The MD Order Page

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

1. Go to Patient > Patient Search 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.

   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; not associated or linked to another MD Order.

5. The Physician Order (MD Order) window opens to the Demographics section as demonstrated in the image below. 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 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 section (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 (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 (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 (as described above).
   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 the Save and Print button initiates a download, creating a PDF copy of the MD Order on the user’s workstation.

    

    Once Printed, the Status changes to Printed.

    

    Selecting the Save & Close button closes the MD Order window and routes back to the Patient MD Order page. The new MD Order record displays.

    

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

An Interim Order is an addendum to an active MD Order. Interim Orders are issued for changes in medication, the type of service the Patient receives, or the frequency of service. Complete the following steps to enter an Interim Order.

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

2. Select the Interim Orders link from the Index.

3. Click the Add button to create an Interim for a Patient.

   

4. The Interim Order window opens. Select the required fields marked with a red asterisk.

   

   Field	Description
   Cert Period	Select the applicable Certification Period.
   Interim Order Dates	The date the Interim Order is issued.
   Order Type	Select if a Verbal or Signed Order.
   Physician Name	Select the ordering Physician. Note: Upon selection, the Physician’s address and phone numbers populate in said fields.
   Nurse	Select the Patient’s nurse.
   Category	Select the reason for the order. The selected Category field determines the remaining fields to complete.
   Start Date	The date in which the order is executed.

5. If multiple Interim Orders are applied to a single Certification Period, select the Merge Interim Order… checkbox at the bottom of the page.

   

6. Click the Save button to complete.

Interim Orders for medication changes are generated by entering the new medication on the Med Profile and selecting the Create an interim order for the Medication checkbox.