CPOE is a physician focused initiative and nursing, as well as other clinicians, play a significant role in promoting its adoption. A consistent approach for physicians to enter all orders into a clinical information system is essential for efficiency and supporting end user satisfaction.
Order Sets frequently contain nursing type orders for such things as patient activity, catheter care, patient education etc. These orders may not be part of the current ordering system and should be created to ensure that order sets are complete allowing physicians access to enter all orders that they currently write on paper. In addition, most systems have connections between the orders and nursing care plans or worklists that allow these orders to 'flow' to those tools.
Recommended activities include:
- Reviewing current order sets and ensuring that all orders in each set can be entered into the system.
- Identify all orders or orders sets that have been approved by policy for initiation by nursing; ensure that these are built in the system and there is a process to initiate them and obtain the appropriate physician signature per hospital and state requirements for these nursing initiated orders.
- Creating a naming convention that meets both the ordering user's (hopefully physician) and the recipients's (usually nursing) need for clarity and ease of use.
- Creating a catalog of individual nursing orders used routinely in the ordering process; this is usually done manually by reviewing current ordering practices in the patient records.
- Ensure processes are in place to stop or discontinue these nursing orders when the care needs change to prevent 'clutter' of outdated orders in the patient record that can lead to confusion.
