Clinical Ordering Norms
All members of the care team rely on complete, accurate, clear and specific orders.
Orders have many effects within a clinical information system. They indicate required investigations or interventions. They also initiate and coordinate care activities, assign accountability, and trigger workflows and start tracking logs. Orders are tightly coupled with clinical decision supports. These guide care while alerting to potentially harmful actions. Any second-hand (e.g., verbal or scribe or other delegated order-entry) process can isolate prescribers from decision-supports and other order-dependent charting activities. Accordingly, it is essential that prescribers directly interact with the clinical information system when placing and managing orders.
There will be situations when prescribers cannot be expected to place time-sensitive orders directly and require the assistance of a qualified health care professional to transcribe important clinical instructions. Allowed exceptions to prescriber order-entry fall into three categories, each explained and exemplified in FAQ and Order Norms documents:
- Protocolized orders
- Urgent verbal orders
- Urgent telephone orders
The following resources are intended to guide order entry and delegation in Connect Care: