# Signing Orders before Selecting a New Patient or Exiting CPRS

Whenever a user leaves a patient chart whether to select a new patient or to exit CPRS completely, CPRS prompts the user to sign unsigned orders that the user has privileges to sign. The dialog that CPRS displays may be different than the Review/Sign Changes… or Sign Selected dialogs based on the parameter settings. By changing the parameters settings, the dialog may display one or more of the following categories of unsigned orders:

· My Unsigned Orders - This Session

· My Unsigned Orders - Previous Sessions

· Others' Unsigned Orders - All Sessions

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 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 selects 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 a number of orders, use these steps:

1. Select the Orders tab.

2. Highlight the orders you want to sign.

To select a range of items, click the order at the beginning of the range; then hold down the < Shift > key and click the order at the end of the range. To select multiple, individual orders, select the first order, hold down the CTRL key, and click the next order.

3. Select Action | Sign Selected...

-or-

right-click and select Sign...

4. (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.

If CPRS displays order checks, carefully review the order checks and take the appropriate action below:

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 signature dialogs will display.

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.

5. If the Electronic Signature dialog resembles Figure A, enter your electronic signature code (if necessary) and click Sign . The orders will now be signed.

If the Review / Sign Changes dialog resembles Figure B or Figure C and contains question marks, continue to step 6.

6. 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 “smart card required” text and the text the provider must acknowledge display

7. The question marks inside the check boxes in Figure B 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 and/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 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:

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

This will toggle the box between checked and unchecked.

o 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.

o Selecting the All button.

This will toggle all the check boxes on the dialog.

8. 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.

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

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

10. 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 .

11. (Conditional) If your PIV or smart card is already set up, you will not see the Digital Signing Setup dialog and you can proceed to step 11. 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.

Note: If the provider has an NPI, it will not display on the screens below.

You may then be asked to enter your PIN.

Then, the signature process will proceed.

12. 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.

13. 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 or smart 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.

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

Add to Signature List

Viewing Unsigned Notes or Discharge Summaries

Identify Additional Signers

CIDC: Entering Diagnosis Codes for Specific Orders