order sets

Unknown
edited May 2016 in CDI Talk Archive
Hi - I need some quick advice. I was just introduced to "Provation Order Sets" - evidence-based orders sets which are customized for the organization. Our organization has been working on this project for quite some time and ready to start rolling them out. We are still a hybrid medical record moving to an EHR within the year. These order sets will also be incorporated in the EHR.

My first reaction is what a great opportunity to slip in some documentation specificity e.g. for CHF - check boxes for our classic systolic, diastolic, acute, chronic etc. HCAP - possible/probable organism with a fill-in-the-blank. My concern - if it sounds too good to be true... it probably is!!!

Is anyone else using Provation or similar product? Any advice if it is worth pursuing incorporating some documentation improvement or is there a drawback I am not recognizing??

Thank you, I always appreciate learning from my colleagues.


Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com



Comments

  • vdavis2vdavis2
    edited May 2016
    I like it... I don't think it is any different than giving the docs a list of diagnoses to pull from when checking off chronic conditions in an electronic progress note template. The MD would be the one "diagnosing" the condition or the order set would not have come into play. J V


    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

  • sharon.colesharon.cole
    edited May 2016
    When we first started doing Aquapheresis, we created an order set and I made sure all the options for CHF were listed as possible diagnoses. It worked well.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • donna.kentdonna.kent
    edited May 2016
    We now have CPOE. I worked on the steering committee for that and,
    contrary to physicians' desires, was able to get a number of diagnoses
    placed. Right now our coding department is only using it for OP.
    Mainly because no-one had alerted the coding staff that they had access
    to these diagnoses in Power Chart. Now they know and the coding manager
    will update the coders.
    Donna

    Donna Kent, RN, BSN, CCDS
    Manager, Clinical Documentation Integrity Program
    Clinical Quality and Accreditation
    Torrance Memorial Medical Center
    ph.:310 784-6884 fax:310 784-6899
    donna.kent@tmmc.com
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