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Order Entry / Results Reporting

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The Module is required to include online communication of physician orders, and patient information between nursing and ancillary departments. Patient charges should be generated upon confirmation of order.

The result reporting function is required to allow users to communicate with laboratory, radiology and pharmacy
The Order Results Management module allow providerís orders for patient services to be entered and electronically transmitted from the point where the order originates to the point of patient services thus minimizing delays , eliminating lost paper , and making information accessible to other providers. Order entry includes pharmacy dispensing for inpatients and outpatients.


The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list.

Order Entry / Results Reporting

Description
Order Entry / Results Reporting

The Module is required to include online communication of physician orders, and patient information between nursing and ancillary departments. Patient charges should be generated upon confirmation of order.

The result reporting function is required to allow users to communicate with laboratory, radiology and pharmacy
The Order Results Management module allow providerís orders for patient services to be entered and electronically transmitted from the point where the order originates to the point of patient services thus minimizing delays , eliminating lost paper , and making information accessible to other providers. Order entry includes pharmacy dispensing for inpatients and outpatients.


>>> General
1 Enter , amend, cancel , print or verify orders
2 Support on-line entry of order to ancillary departments( ex: lab, radiology, pharmacy ) from nursing stations
3 Display patientís demographic, medical and physician data on all order entry screens
4 Support entry of order duration
5 Allow user to select a sub-set of a standard order set
6 Automatically date and time stamp all orders
7 Allow hospital to define formats for results reporting
8 Access all patients on a location
9 View clinical results and reports
10 Provide possibility to assign clinical and diagnostic codes ( ex : ICD , user defined codes , ..)

>>> Order Entry
11 Allow update of current orderís priority, duration, and frequency with notification to ancillary department
12 Support order sets ( ex: multiple orders ) activated by entering a single order code
13 Support recurring orders with entry of a stop date
14 Automatically cancel recurring orders for discharged patients
15 Support the entry of patient requests for meals and transmit to dietary department
16 Support entry of text messages with orders sent to ancillary departments
17 Support the holding of orders for verification and approval before processing
18 Support suspension of orders and reactivation later on
19 Allow clinician to specify a time period during which no tests are permitted for a patient
20 Provide an audit trail identifying staff who enter, review, and cancel each order
21 Check for duplicate orders and prompt for verification or cancellation of the duplicate order before processing
22 Support cancellation of duplicate orders and maintain an audit trail
23 Provide ability to identify STAT orders transmit to the ancillary department
24 Display patientís current and discontinued orders by service in chronological and reverse order
25 Support remote order entry from a PC in the physicianís office
26 Support the entry of specimen collection information
27 Support manual entry of test results by ancillary department and print at nursing station
28 Support entry of test results in a free text format
29 Include Ďnormalí test results with patientís actual results
30 Support sending of laboratory and radiology results to computers in physician offices
31 Support holding of results and release only after verification by authorized personnel
32 Enter and track the status, request date , and service date of an order
33 Enter and retrieve clinical data
34 Capture costs and charges of procedures
35 Retrieve information from archival storage
36 Enter an unlimited number of orders from different departments
37 Enter an unlimited amount of order sets, series orders , and clinical interventions

>>> Order Results Management
38 Allow a provisional order to be entered, subject to confirmation by another user
39 Allow the retroactive entry of orders that have been completed and should not be repeated (Example: Lasix 40mg, IV, STAT - DONE)
40 Ability to attach multimedia to action results and also provide links to third party diagnostic imaging systems for the handling of very high-resolution clinical images of data
41 Allow the setting up of order sets
42 Capability of handling duplicate orders and conflicts with other orders
43 Provide the ability to carry out secondary tasks associated with an order that are required to complete performance of the order (e.g. print patient instructions, print specimen labels, send notice of transportation, request catheter etc)
44 Support on-line ordering for dietary meals and supplements
45 Support types of medications ordering ( ex: generic , trade name , ..)
46 Support the ability to order type and units of blood or blood products
47 Generate specimen labels as a by product of order entry and print on the nursing unit
48 Customize labels and revise when necessary
49 Ability to provide an on line summary of medications administered
50 Support auto printing of lab results by individual patient, entire nursing unit, or by ordering location
51 Receive orders from other modules

>>> Alerts and Warnings
52 Track orders statuses
53 Provide warnings / reports of uncollected / unacknowledged orders
54 Provide order statuses ( ex: Ordered/ To be collected/ Collected/Received in lab/Completed )
55 Provide Pharmacy statuses ( ex : Ordered Dispensed Administered Cancelled Discontinued Suspended Resumed Auto stopped Revised )
56 Ability to provide an alert upon patient discharge of outstanding orders needing action or completion
57 Ordering screens to facilitate the entry of multiple orders for all departments
58 Check for duplicate procedures during the ordering process
59 Generate a visual or audible alert on workstation, CRT or printer at nurse station upon receipt of STAT or abnormal test results

>>> Order Costing and Charging
60 Enter charges per order and amended orders in the ordering module
61 Support pricing by financial class and special agreement
62 Handle multiple price changes
63 Pre-load pricing information
64 Ability to present ordered item / service cost information at the time of order confirmation as part of the confirmation
65 Set charge for each test or treatment
66 What status an order is charged
67 Determine which charges can be edited

>>> Query
68 Allow on-line inquiry into lab results
69 Support on-line inquiry and reporting of all orders during the patientís stay
70 Provide ability to highlight abnormal test results on printed forms and results inquiry screens
71 Allow alternative search of diagnostic codes
72 Allow alternative search of procedures
73 Allow alternative search of investigations
74 Allow alternative patient search by confirmed or provisional diagnosis
75 Allow alternative patient search by Planned procedures ( completed and incomplete )
76 Allow alternative patient search by Planned investigation ( still outstanding , completed )
77 Instant access to current data such as diagnosis, patient condition , visitor permissions, allergies, test results, and current diet
78 Ability to review and update orders to check priority, service date, and status
79 Ability to review all orders entered for a patient or location on a specific date

>>> Reports
80 Support optional printing of orders on a standard or user defined forms
81 Support optional printing of ALL results during a patientís stay
82 Print patient schedules of ordered tests
83 Print patient order documentation at the nursing station
84 Print list of current and complete orders by patient and by physician
85 Print summary report in dietary department totaling patient requests for each meal choice
86 Print order summary report of total routine and STAT orders by service and physician
87 Print list ( ex: on demand ) of all results in past 24 hours for patient
88 Print lists of patientsí charges
89 Orders by date , GL period , location , technician , doctor
90 Reports listing : Duplicate , canceled , incomplete , overdue , uncharged orders
91 Ability to provide a printed summary of medications administered
92 Ability to provide a printed summary of selected order types
93 Lists of verified, unverified, incomplete, canceled, uncharged, and overdue orders
94 Lists of patientís daily orders itemizing all tests and treatments
95 Dietary reports detailing patientís diet histories, current diets, and restrictive diets
96 Generate reports and statistics for nursing areas and ancillary departments

>>> Integration
97 Medical Records
98 Inpatient / Outpatient Care System
99 Laboratory Information System
100 Imaging and Therapeutic Services
101 Pharmacy
102 Dietary module
103 Financial and Billing
104 Material Management and Inventory


Last Updated ( Tuesday, 28 October 2008 00:57 )  

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