Clinical Ordering Norms
The following norms apply wherever Connect Care is used as the record of care for a clinical activity that the order relates to ("Connect Care encounter"). Accordingly, included are situations when a prescriber generates a request from an external (e.g., home or office via computer or mobile app) setting. What matters is that the order relates to a patient's Connect Care encounter.
Computerized Provider Order Entry (CPOE)
All members of the care team rely on complete, accurate, clear and specific orders. Orders have many effects within a clinical information system (CIS). They indicate required investigations or interventions. They also 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:
Protocolized orders
Urgent verbal orders
Urgent telephone orders