Create Clinical Order

You can create clinical orders in almost all views of the clinical work station.

Prerequisites

System administration makes this function available in the view of the relevant view type (e.g. Occupancies view type) that you use. I.e. the function variant of the view contains the Create Clinical Order function.

Procedure

To create a clinical order in the clinical work station, choose (Create Clinical Order).

If you previously selected a patient in the view, you will create the clinical order for this patient. The system will preset the patient data in the clinical order.

Depending on the definition of the user parameter N1VKGTPA you access the Order Type Selection List (Create Order: Service Selection dialog box) or the Create Clinical Order screen directly.
On the tab pages you select the desired order type(s) and services or order templates, and confirm by choosing (Continue). You access the Create Clinical Order screen.

Note
If you selected order templates for the order type in the selection list, the system will preset a new clinical order. See Order Templates Tab Page

End of the note.

You can also create an appointment in combination with a clinical order. See Creating Appointments and Clinical Orders
Enter the patient data:

The patient data is obligatory in every clinical order.

If you have selected a patient in the view of the clinical work station, the system will display the patient data in the order header. Choose (Change Patient) to change the patient master data.

Otherwise enter the new patient data. You can also create the patient in the clinical order with provisional patient master data.

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).

See Health Insurance Card

When you save the clinical order the system will check whether the patient already exists in the patient master data and branches, if necessary, to the patient search (depending on system parameter NAPPSVSR).

You can also call the (patient search) directly in the patient data of the clinical order.

You can create a patient from the patient search.
Enter the order data.

The order data is obligatory in every clinical order.

The system can automatically assign the order number.

The title of the clinical order is preset from the first order item. You can change the title.
Enter the necessary data in the header level tab page:
Depending on the selected order type, the clinical order will display one or more tab pages for entering order header information.

See Tab Page on Header Level

The system will display these header level tab pages compressed as standard, separated by commas.

With the user parameter N1CORD_HEAD you can control whether the header level tab pages are displayed in expanded form.

Open the header level tab pages using (Expand Data Areas) or close them using ( Compress Data Areas).
Enter the order items:

Depending on the selected order types, the system will create corresponding order items and preset the following fields:
- Order Type
- Addressed OU/Person
  If you wish to address the order item directly to a person (e.g. physician), choose (Addressed OU/Person). In the order type, system administration must have defined the possibility of addressing a person directly.
  
  In the Addressed OU/Person dialog box, enter the person and choose (Transfer).
  
  Depending on the definition on the Order Fillers tab page in the order type, the system will check the employee – position assignment of the person entered.
- Treatment OU (treatment organizational unit)
  The system presets the treatment OU either from the order filler of the selected order type, or from the treatment OU in the work environment in use.
  
  The order fillers are defined by system administration during the definition of order types on the Order Fillers Tab Page.
  
  Note
  For an admission item, the treatment OU is the care unit/outpatient clinic for which you are admitting the patient or preregistering for admission.
  
  For a planned surgery or treatment it is the service facility in which you are preregistering or referring the patient for surgery/treatment.
  
  End of the note.
- Dept. OU (departmental organizational unit)
- Status (first item status from the status profile used in the order type)
  
  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.
  
  Caution
  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.
- Preg (Preregistration indicator)
  With this indicator, you can determine that the treatment or admission item of the clinical order should not be ordered, but preregistered by the order initiator at the treatment OU. You can place preregistered order items on waiting lists if this is permitted in the order type. You can then manage and process this waiting list in the views of the Preregistrations view type.
  
  See Preregistrations View Type
  
  See Example: Preregistration and Waiting List Management
If you do not use the order type selection list, you must enter an order type. Input help is available for the selection.
- Date/Time
  
  The system uses the following logic to preset the Date/Time field and the corresponding pushbutton when creating a clinical order.
  1. chronologically first plannable appointment (change possible with direct entry or planning tool)
  2. chronologically first planned visit
  3. chronologically last actual visit
  4. chronologically first, non-plannable appointment
  5. Desired date
  System administration can override this presetting using the customer-specific business add-in (BAdI) Control Dialog for Order Items.
  
  See Customer-Specific Enhancements for the Clinical Order
  
  Depending on which icon the pushbutton contains, the system will display the following information in the Date/Time field:
  - (Change Appointment)
    
    The system will display the time of the desired date in the Date/Time field. Depending on various factors such as, for example, screen modification, you can change the content of the field.
  - (Appointment)
    The system will display the time of the appointment in the Date/Time field. Depending on various factors, such as authorization, appointment allocation indicator, you can change the content of the field.
  - (Movement)
    The system will display the time of the visit in the Date/Time field. You cannot modify the content of the field.
  - (Appointment Template) or (Appointment) or (Movement)
    If the corresponding date and time does not exist, the Date/Time field remains empty.
  A drop-down list containing the following options is available for entering appointment data:
  - For input, choose (Appointment Template).
    
    See Create/Change Appointment Templates for Order Items
  - If the system displays the icon (Appointment Template), you can also directly enter a desired appointment in the Date/Time input field in the order item. If you have already planned an appointment for this order item (for example, using the planning grid), the system will show the date of the planned appointment in this field.
    If the initiator of the clinical order cannot actually plan appointments (appointment allocation indicator in the order type), this field will display the entered date, or the date you entered in the appointment template as the desired date, as long as no appointment is planned.
  - To enter details for this appointment, choose (Change Appointment). The Maintain Appointment dialog box appears.
  - You can also choose (Movement).
    
    Note that you cannot create or change a visit by entering or changing the value in the Date/Time field. You must still create movements using the (Visit) or (Admission) pushbutton.
  Furthermore you can use the following status-dependent methods for the item row when changing the status of the order item to change the information displayed in the Date/Time field:
  - SET_PLNICON_2_APCN
    When the status is changed, the system always displays the appointment template data.
  - SET_PLNICON_2_APPMT
    When the status is changed, the system always displays the appointment data.
  - SET_PLNICON_2_VISIT
    When the status is changed, the system always displays the visit data.
- You can search for an appointment. The prerequisite for this is that you can allocate appointments for the treatment OU (order filler) as an initiator. The system administrator makes this setting in the order type.
  Choose (Find Appointment). Depending on the planning mode of the treatment OU (day-based planning, time-based planning, determined by the system administrator in OU parameter N1VKGPLMOD) the system will call the day-based planning function or the planning grid. You can find a detailed description of the planning functions in the following sections:
  Once you return to the clinical order the order item will contain the date and time of the appointment.
- If several appointments exist for an item, you can display them by choosing (Further Appointments).
  
  You can find a complete description under Display Further Appointments.
You can assign the order item of a clinical order to a case. If you create the clinical order for a patient, who you previously selected, the system will enter the case in the order item.

You can detach an order item, which is already connected to a movement, from the case by choosing (Case). This only applies as long as no services for this item have been performed or released.

Depending on the order type, you can create a visit for the order item by choosing (Visit) or you can create an admission by choosing (Admission).

Note
As standard, the system will display the order items in collapsed form, i.e. the item level tab pages are not displayed.

With the user parameter N1CORD_POS you can control whether the item level tab pages are displayed in expanded form.

You can open item level tab pages with (Expand Data Areas) and close them with (Compress Data Areas).

End of the note.
You open the item level tab page and enter the required data. See Tab Page on Item Level
If you wish to create additional order items, choose (New Order Item).

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

Using Edit Cancel Order Items you can cancel the order item.
Once you have entered all required data, you can check the clinical order. Choose (Check Correctness of Entire Order).
The system will check whether entries are missing or are incorrect. You then change or enhance your entries.
If you wish to print the entire clinical order, choose ( Overview Print). If you also wish to print the details for a clinical order, choose (Detail Print).
- Print Form pushbutton
- Print Details pushbutton
Save the clinical order.