# Review / Sign Changes Dialog

The Review / Sign Changes dialog allows you to simultaneously sign several orders and documents at the same time. The Review/Sign Changes option is on the File menu and brings up a dialog with the items that need a signature from the current ordering session.

Sometimes during the ordering process, the status of a patient changes from outpatient to inpatient or vice versa. This might happen because an outpatient was admitted to the facility, or because an inpatient was sent to a clinic for treatment, or because of using Inpatient Medications for Outpatients (IMO) feature. When written unsigned orders exist and the patient's status changes, the user must indicate which location the orders are associated with.

To designate which location written unsigned orders are associated with, the following dialog will appear:

This dialog asks to which location CPRS should associate the orders that have been placed but not signed.

The order location dialog shows the user the two locations the user can choose from, generally an outpatient clinic and an inpatient location. The user the has two basic options:

· Associate all of the orders with a single location by selecting the appropriate button above the list of orders. The buttons will read All location where location is the name of the clinic or ward location. In the above screen capture the buttons read All MICU and All Mental Health Clinic.

· Individually associate each order with one of the two locations. At the end of each order is a column to select the location for each order.

If the user is keeping the patient's chart open, such as selecting File | Review / Sign changes... and this dialog appears, the "Where would you like to continue processing patient data?" prompt displays enabling the user to choose either the ward location or the clinic location. This prompt does not appear if the user is exiting the chart or switching patients.

To sign orders and documents with the Review / Sign Changes dialog, follow these steps:

1. Do one of the following

o Select File | Review / Sign Changes.... to sign orders or documents and stay in the current patient record.

o Choose File | Select New Patient to sign orders or documents and select a new patient.

o Choose File | Exit to sign orders and documents and exit CPRS.

2. (Conditional) If CPRS displays order checks, review the order checks and take the appropriate action below:

In this screen capture, CPRS displays a conflict between ordered medications. Users should review each item carefully before completing the order. Each order that has a high-level order check requires you to select that order and an override reason for it. All orders with an “Action is required” status require an override reason in order to be signed. These order checks are designated by the “*Checks marked with **** require reason to override” text in red and the order check text in blue. The Accept button will not activate until all orders have been viewed, and all override reasons have been entered as needed.

a) To redo the orders to avoid a possible interaction, select Return to Orders. This will cancel the signature process, but not the order.

b) If the orders should not be placed, check the cancel check box in front of the orders that should not be placed and select Cancel Checked Order(s).

c) If the possible interactions are not a problem, type a reason for override (required only for critical order checks) select Continue.

After performing step 1 and after addressing any order checks in step 2, one of the Review/Sign Changes dialogs shown below will appear. Each item that requires a signature will have a check box in front of it.

Note: All non-controlled substances orders will be checked for signature when the dialog displays. To sign controlled substances orders, the user must check the box for each order individually.

One of the following dialogs displays.

This is for providers that can sign orders by policy, such as nurses or clerks. If users decide to release to service, The user can select Verbal, Telephone, or Policy. Each site can choose what the default should be or if there should be a default.

Figure B: The Review/Sign changes dialog may have additional elements depending on the nature of the patient. In this case, the provider can sign controlled substances orders and the patient's conditions are not service-connected.

Figure C: In this example of the Review/Sign Changes dialog, the provider can sign controlled substance orders, and the patient has either Combat Veteran status or service-connected conditions for which the provider must indicate the orders pertain.

3. Deselect any items under the All Orders Except Controlled Substance Orders pane that you do not want to sign by clicking the check box to the left of the order or document.

4. If the Review / Sign Changes dialog is the simpler dialog, enter your electronic signature code and select Sign . The documents and orders will now be signed.

If the Review / Sign Changes dialog resembles Figure B or Figure C and contains question marks, continue to step 5.

5. To select Controlled Substance order to sign, place a check mark in the box to the left each Controlled Substance order to sign by clicking in the check box, or tabbing to it and pressing the <Space bar>.

Note: When the user checks the box to the left of any Controlled Substance order for signature, the phrase SMART card required displays next to the label Controlled Substance Orders.

This is what the dialog looks like before controlled substance outpatient orders are checked for signature.

After the controlled substances orders are checked, the text about the "smart card required" and the text the provider is acknowledging display.

6. The blue question marks inside the dialog's check boxes indicate that you need to specify how that order is related to the medical condition in that column. (SC = Service Connected Condition, CV=Combat Veteran, AO=Agent Orange Exposure, IR=Ionizing Radiation Exposure, SWAC=Southwest Asia Conditions, SHD=Shipboard Hazard and Defense, MST=Military Sexual Trauma, and HNC=Head or Neck Cancer). If you place a check in a box, you are indicating that a medication order is related to the condition in that column. If you create an empty box, you are indicating that the medication order is not related to the condition in that column. You must either check or uncheck every box that contains a blue question mark before you can sign the order.

Note: Definitions for service connection and treatment factors are available to users by hovering the cursor over the term or using the appropriate keyboard shortcut as shown in the list below:

o Service connection (SC) Alt + c

o Combat Veteran (CV) Alt + v

o Agent Orange (AO) Alt + o

o Ionizing Radiation (IR) Alt + r

o Southwest Asia Conditions (SWAC) Alt + a

o Shipboard Hazard and Defense (SHD) Alt + h

o Military Sexual Trauma (MST) Alt + m

o Head and/or Neck Cancer (HNC) Alt + n

You can toggle the check boxes by:

· Selecting an individual check box or tabbing to the check box and pressing the spacebar.

This will toggle the box between checked and unchecked.

· To check all check boxes in a column, select the button above the appropriate column.

This will toggle all the check boxes in that column.

· Selecting the All button.

This will toggle all the check boxes on the dialog.

7. If you have not already done so, insert your PIV or smart card.

Note: If you do not insert your PIV or smart card before attempting to sign the selected Controlled Substance orders, you will see the following two dialogs:

8. When you have removed all of the question marks from the dialog, enter your electronic signature code (the button will change from Don't Sign to Sign) and click Sign .

9. (Conditional) If your PIV card is already set up, you will not see the Digital Signing Setup dialog and you can proceed to step 10. If your PIV or Smart card is not yet linked to your VistA account, you will need to set it up before you can sign outpatient controlled substance medication orders. To set up your PIV or smart card to order outpatient controlled substance orders, select Yes.

You may then be asked to enter your PIN

Then, the signature process will proceed

10. If the Order Check dialog appears, deal with any problems in the dialog: such as entering a reason for override, cancelling specific orders, etc. When ready, select the Accept Orders button.

11. When prompted, enter your PIN to sign the Controlled Substance orders and select OK or press <Enter>.

Warning: Do NOT enter an incorrect PIN five (5) consecutive times! If you enter the incorrect PIN five (5) consecutive times, your card will be until you visit a PIV issuing station.

If you enter the incorrect PIN three (3) times, CPRS temporarily locks your PIV card for 15 minutes. Then, it will allow you to try again. However, you only have two (2) more attempts to get the correct PIN. If you get to five (5) consecutive incorrect PIN entries, the PIV card will be locked and you will have to go to a PIV station to unlock the card.

Criteria Used to Determine if the Copay Buttons are Displayed on the Review/Sign Changes Dialog

The Review/Sign Changes dialog may contain the Copay buttons (SC = Service Connected Condition, CV=Combat Veteran, AO=Agent Orange Exposure, IR=Ionizing Radiation Exposure, SWAC=Southwest Asia Conditions, SHD=Shipboard Hazard and Defense, MST=Military Sexual Trauma, and HNC=Head or Neck Cancer) if the current patient has outpatient medication orders that need to be signed and certain additional conditions are met. The additional conditions are explained below.

Note : The Copay buttons will not appear until after December 31, 2001 and PSO*7*71 has been installed.

Note: Previously, CPRS did not display the buttons if a veteran was 50% or more service connected. If Clinical Indicators Data Capture (CIDC) is installed and the user is not enabled for CIDC, the buttons display for outpatient medications regardless of the patient's level of service connection based on the criteria below. The 50% criterion below does not apply with CIDC installed.

· To qualify for the Combat Veteran (CV) exemption, the veteran must have served in combat operations after the Gulf War or in combat against a hostile force after November 11, 1998. In addition, the condition for which the veteran is treated must be related to that combat, the veteran must have registered as a combat veteran, and be within two years of separation from active military service. Finally, the condition must not be already considered to be service related or that exemption should apply.

Note: The Combat Veteran exemption is valid for two years from the date of separation from military service, not the registration date. For example, if a veteran registers for Combat Veteran status 18 months after the date of his or her separation, the veteran would be eligible for Combat Veteran exemption for six months only. For further details, see VHA Directive 2002-049, Combat Veterans Are Eligible for Medical Services for 2-Years after Separation from Military Service Notwithstanding Lack of Evidence for Service Connection. If a patient is a veteran and 50% service connected or greater then the Copay buttons will not be displayed on the Review / Sign Changes dialog.

· If a patient is a veteran and 50% service connected or greater, then the Copay buttons will not be displayed on the Review / Sign Changes dialog.

· If a patient is a veteran and less than 50% service connected and the patient is exempt from copay then the Copay buttons will not be displayed.

· If a patient is a veteran and less than 50% service connected and the patient is not exempt from copay then the Pharmacy package checks to see if the drug specified in the medication order is marked as supply or investigational. If the drug is marked as supply or investigational, the copay buttons will not appear.

However, if the drug specified in the order is not marked as supply or investigational than CPRS checks if the patient has any other exemptions (Service Connected Condition, Agent Orange Exposure, Ionizing Radiation Exposure, Southwest Asia Conditions, Shipboard Hazard and Defense, Military Sexual Trauma, or Head and/or Neck Cancer). If a patient has any of these exemptions then CPRS displays the appropriate Copay button(s).

Related topics

Understanding Service Connection and Treatment Factors

Digital Signature (PKI) Overview

Electronic Signature (overview)

Sign Selected Orders Command

Sign Note Now and Sign Discharge Summary Now Commands

Signing Orders before Selecting a New Patient or Exiting CPRS

Add to Signature List

Viewing Unsigned Notes or Discharge Summaries

Identify Additional Signers

CIDC: Entering Diagnosis Codes for Specific Orders