MD Orders Feature

An MD Order pulls information entered in the Info, Med Profile, and Certification pages.

The MD Order is comprised of 5 sections Demographics, Medications, Other, Order/Goal, Review MD. To ensure all information is included, it is advised to review, add, and verify the information within.

To create an MD Order in the system, follow the steps provided below.

1. Go to Patient > Search Patient and select a Patient.

2. Select the MD Orders link from the Index.

3. Click the Add button to create the MD Order for a Patient.

   

4. Select the applicable Certification Period for the MD Order when prompted by the system.

   Optional: Select an Associated Document from the dropdown.

   Select the Yes radio button, if the same medication and care regiment (from a previous MD Order) applies to the new MD Order. Click the link provided to verify what was included in a previous order before copying the information.

   Click the Save button to proceed.

   

   Only one Certification Period can be selected that is not associated or linked to another MD Order.

5. The Physician Order (MD Order) window opens to the Demographics section. The Demographics page primarily consists of the information entered on the Info page, such as the Primary DX and Surgical Procedures. If required, users may edit this information, add or remove diagnosis.

   The Nurse Signature field is required as well as the Physician Name associated with the Order.

   Click the Save & Next button to continue to the next page.

   

6. Medications entered on the Med Profile page automatically appear on the Medications section. Review the information. Remove or add medications as applicable to the Order.

   Click the Other tab to continue.

   

7. The Other page is used to record further information such as supplies, safety measures, limitations, and activities as recommended by the Physician. Refer to the table below the image for further details.

   Complete each section as applicable and click the Save & Next button to continue.

   

   Section	Description
   DME and Supplies	Durable Medical Equipment (DME) includes items such as canes, wheelchairs, and bedpans. Values/options are entered in the Reference Table Management functionality under Admin > Reference Table Management.
   Safety Measures	Precautionary orders in place to prevent a Patient’s accident (such as 24-hour supervision, fall precaution, or Face Mask requirements). Values/options are entered in the Clinical Safety Measures Reference Table under Admin > Office Setup > Search Office > Edit Office > Office Option Setup.
   Nutritional Requirements	Select the Patient’s nutritional requirements as prescribed by the Physician. Values/options are entered using the Clinical Nutritional Requirements Reference Table in the Office Option Setup.
   Functional Limitations	Record the Patient’s functional limitations such as hearing issues or speech problems.
   Activities Permitted	Indicate activities the Patient is permitted to engage in.
   Mental Status	Indicate the Patient’s mental status.
   Prognosis	Indicate the Patient’s prognosis.

8. The Orders and Goals section defines the type of therapy a Skilled Caregiver is to provide containing rehabilitative milestones for the Patient to achieve, as prescribed by the Physician. Orders and Goals are unique to each Skilled Caregiver discipline.

   Select the applicable discipline and make notes. Click the Save & Next button to continue.

   

9. The Review MD Order page provides an overview of the entire MD Order, allowing users to verify the information entered in the previous sections before saving the order.

   Click the Save and Print button or the Save and Close button to finalize.

   

10. Selecting Save & Close allows you to choose whether the MD Order is Complete or In Progress. Once the window is closed, the new MD Order record displays.

    

    Selecting the Save and Print button initiates a download, creating a PDF copy of the MD Order.

    

    Once Printed, the MD Order Status changes to Printed.

    

Assessment and Reassessment eDocs can be integrated with an MD Order to reduce duplicate documentation. As nurses complete their Patient visit assessments, they have the option to create an MD Order directly from within the eDoc. The assessment entered in the eDoc then flows into the MD Order. After the integrated MD Order is created, information continues to flow as the assessment is edited.

Because the Medications tab on the MD Order and the eDoc assessment are so closely matched, only one version exists in the integrated MD Order. The Medications tab on the eDoc assessment continues to be available and syncs to the Review tab on the integrated MD Order.

The Medications tab on the eDoc assessment syncs to the MD Order Review tab, even after the MD Order is created. This behavior differs from what happens when a medication is added or edited in the Patient Profile after creation of the MD Order, in which case the modifications do not sync.

As stated previously, when a Patient’s medication is added, edited, discontinued, or deleted in the eDoc or MD Order, the change syncs displaying in the Patient Med Profile page under Patient > Med Profile. When a medication is changed to a different one, then the new medication information replaces the older one. If deleted, then the medication is deleted from the Med Profile.

The following table provides the various Status types and descriptions for MD Orders.

Status	Description
In Progress	The MD Order has been created pending completion. but has not yet been completed or printed.
Complete	The MD Order is completed but not yet Printed.
Printed	The MD Order has been completed and downloaded to the user’s workstation as a PDF.
Sent	The printed MD Order has been sent to the Physician for review and approval.
Signed	The MD Order has been signed by the Physician.

Several sections of the MD Order are configurable such as Clinical Category Goals, Clinical Category Orders, Clinical Discipline Category, Clinical DME and Supplies, Clinical Nutritional Requirements, and Clinical Safety Measures. The system uses exact (matching) text for the information to flow from the eDoc assessment to the MD Order in these sections.

Values can be set to inactive in the Office Option Setup section under Admin > Office Setup > Office Edit. A field that does not match the corresponding field in the assessment, can be inactivated and then replaced with a label that matches.

For example, in the following image, Rails is set to Inactive and replaced with Side Rails. Once saved, the custom MD Order field matches the text on the eDoc assessment DME and Supplies tab.

Several columns on the Patient MD Order under Patient > MD Orders in the Medication and Review MD Order tabs provide better visibility for a physician or nurse to view to include a Comments column in the Medication tab.

Amount, Form, and Comments columns are displayed on the Review MD Order tab.