Quick Guide to Outpatient Orders by Students For more detailed information on ordering medications, refer to the user guide, Neehr Perfect EHR Quick Guide to Ordering Med (for students).

In the patient chart, order menus are found in the Orders tab.

This is the patient order menu located on the Orders tab. Pay close attention to which order menu you need to select based on the location of the chart you are working in…Inpatient or Outpatient. The exception: To order any labs, for inpatient or outpatient, select the IN PT LABORATORY menu. The EHR will automatically list the labs available based on the location of the chart.

Orders for an outpatient chart 1. The first step when working in an Outpatient chart is to select a Visit and a Provider. The Provider will always be your instructor unless you are told otherwise. Click on the box that reads Visit Not Selected.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

2. At the pop up, Provider and Location for Current Activities, locate and select your instructor. For the Visit Location always select Family Clinic, unless told to select another clinic by your instructor. Click on the calendar ‘button’ to select NOW, or another date and time. Once you have completed all three steps click OK.

3. Go to the Orders tab. Select the Order Menu that is needed to complete the order. In this example, we will be ordering an outpatient unit dose med for a patient chart.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

4. The medications you see listed on this screen are “Quick Orders.” You may select one of them if you would like. Clicking on ORDER ANY OPT MED gives you access to all outpatient medications in your EHR formulary. Click on ORDER ANY OPT MED.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

5. Begin typing the medication you need to order. Most medications will be listed in the Generic name. However, you may find some medications listed in the EHR with the Generic and Brand name. 6. Once you have located the medication you want to order, highlight the medication and click OK.

Here we will scroll down further and select Promethazine Syrup – when you click on this item it should be highlighted. Then Click OK.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

7. Complete the Medication Order, entering a Dosage, Route, Schedule, then Days Supply, Quantity and the Refills authorized . If you leave out any information, or have entered the order incorrectly, the EHR will give you a pop-up box with the details of what you must correct before accepting the order. Once you have entered the order, click on Accept Order.

8. At this pop-op, click Accept Order. The EHR is letting you know that it is checking on this EHR only and not with other EHRs on the Internet.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

9. Once back on the Orders tab, you can now release the order. As a student, you cannot place an order and “sign” the order as a provider. The steps you will be following are placing an order on behalf of a provider. (Or on behalf of your faculty.) 10. Highlight the order(s) and click on the Action menu > Release without MD Signature.

11. Check the order for accuracy. Click Continue.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

12. Click on the Policy button and click OK. You are releasing these orders per policy. If you attempt to release the orders per a verbal or telephone order, you will receive an error message and you will not complete the order process.

13. Release the order by entering your Username. Click OK.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

14. This screenshot shows the order released with a “status” of ‘Pending’. This status is related to the EHR program, the Auto-Pharmacist. The Auto-Pharmacist acts as a real pharmacist does in practice by electronically approving and releasing the order.

15. Click on the File Menu > Refresh Patient Information to have the order move from ‘Pending’ to ‘Active’.

16. To place other orders for the Outpatient Setting, click on OUTPATIENT NURSING. 17. The orders you see listed on this screen are “Quick Orders.” You may select one of them if you would like. Or by clicking on ORDER NOT ON THIS LIST you are able to enter “free-text” orders. Click on ORDER NOT ON THIS LIST.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

18. Enter the order. Optional: selecting the Start Date/Time and Stop Date/Time. Once you have entered your order click on Accept Order.

19. To enter orders for Outpatient Labs you only have one option. Click on the IN PT LABORATORY menu. The EHR will automatically list the labs available based on the Outpatient location of the chart. 20. The lab orders you see listed on this screen are “Quick Orders.” You may select one of them if you would like. Or by clicking on ORDER ANY LAB you are able to choose from all available Outpatient orders. Click on ORDER ANY LAB.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

21. You may search the Available Lab Tests by scrolling through the list, or begin typing the name of the lab you are looking for. Once you select the lab test the order menus will populate with the most common order entries. When you have completed all changes to any of the pre-populated sections, click Accept Order.

22. Once back on the Orders tab, you can now release any orders you have entered. Follow the same steps as you did above with steps #9-15 of entering outpatient orders. 23. Highlight the order(s) and click on the Action menu > Release without MD Signature.

24. 25. 26. 27.

Check the order for accuracy. Click Continue. Click on the Policy button and click OK. Release the order by entering your Username. Click OK. Click on the File Menu > Refresh Patient Information to move any ‘Pending’ orders to ‘Active’.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

Why not choose ‘Signature on Chart’?

Selecting the option for Signature on Chart will result in the student user receiving an error message.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

What else can I do with orders? Most commonly used ‘Actions’

Change – This allows you to change any component of an order. I.e. the dose, or add a comment. Copy to New Order – Use this option when an order has expired and you need to “Reactivate” the order. This will also reactivate the medication in the eMAR allowing the medication to be documented in the patient’s eMAR as being given, using a barcode or not having a barcode available. Use this option instead of the “Renew” option for expired medications. Hold - Only active orders may be placed on hold. Orders placed on hold will continue to show under the ACTIVE heading on the profiles until it is removed from hold. An entry is placed in the order’s Activity Log recording the person who placed/removed the order from hold and when the action was taken. Flag - You can flag an order to draw attention to it. When an order is flagged, the order will appear on the Orders tab with a red box in the service column. The order will remain flagged until someone "unflags" the order. CPRS (the EHR) records the name of the person who flagged the order and the date and time that it was flagged. Unflag - You can remove the flag from an order very simply. You can enter a reason for removing the flag, but CPRS does not require you to enter a reason. In the order's detailed display, CPRS will record the name of the person who removed the flag and the date and time that person removed it. Verify - shows that the nurse has seen the order. When a nurse (or student) verifies an order, the nurse's initials are then placed in the appropriate column on the Orders tab.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016

Different ‘Views’ of orders

Selecting Custon Order View is the most commonly used option. You may select All to view all orders ever written in the chart. You may select to change the Chronolgoical Sequence of the orders.

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Neehr Perfect EHR Quick Guide to Outpatient Orders by Students v2 Archetype Innovations, LLC ©2016