Order Set Quick Reference Guide

Introduction

An Order Set is a group of Labs, Tests, Imaging Procedures, Medications and/or Referrals given to the patient at the time they are diagnosed. For example, if you always order the same labs and give the same medications for a specific diagnosis, then you would set up an Order Set. Order sets will save you time completing the note since the system will automatically selects the common procedures performed.
 

Sending Orders is a process that is done after a procedure has been selected in a note. Sending orders does the following:
 

• Adds a notation to the Face Sheet
  
  
  
   

• Adds a reminder to the physician’s To-Do List
  
  
  
   

• Gives you the ability to print a script for this procedure from ChartMaker® Clinical, instead of hand-writing it.
  
  

In-House v. Off-Site:

Orders can be configured as In-House or Off-Site. The difference between the two configurations is how you review them and whether the system creates a note or not. Note that this is only our terminology. If you prefer to set everything up as In-House because you like the system creating a note for you, then you can do so.

In House Orders:

• Orders are reviewed from the Face Sheet
  
  
  
  
  
   

• An auto-generated note is created once the order is reviewed

Off-Site Orders:

• Orders are reviewed from the top of the chart by clicking the Order Status button.
  
  
   

• In the  Pending and Completed order section select the applicable orders you want to update, and then click the appropriate status option (Pending, Completed, Reviewed, Completed with Image, or Reviewed with Image).
   

• In the Reviewed orders processed for this note section select the applicable procedure, and then click the appropriate status (Reviewed or Reviewed with Image).
  
  
   

• No note is created (we assume if a test is done off-site, a report will be sent back to you and scanned into the chart)

Setting Up Orders and Order Sets

To configure a test, image, etc.:

1. Click Edit > System Tables > Conditions > Procedures
    

2. Search for the item you plan to make a part of an order set
    

3. Highlight the item, and then click Properties
    

4. Check the Procedure radio button
    

5. Select the appropriate Type (Image, Injection, Lab, Test)
    

6. Check the Track box
    

7. Check the In House box if you perform the procedure in your office
    

8. Click Save
    

9. Click Close to exit the Condition Search dialog
   
   

To Configure an Order Set:

1. Click Edit > System Tables > Order Set
    

2. In the Order Set List dialog, click the New button.
   
   
   
    

3. In the Order Set Template dialog, enter the Order Set Name in the corresponding field.
    

4. Check the Global Order Set option to allow the order  to be accessible by other users.
    

5. Click Add next to the option you would like to attach to this order set.
   
   NOTE: You will only see the item in this dialog if you have performed steps 1 - 9 in the To configure a test, image, etc. section above. You are not required to fill in all of the sections. Also, if you are performing the test in your office, check off the In House box. (If the test was previously configured as In House, then the box will automatically be selected.)
   
   
   
    

6. Click the Link Diagnosis button.
    

7. In the Order Set field of the Order Set Manager dialog, select the Order Set you are adding.
    

8. In the Linked Diagnoses section you can perform an ICD10 Search, an ICD9 Search, as well as utilize the Crosswalk functionality which allows you enter an ICD9 code and then the system will return the applicable ICD10 code(s) that match that initial ICD9 code.
   
   Once the applicable code or codes have been located, highlight that code and then click the Add to Selected Codes button. The code, or codes, will then appear in the Selected Codes area under the applicable column. Codes can be removed if needed, by highlighting the code in the Selected Codes area, and then clicking the Remove from Selected Codes button.
    

9. Once all of the applicable diagnosis codes have been selected, click the Apply button, and then click the OK button.
   
   
   
    

10. In the Order Set Template dialog, click the Save button.
     

11. Click the Close button in the Order Set List dialog when finished.

Link Order Sets to a Diagnosis

1. Click Edit > System Tables > Conditions > Diagnoses.
    

2. Search for and  highlight the diagnosis, and then click the Properties button.
    

3. Click the Manage Order Set button.
   
   
   
    

4. In Diagnoses tab of the Order Set Manager dialog you can perform an ICD10 Search, an ICD9 Search, as well as utilize the Crosswalk functionality which allows you enter an ICD9 code and then the system will return the applicable ICD10 code(s) that match that initial ICD9 code.
   
   Once the applicable code has been located, highlight that code, and to add an Order Set to this diagnosis, highlight the applicable Order Sets in the All Order Sets column, and then click the Add>> button. To remove a linked diagnosis or set of diagnoses, highlight the applicable diagnoses in the Linked Diagnoses column, and then click the <<Remove button.
    

5. Check the Default box next to the applicable order set.
    

6. When finished, click the Apply button, and then click the OK button.
   
   
   
    

7. In the Conditions Properties button, click the OK button.
    

8. Click the Close button in the Conditions Search dialog when finished.

Using Orders and Order Sets

To use an order set:

1. Select the Diagnosis in a note
    

2. Leave the Use Order Set box checked, and select the Order Set, if needed.
   
   
    

3. Click OK
   
   NOTE: ChartMaker will automatically open the Prescribe Medication window if there is a configured medication. Highlight the medication and click Select to complete the prescribe process.
   
   
    

4. Once you complete the prescribe process, it adds the medication to your note, along with the tests and images that you ordered.
   
   
   
   
   
   NOTE: You must have a Procedure checklist in your template in order to see the order set items appear. You must have the Misc Note field in order for a referral to appear.
    

5. Click Note > Send Orders
   
   
    

6. Check the box under Send for the orders you want to send
    

7. Click OK
   
   NOTE:  They will now show on your Face Sheet as Pending
   
   
   
   If you close out of the chart, you will also notice Reminders on your To Do List:
   
   

To change the status of an off-site order:

1. Open the patient’s chart
   
   NOTE:  You do not have to open the original note; all you have to do is be in the patient’s chart.
    

2. Click the Order Status button.
   
   
    

3. In the  Pending and Completed order section select the applicable orders you want to update, and then click the appropriate status option (Pending, Completed, Reviewed, Completed with Image, or Reviewed with Image).
    

4. In the Reviewed orders processed for this note section select the applicable procedure, and then click the appropriate status (Reviewed or Reviewed with Image).
   
   
   
    

5. Save or close out of the chart. You will notice it saved those changes and now the reminder on your To-Do List reflects the changes.
   
   

To change the status of an in-house order:

1. Open the patient’s chart.
   
   NOTE:  You do not have to open the original note; all you have to do is be in the patient’s chart.
    

2. Right-click the procedure in the Face Sheet.
    

3. Select Review In House Order.
   
   NOTE: This method can only be used if the procedure is designated as an In House procedure in System Tables.
   
   
    

4. Select the Order Status at the bottom.  The options for the results will become available.
   
   
    

5. Click Save.
   
   NOTE: Once the status is changed to “Reviewed”, the reminder is removed from your To Do List and the Face Sheet.
    

6. You will receive an auto-generated note if you Reviewed an In-house Order.
   
   
   
   NOTE: If it is not an In-House Order and you use the drop-downs at the top of the note, no auto-generated note is created.

To print an order (using an order set):

1. Right-click the item from the Face Sheet.
    

2. Choose Queued for Printing.
    

3. Right-click and choose Print Procedures & Prescriptions.
   
   
    

4. Click OK.
   
   
   
   NOTE: It will print using the same layout as your prescriptions.

To print an order (not using an order set):

1. Select the item in your note and send orders so it is showing on your Face Sheet.
   
   NOTE: The item you are ordering needs to be configured correctly. Perform the steps in To configure a test, image, etc. first.
    

2. Right-click the item from the Face Sheet.
    

3. Right-click and choose Print Procedures & Prescriptions.
   
   
    

4. Click OK.
   
   
   
   NOTE: It will print using the same layout as your prescriptions.