Order a Procedure from the Orders Tab

To order a procedure, follow these steps:

1.     Select the Orders tab.

2.     Select Procedure in the Write Orders list box.

Note     The procedure order may be labeled differently or may not be available from your Write Orders list box.

Note     If encounter information has not been entered, the encounter information dialog will appear before the Order a Procedure dialog. You must complete the encounter information dialog before proceeding.

The Order a Procedure dialog displays.

 

3.     Locate and select the desired procedure in the Procedure list.

When you select the Consult Service or Specialty, several things may happen:

     If the service has some prerequisites, a dialog will display stating what those are and will allow you to print the information, continue to place the consult order, or cancel the order.

     In addition, any predefined text or template will display to help the user fill out the Reason for Request field.

     The Provisional Diagnosis field becomes active as well.

 

4.     Select the urgency from the Urgency field.

5.     Select an individual from the Attention field.

(Note about providers with similar first and last names.)

 

6.     If needed, designate a different Earliest Appropriate Date (the default is Today).

Note:      The Earliest Appropriate Date field does not apply to Prosthetics consults services, and the field is not available when the user selects a Prosthetic service.

 

7.     If necessary, select a service that will perform the procedure by using the down arrow to open the list and then selecting the service.

Often, the service is already defined. However, sometimes, the user has the chance to choose.

 

8.     Select whether the patient is an inpatient or outpatient.

9.     Select a place of consultation from the Place of Consultation drop-down list.

10.   Enter a provisional diagnosis in the Provisional Diagnosis field. (Click the Lexicon button to access the lexicon.)

For each procedure, this field is either set up to require that

     the user type in an answer (the box will be white and the Lexicon button unavailable), or

o      the user must select a response must be from the Lexicon (the field will be yellow and the Lexicon button is available).

§      CPRS will search for diagnoses that contain the search term. The matching terms will display in the bottom portion of the Problem List Lexicon Search dialog. The search now looks for SNOMED Concepts Terms (SNOMED CT) items. Most items will also be mapped to an ICD-9-CM code. The list will show the SNOMED concept text, the SNOMED code, and the ICD-9-CM code if the term is mapped to one.

§      If you do not see the appropriate problem listed, select the Extend Search button. On the Consults tab, the Extend Search button extends the search to the ICD-9-CM clinical hierarchy to find additional terms.

 

Note:      If a user tries to enter a diagnosis with an inactive code, CPRS will bring up a message indicating that the code must be changed and giving the user the chance to choose a diagnosis with an active code.

 

11.   Enter a reason for this request in the Reason for Request field.

Sites can help users by putting in predetermined boilerplate text, text with TIU objects, and/or it could be linked to a template that users can fill out. Users can then add to the text already present. Or the field may be left blank for the user to fill in the reason. However, a reason for request is required and the consult cannot be saved without a reason for request.

 

12.   Select Accept Order.

13.   Enter another procedure order

-or-

select Quit.

Note     The order must be signed before it is sent. You can either sign the order now or wait until later.

 

Related topics

Consults (overview)

Complete a Consult from the Consults Tab

Complete a Consult from the Notes Tab

New Consult from the Consults Tab

New Consult from the Orders Tab

New Procedure from the Consults Tab

Viewing Consults