Minimum Use Ordering Norms

What is it?

Clinicians indicate intended healthcare investigations, interventions and care services through “Orders” placed in the digital health record. Order entry relates to complete capture of all orderable health services provided to a patient together with order properties (e.g., duration, repeats, stopping rules, alert and review parameters) that assure safe and effective fulfillment of the request.

Why does it matter?

All members of the care team rely on complete, accurate, clear and specific orders to coordinate care activities, assign accountability, and enable surveillance of the health outcomes associated with orders. Orders are one of the most common triggers for clinical decision supports. These help avoid inappropriate healthcare services while flagging potentially harmful interventions. Any second-hand (e.g., “verbal” or “scribe” or other delegated order-entry) orders isolate the prescriber from decision supports and other aids to patient safety.

Who is responsible?

All clinicians are responsible for good order management – those entering orders, those validating orders and those carrying out activities based on the orders. Connect Care is committed to 100% prescriber order entry in the clinical information system (CIS). Hybrid (CIS and paper or CIS and alternate information system) order management is not permitted.

How is it done?

Orders are managed in the orders activity parts of the chart in all care contexts. A “Mark as reviewed’ should additionally be used by team members to attest awareness of currently active orders. Indeed, “orders” are not directives, but rather information tools used in task management, care coordination and therapy optimization. They are part of the record of care and support practice audits, reporting and safety assurance.

All medication orders must be entered to Connect Care where it is the record of care. This includes any new or changed medications prescribed at discharge from a Connect Care facility.