a resident chart. There are multiple sections to this popup that are of importance for each order entered into a resident's chart and they include:

  • Order Details - Contains order related information including Order Category and ordered item (ex: medication name, diagnostic test, diet type, etc)
  • Order Date and Time (defaults to current date and time) is required and should reflect the date and time the order was written
  • Order Category is required and reflects the broad category that your order would fall under. For therapy orders choose Other
    • Other - Advanced Directives and orders that may not require documentation on an administration record
  • Communication Method is how the order was given and is required

·  

    • Phone - Orders taken from a practitioner over the phone. EMERGENCY ONLY
    • Verbal - Orders taken from a practitioner verbally. DO NOT USE
    • Prescriber Written - Orders written by the practitioner on paper. DO NOT USE
    • Prescriber/Agent Entered - Orders entered into the resident's electronic chart by the practitioner or an agent of the practitioner
  • Ordered By is the practitioner who is doing the ordering. Only this medical professional can electronically sign this order
  • Order Template Search-Type the first letters in this predictive text box and find templates for common orders. Templates will fill in many fields for you once chosen
  • Description –If not using the template, you can type into the description box the therapy order.
  • Order Type- Place all Therapy orders in “Physician Order Sheet Only”
  • Scheduling Details-Contains the timing, frequency, indications for user, date range and directions. Here you can determine the start date and end date of the therapy order.
    • Routine - for orders that are needed routinely for a specific date ranges or indefinite period of time. Can have multiple routine schedules per order.
    • PRN -  for orders that are only needed as necessary for a specific date range or indefinite period of time. Can have multiple PRN schedules per order.
    • One Time Only - for orders that are needed one time on or during a specific date range.
    • Titration - for Pharmacy orders that are required to change dosing over a specific period of time.
    • STAT - for orders that are needed immediately.
  • Order Summary - As the Order Details, Scheduling Details and Source Details sections are completed, the Order Summary summarizes the order in the upper right hand corner

Communication method for orders will default to Prescriber/Agent entered as per NYS mandate.

Other communication methods remain available to be used per State regulations and would not be considered an electronic prescription.

Phone as a communication method should only be used in emergency circumstances that render all medical professionals affiliated with the facility unable to access mobile or internet access and thus be unable to sign orders. This method should only be used under the direction of a Nursing or Administrative staff member.

Orders entered by the prescriber will default to the Pending Confirmation portal for a nurse to review and confirm the order before the order will transmit to Pharmacy to be filled or appear in the eMAR in a way the nurse will be able to document administration.

Orders entered by an agent of the prescriber will default to the Pending Order Signature portal for the medical professional to sign before it will transmit to the pharmacy to be filled or appear in the eMAR in a way the nurse will be able to document administration.

All designated prescriber and agents of the prescribers will be able to view, discontinue, hold, resume orders.

Based on role security some users will be able to strike out an order.

Users will be able to create a progress note related to an order

· Show on Shift Report: include the Progress Note on the Shift Report.

· Show on 24 Hour Report: include the Progress Note on the 24 Hour Report.

· Show on MD/Nursing Communications Report: include the Progress Note on the MD/Nursing Communications Report.

· Edit Care Plan Immediately: Selecting this option while choosing a focus statement directs you to the resident's care plan. Based on the selection made in the focus statement the system directly edits the users care plan or edits the library of statements for use within the resident's care plan.

Users may view files scanned to the database under files link

Users will be able to view order status relation to the medication and the pharmacy from the order tab of the resident chart. Users will expected to complete functions under this link including reorder, receive and exhaust supplies from pharmacy

Users will be expected to monitor Order using the Care Management portal.

· Order Search –report set up of all orders

· Order in the Queue

· Orders Pending Confirmation

· Orders Pending Signature

· Pending Order Reviews

· Pharmacy Orders

 

 

PCC designated users will be responsible to ensure all orders are received from the pharmacy into the Pointclickcare system. Facilities will be equipped with scanners for this purpose. Receiving medications can be done manually without the use as scanners as well and requires the user to review the supply against an order for a resident and link the appropriate matches together.

Nursing Administrative staff  or designates are expected to review dashboards and reports in relation to successful transmission of orders to pharmacy on a regular daily basis.

Faxing requirements

Any electronically signed order which fails initial communication.

• Internet / connectivity issues.

• Orders which exceed 140 characters. (Sliding Scale, Titration, etc.)

IV Orders (Details which accompany actual medication order).

Reorders for Class-2 controlled substances. Additional details for Compound orders.

EMAR back up

An e MAR back up system will be maintained by all facilities at all times. In the event of a loss of  Pointclickcare access, a designee of the facility will access the most recently downloaded eMAR for the facility from Pointclick care and  distribute to medication nurses. (See policy for back-up eMAR)