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Order Entry
Order Entry allows the user to document a Order and then place that Order into a patient's chart. From the chart, the provider will be able to fax or print the orders to other clinics, hospitals, labs etc.
An Order is a structured SMARText item and can be located in the structured plan items category.
Work Flow
1. Create an Order Item
2. Insert the item into a SOAP encounter note
3. Order Items
Creating an Order in SMARText
- Go to Docutainers in the main menu bar and Select SMARText Items. Click on the Create button.
- Select Order from the SMARText Type Selection and then Click on the Create button.
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- The SMARText Designer will open
You will notice that most but not all subitems (Blue, Underlined text) are automatically placed in the textbox in the middle section of the SMARText Designer. Here, you can set default information to automatically populate the subitems whenever you choose to use this Order for a patient.
- Enter a Shortcut for the order-this is what you will type into the Plan field of the SOAP encounter notes when you want to use this Order Entry
- Description-a description of the Order Entry
- Keywords-these will be used whenever your want to search for this Order Entry from the SMARText Items list or from patient Charts
- Left click over Assigned To in the General (middle) section of the SMARText Designer. This will open the SMARText Quick Access list of users in the system.
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- From this list, Click once on the user to be assigned to this Order. For this example, we will select Sample Nurse, R.N. The user will be placed into the order next to Assigned To . What this means, is that this order will be assigned to Sample Nurse, R.N. anytime you insert it into a patient's chart, unless you manually assign it to another user at that time.
- Repeat this for each item with Blue Underlined Text that you want to set as a default item for this order. Each time you click on an underlined item, a new SMARText Quick Access list to select from will pop up: Priority/Urgency, Action/Status, Location,etc.
In the Item Properties (bottom) section of the SMARText Designer, note that you can define a time span. This relates to due dates and reminders, we can't set a default for this in the traditional sense so we define how many days, hours, etc. that need to pass before these come due. In our example shown below, we have set the item to be ordered in 10 days and we will receive a reminder to Order the test in 6 days.
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- After all items have been completed , Click on Save. Your finished Order is now ready to insert into a Chart
Destination Manager
Destinations are facilities that we define where Orders can be submitted. So for example, a blood lab could be a destination. It's a place where we are sending Orders (tests/labs) to be processed, and documenting where those Orders were sent.
Location:
Under Docutainers on the SOAPware menu bar, select Order Entry, Destinations
Creating:
Click on the Create New Destination icon
Fill out the Name, Address, Phone# and Fax# for the Destination and Click on Save
Editing:
Click on the line item to be edited and then on the icon Edit Destination
Deleting:
Click on the line item to be deleted and then the icon Remove Destination
The Orders must be placed into the Plan field of the patient's chart.
Inserting an Order into a SOAP encounter note
- Select your patient from the Chart Rack, Open the Chart and Click on the SOAP encounter notes tab.
- Click on the Create Docutainer button.
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- This will open the Add Document Task window. For the sake of Order Entry, the user can click on the Cancel button.
- You should now have a new (blank) SOAP encounter note.
- Click on Docutainers in the Main Menu and Select Insert Order, or you can Press the F4 button on your keyboard.
- The Place Order window will open.
- Orders can be found either by searching for them using the Find and Search feature or by scrolling through the list using the scroll bar. To use the Find and Search feature, enter the complete Shortcut in the field next to Find.
- Click the Search button.
- When the order appears in the window double-click the order or click on the Select button at the bottom of the window.
- When placing an order the user has the option to create a Task. To skip creating a Task, click Cancel; the order will still be placed.
- Select the user the task needs to be assigned to from the Assigned To drop down box and then Press the Select button.
- The order and task have now been placed. The order will now appear in the Plan section of your SOAP note.
Placing an Order Using Order Manager
- Select your patient from the Chart Rack, Open the Chart and Click on the SOAP encounter notes tab.
- Click on the Create button to Create a new Docutainer.
- This will open the Add Document Task window. For the sake of Order Entry, the user can click on the Cancel button.
- You should now have a new (blank) SOAP note.
- Click on Docutainers in the Main Menu and Hover over Order Entry, Select Order Manager.
- The Order Manager window will open. Click on the Create New Order button.
- The Place Order window will open.
- Orders can be found either by searching for them using the Find and Search feature or by scrolling through the list using the scroll bar. To use the Find and Search feature, enter the complete Shortcut in the field next to Find.
- Click the Search button.
- When the order appears in the window double-click the order or click on the Select button at the bottom of the window.
- The Order Manager window will open again with the selected order ready to be placed. Notice the
next to the order. This means that the order is waiting to be placed.
Customizing an Order from Order Manager
Before placing an order, the user has the option of customizing with the SMARText items. Some of these fields may already be set to a default if they were customized when the order was originally designed. You can change any of the defaults prior to placing the Order, also.
- Click on the Blue Underlined SMARText item to display the SMARText Quick Access window. In the image above, we selected the Priority/Urgency item.
- From the SMARText Quick Access list, Click to select Urgent, Normal, Low or High.
- Continue moving through the selections by clicking the navigation buttons in SMARText Quick Access.
- After completing the items you want to customize or change, Click on the Order Selected Item button located in the Order Manager.
- When placing an order the user has the option to create a Task. To skip creating a Task, click Cancel; the order will still be placed.
- Select the user to be assigned to the task from the Assigned To drop down box and then Press the Select button.
The order and task have now been placed. The order will appear in the Plan section of your SOAP encounter note
Transferring an Order to the SOAP encounter note Using Order Manager
- Select your patient from the Chart Rack, Open the Chart and Click on the SOAP encounter notes tab.
- Click on the Create button to Create a new Docutainer.
- This will open the Add Document Task window. For the sake of Order Entry, the user can click on the Cancel button.
- You should now have a new (blank) SOAP note.
- Click on Docutainers in the Main Menu and Hover over Insert Order, Select Order Manager.
The Order Manager will open. Notice the 
next to the order. This means that the order has not been transferred yet.
Before inserting the order, the user has the option of customizing with the SMARText items. Some of these fields may already be set to a default if they were customized when the order was originally designed. You can change any of the defaults prior to placing the Order, also.
- Select the Order to be transferred to the SOAP Note. In our example, we will select CBC. This will activate the Transfer to SOAP Note button.
- Notice that the has changed to
This means the Order has been transferred to the Plan section of the SOAP encounter note.
Also see:
Important Notes:
- Order Entry items can only be entered into charts via the Order Manager. They will not function properly if entered directly into documentation as is possible with all other SMARText items (i.e. expanding from the shortcut codes in the Plan field).
- Searching for Order Entry items that are in the online library is not yet possible from within the Order Manager. Only the items that are in the local database are available. So, download needed items from the library from within the SMARText Manager before searching for them in the Order Manager.
- Order Entry is currently a first phase implementation. Many functionalities have yet to be implemented.
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Andy