Notes used during OMRS13 Order Entry session

1. Order Entry

2. Metoprolol 50 mg PO twice daily
CD4 Count
Full Hemogram in am
X-Ray left arm for trauma
Low Sodium Diet
Up In Chair for 10 min four times daily
Call for pulse > 120

3. Metoprolol 50 mg PO twice daily
CD4 Count
Full Hemogram in am
X-Ray left arm for trauma
Low Sodium Diet
Up In Chair for 10 min four times daily
Call for pulse > 120

4. Definitions
Orderable
A concept that can be ordered.

5. Definitions
Order
A request from a provider to do
something to/for a patient.

6. Definitions
Order Type
Defines the major category of the
order.
drug, test, referral, diet, activity,
nursing, call orders, letter, handout

7. Definitions
Urgency
When an order should be done
STAT, routine, scheduled, conditional

8. Definitions
Order Number
An identifier used to track the life
of an order (in HL7, it’s the
“placer” number), which may be
sent to external systems as a
reference to the order.

9. Definitions
Order Action
The action being taken on the
order.
new, revise, continue, renew,
discontinue, supplement, hold

10. Definitions
Active Orders
Orders that have not been
discontinued or expired.

11. Definitions
Structured Dosing (Drugs)
Codified dosing instructions, where
individual components are captured:
dose, dosage form, route, frequency,
duration, duration units, PRN
condition, additional instructions

12. Definitions
Complex Dosing (Drugs)
When dosing instructions cannot be
fully codified and must be captured as
free text.
eg: “2 tabs QAM and 1 tab QPM”
“as directed”

13. Definitions
Order Template
The definition of an order, which
may be used to aid in the creation
of an order.

14. Definitions
Order Set
A collection of order templates
that defines a useful set of orders
(regimen, convenience sets, etc.).

15. Definitions
Order Group
Ties together orders that were
placed together (e.g., as part of a
regimen or convenience set) – e.g.,
a record of the order set used.

16. Orders 1.9
order_id
patient_id
encounter_id
urgency
concept_id
instructions
start_date
auto_expire_date
discontinued
date_discontinued
discontinued_reason

17. Orders
order_id
order_type
order_number
previous_order_id
patient_id
encounter_id
order_group_id
urgency
order_action
concept_id
indication
instructions
start_date
auto_expire_date
discontinued
date_discontinued
discontinued_reason
orderer
fulfilled ±
fulfilled_by/accession_number
vs. status
?comment_to_fulfiller

18. Drug Orders
order_id
drug_id
structured_dosing
dose
dose_units
route
frequency
duration
duration_units
as_needed
as_needed_condition
administration_instructions
quantity
quantity_units
num_refills

19. Test Orders
order_id
specimen_source
laterality
clinical_history

20. Order Group
order_group_id
patient_id
order_set_id

21. Order Set
order_set_id
order_set_status
name
description
title
comment
operator

22. Order Set Member
order_set_member_id
parent_order_set_id
sort_weight
title
comment
order_set_member_type
concept_id
order_template
order_set_id
concept_class
concept_set

23. IMPLEMENTATION GUIDANCE FOR THE NHS DOSE SYNTAX