Order Entry

Metoprolol 50 mg PO twice dailyCD4 CountFull Hemogram in amX-Ray left arm for traumaLow Sodium DietUp In Chair for 10 min four times dailyCall for pulse > 120

Metoprolol 50 mg PO twice dailyCD4 CountFull Hemogram in amX-Ray left arm for traumaLow Sodium DietUp In Chair for 10 min four times dailyCall for pulse > 120

Definitions

OrderableA concept that can be ordered.

Definitions

OrderA request from a provider to do something to/for a patient.

Definitions

Order TypeDefines the major category of the order.drug, test, referral, diet, activity, nursing, call orders, letter, handout

Definitions

UrgencyWhen an order should be done

STAT, routine, scheduled, conditional

Definitions

Order NumberAn 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.

Definitions

Order ActionThe action being taken on the order.new, revise, continue, renew, discontinue, supplement, hold

Definitions

Active OrdersOrders that have not been discontinued or expired.

Definitions

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

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”

Definitions

Order TemplateThe definition of an order, which may be used to aid in the creation of an order.

Definitions

Order SetA collection of order templates that defines a useful set of orders (regimen, convenience sets, etc.).

Definitions

Order GroupTies 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.

Orders 1.9

order_idpatient_idencounter_idurgency

concept_idinstructionsstart_dateauto_expire_datediscontinueddate_discontinueddiscontinued_reason

Orders

order_idorder_typeorder_numberprevious_order_idpatient_idencounter_idorder_group_idurgencyorder_action

concept_idindicationinstructionsstart_dateauto_expire_datediscontinueddate_discontinueddiscontinued_reasonordererfulfilled ± fulfilled_by/accession_number vs. status?comment_to_fulfiller

Drug Orders

order_iddrug_idstructured_dosingdosedose_unitsroutefrequency

durationduration_unitsas_neededas_needed_conditionadministration_instructionsquantityquantity_unitsnum_refills

Test Orders

order_idspecimen_sourcelateralityclinical_history

Order Group

order_group_idpatient_idorder_set_id

Order Set

order_set_idorder_set_statusnamedescriptiontitlecommentoperator

Order Set Member

order_set_member_idparent_order_set_idsort_weighttitlecommentorder_set_member_typeconcept_idorder_templateorder_set_id

concept_classconcept_set

IMPLEMENTATION GUIDANCE FOR THE NHS DOSE SYNTAX