Procedure documentationEditing Clinical Orders

 

Various functions for editing a clinical order or displaying additional information are available in almost all views of the clinical work station (e.g. views of the Occupancy view type).

Procedure

To call the editing functions in the table, choose the following functions from the corresponding view in the clinical work station:

Function

Procedure

What You Should Know

Find Clinical Order

To find a clinical order choose Find Clinical Order (Find Clinical Order).

Enter the desired selection criteria.

If you search using the order number, the Change Clinical Order screen appears.

If you search using the patient number, the system displays the clinical orders of the patient. You can select and edit an order from this list.

If you search using the patient search and the system finds this patient, the system displays the clinical orders of the patient. You can select and edit an order from this list.

Display Clinical Order

To display a clinical order choose Display Clinical Order (Display Clinical Order).

Open the patient data and order data, the header level tab pages and the item level tab pages using Expand Data Areas (Expand Data Areas) or close them using Collapse Data Areas (Collapse Data Areas).

You can use Start of the navigation path Order Next navigation step Change End of the navigation pathto toggle to the Change Clinical Order function.

Change Clinical Order

To change a clinical order choose Change Clinical Order (Change Clinical Order).

Open the patient data and order data, the header level tab pages and the item level tab pages using Expand Data Areas (Expand Data Areas) or close them using Collapse Data Areas (Collapse Data Areas).

Change the necessary order data, data in the header level tab pages, order item data, and data in the item level tab pages.

If you change an order which was created for a patient with patient master data, the system displays the patient data.

If you change an order which was created for a patient with provisional patient data, you can change or supplement the patient data or create the patient master data.

You can call the patient search Find Patient (Find Patient) in the patient data of the clinical order. You can create a new patient in the patient search.

If you use health insurance smart cards in your hospital, you can also import the patient master data into the clinical order using Transfer Healthcare Smartcard (Transfer Healthcare Smartcard).

Caution Caution

When changing a clinical order you should note the following:

In the input help the system displays only the status which the system administrator defined as the subsequent status in the status profile and for which you have authorization.

You should note that the system only checks required entry fields when the work process is continued, this means you can save the clinical order, even if not all required entry fields have been filled. The system only checks the required entry fields when you enter the status change in the order item.

You can therefore temporarily save the clinical order without having made an entry in all required entry fields.

If you enter a next status, the system saves the clinical order in the entered status. If you are not authorized to set this status you will return to the clinical work station. You can no longer process this clinical order due to missing authorization for the status.

End of the caution.

To edit order items, print the clinical order, or display additional information you can call the following functions in the change or display mode of the clinical order:

Function

Procedure

What You Should Know

Create New Order Item

To create new order items, choose New Order Item (New Order Item).

The system creates a new order item where you can enter the necessary data.

Cancel Order Item

To cancel an order item, choose Start of the navigation path Edit Next navigation step Cancel Order Item End of the navigation path.

Print Overview

To print the entire clinical order choose Print Overview (Print Overview), see Overview Print.

Print Order Detail

To print the details of the clinical order choose Print Details (Print Details), see Print Details.

Print Order Item Details

To print an order item with all details of the clinical order, choose Start of the navigation path Order Next navigation step Print Next navigation step Details Next navigation step Order Item End of the navigation path.

See Print Clinical Order – Print Order Item Details

This print function enables the order filler to print only the order items of a clinical order which are addressed to him.

Display Change Documents

To display any changes which have been made, choose Display Change Documents. The Change Documents Selection List dialog box appears.

You select the desired field of the clinical order by selecting the gray pushbutton at the beginning of the row. Choose Continue (Continue).

The change documents of the selected field are displayed.

Position the cursor on a change document and choose Details (Details) to access a detailed view of this change document.

The system displays information on the changes to the field content, e.g. user ID (user who made the changes), date, field label, old value, new value, etc.

Further functions are also available in the change documents display (e.g. sort, find, filter, print, etc.).

Note Note

When saving the clinical order the system checks whether the entered appointments of the order items correspond to the opening times and the deadline of the treatment organizational unit (planning objects).

Also, the system checks whether the service quota, which the treatment OU determined for the initiator, has not been exceeded.

If the entries do not correspond to the opening times, the deadline, or the service quota (is exceeded), the system displays a warning or an error message (system parameter N1KPMSG).

End of the note.