Clinical Ordering Norms
All members of the care team rely on complete, accurate, clear and specific orders.
Computerized Provider Order Entry (CPOE)
Orders have many effects within a clinical information system (CIS). They indicate required investigations or interventions. They also initiate and coordinate care activities, assign accountability, 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 CIS when placing and managing orders.
CPOE Allowed Exceptions
There will be situations when prescribers cannot be expected to place time-sensitive orders directly and require the assistance of a qualified healthcare 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:
Urgent verbal orders
Urgent telephone orders
CPOE Approved Exceptions
Unforeseen situations may arise where an alternative to CPOE is compellingly justified by safety and/or efficiency considerations. Such exception-cases must be described in standardized way and submitted for approval at the level of the Connect Care Executive Committee.
Some prescriber groups may advocate for situations where "medical scribes" (extended role non-physician clinicians) could increase the productivity of prescribers with whom they are paired.
Facilitating acceptable indirect prescriber orders (real-time, with engagement of all linked clinical decision supports) may be acceptable, if implemented under an explicit scribe initiative that has been reviewed and approved by AHS (Medical Affairs). A CPOE Exception Request should be completed.
Any health care providers supporting prescriber-delegated real-time CIS order-entry and/or documentation must be appropriately trained, including privacy training, and certified to enter order(s) to the CIS. They can do this only if this is within their AHS-approved scope of practice and training.
The following resources are intended to guide order-entry and delegation in Connect Care: