ORCHID ED Provider Quick Reference
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Table of Contents
Getting Started
Checking in
Signing up for a patient
Starting a note
Incomplete notes
Attending notes
Patient Care
Placing Orders
Order sets
Patient Weight or Vital Signs
Checking on order status and viewing labs / images
Marking critical/abnormal result as reviewed
ECG viewing
Procedures
Ultrasounds
ED prelim wet reads
Consults
Blood Transfusions
Finishing Notes / End of shift
Signing Notes and Requesting Co-Signature
Pickups and Follows
Medical Student Notes
NP cases
Admissions
Requesting Interqual
Running the admission
Inpatient team places admit orders
Holding Orders
Checking for old MRN
Checking for PMD, Family medicine
Observation and CORE
Discharges
Running the Discharge
Printing Spanish Discharge Instructions
Writing Prescriptions and Medication Reconciliation
Follow up appointments
72 hour treadmill stress test
Work/School Notes
Printing Lab Results
Transfers
Resident running the board
Adding new/clinic patients to the board
Physician Ambulance Triage Note
RIPT Note
Calls from the lab, radiology
Pediatric ED specific issues
Customization
Personal Macros
Personal Autotext
Favorite Printers
Outpatient prescription favorite folder
Favorite Order Folder
Adding Common Orders to Your Favorite Folders
Creating Favorite Order Sets
Accessing Your Favorite Folders
Default Note Types
MSE
Miscellaneous Tips:
Ordering a blood gas
Ordering drips
Ordering medications, use generic names
Getting your prescriber information into ORCHID
Selecting a patient’s encounter
Continuing a 5150 order
Patient List for Follow Ups
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Orchid ED Provider Quick Reference Guide
Last updated awu 11-17-14
Getting Started
Checking in
The system should prompt you to go straight to the check in screen. If not, do so by clicking the icon of the white man with a green check mark on him. Use your last name as the “display name”. Choose a color to express your flare, sass, or general mood. Choose a “Provider Role” and “Default Relation”. Be sure that you checked “Available Provider” and “Available Reviewer”. In the display name, put your last name, and the VOIP phone you will be carrying for your shift.
Viewing “The Board”
Click the “HAR Provider” tab. “HAR All Beds – Provider” is the same but also shows empty beds. You can filter the list in much the same way you could in Wellsoft.
Signing up for a patient
Click once on the patient. Then click the icon of the white man. Your name will appear in the ATT column if you chose Attending as your Provider Role at check-in. They will appear in the RES column if you chose resident or NP.
Starting a note
Click “Provider Notes” from the tracking list then “+ Add” in the Provider Notes band. Until a provider starts a note there will be a red clipboard in the “Note” column of the tracking list.To choose a template, it’s easier to search in the “Reason For Visit” tab. If the nurses put in a reason for visit, a template may be suggested for you. If you would like a different template, you can search by system or free text search.
Remember you also need to do an MSE note for all patients! If the M icon is still showing on the Events column, then click on the MSE button on the toolbar to complete an MSE note.
Incomplete notes
As long as the patient is on the tracking board, you will see a yellow clipboard in the “Note” column to let you know your note is saved but not signed. Unlike Wellsoft, patients can be removed from the board before you finish/sign your note. In this case, incomplete notes will show up in the Message Center.
Attending notes
There are several pre-loaded templates already in place
.edteachsawnotedone
ED Attending Supervisory Note (acceptable for Medicare billing)
I have seen and evaluated the patient. I reviewed and agree with _ the resident/PA/NP’s note.
.edteachsawnonote
ED Attending Supervisory Note(acceptable for Medicare billing)
I have seen and evaluated the patient. I have discussed the case with the _ resident/PA/NP and agree with the assessment and plan.
.edteachdiscussed (Not be acceptable for Medicare billing)
ED Attending Supervisory Note
I discussed the case with the resident. I reviewed and agree with the _ resident/PA/NP’s documentation.
.edteachreviewed(This would only be used for patients discharged from the PEDS ED without attending involvement until morning rounds, or with 2nd attending).
ED Attending Supervisory Note
I reviewed and agree with the resident/PA/NP’s documentation.
Patient Care
Placing Orders
Quick Orders page: From the orders tab, click as many of the quick orders as you want or search for your order manually. When you are finished, click the green folder in the top right. Click “Sign”.
Searching/Adding a new order: Within the Quick Orders page, you can search for an order in the “New Order Entry” area.
Order Sets: Many order sets are on the Order Sets section of the Quick Orders. Additional ones can be find by searching in the “New Order Entry” area.
Tip: Use the ED Trauma order set to place the many orders on critical trauma patients quickly. Blood Transfusion order set is available from within the ED Trauma order set as well.
Tip: -If you order multiple radiology studies, you can fill in the same order details for all studies by shift-selecting on all the orders after you go to modify them.
Order sets
Order sets can be found in either the search for new order or in the Quick Orders page, there is a folder for order sets. They are organized by chief complaint/diagnosis vs procedure oriented order sets. Click on the order set you would like to use. Inside the order set, you can select the orders you would like to initiate. Some order sets have subphases, which include commonly bundled orders, for example “ED Peripheral IV Insertion Subphase” which orders a peripheral IV insertion and saline lock.
Click on “Initiate” and “Orders For Signature” to review the selected orders, then click sign.
While inside an order set, after checking the items you would like to order, you have the option to “Save As Favorite” at the bottom of the screen. Doing so will save this order set in your Favorites area. (See separate section on creating favorite orders.)
Patient Weight or Vital Signs
You can do this from the “Provider Forms” menu.
Choose “Vital Signs”. The powerform has two bands, one for Vital Signs and the other for Height/Weight. Enter the weight in the “Dosing Weight” field, as it is the only field which displays in the banner bar or is connected with drug dose calculations.
***Be aware that there is no maximum dose checking in ORCHID, so you will need to know the normal adult dose and not exceed it for larger children.
Checking on order status and viewing labs / images
Go to the tracking list and click the refresh button in the top right. In the Lab column, 3/0 means three labs ordered, 0 resulted. In the rad column, 1/0/0 means 1 study ordered, 0 completed, 0 reported.
There are two ways to view the results on your patient. Highlight your patient, double click on the lab or rad column from the tracking list, or going to the ED Summary Page when you open the chart. To change the date range of the listed results, right click the grey date banner bar at the top. Then change the range to your desired dates by selecting “change the search criteria…”.
To view the images in Synapse, select the image you would like to view. Then on the upper right tool bar there is picture icon called “view image” which will link you to Synapse.
Marking critical/abnormal result as reviewed
A red star on the tracking list indicates a critical lab or vital sign.It is very important that these are marked as reviewed.Leaving the tracking list littered with red stars is a patient safety risk, as it obscures the arrival of the next critical value. Marking the result as reviewed clears the star for everyone, so each team should designate who should be responsible for clearing the star (generally the senior resident on the case).
-When signing in the for the day, be sure “Available Reviewer” is selected.
Reviewing
-Double-click on the vital sign or the lab results column.
-Choose the Quick View tab.
-Look for the critical value in RED.
-Click “Review” and “Close”.
ECG viewing
If a patient had an ECG performed, double click the ECG column from the tracking list to view the ECG. If the patient had an old ECG in ORCHID, then you can view it by going to Flowsheet in the patient’s chart.
Procedures
Two steps:
1.Order: In the Quick Orders page, order the procedure (necessary so that the procedure is auditable, and the coders know a procedure was done). There are also some order sets for procedures that may be useful to you.
2.Documentation: Click “Provider Forms” from the tracking board toolbar. Select “ED Procedures,” which will start a note. For central lines, select “Central Line Insertion (CLIP)”. Select the note for the procedure being performed. At the bottom on the form, select the performing provider, supervising provider, and attending provider. Do not use the procedure documentation tool that is within the ED Powernote Provider Note.
Ultrasounds
Like procedures, two steps (order and documentation):
- In the Quick Orders page, order the “ED ultrasound by clinician”, then sign the order (necessary in order to have ultrasounds be auditable).
- Click “Provider Forms” from the tracking board toolbar, select “ED Ultrasounds.” Choose the type of ultrasound performed. Fill out the necessary information. Don’t forget to mark who performed, supervised, etc. at the bottom of the note. To sign, click the check mark at the top left.
ED prelim wet reads
1.Once a radiology order has been completed, the Radiology Order/Activity Count column, labeled “Rad” will show a clipboard icon.
2.Inthepatient'sTrackingListrow,right-clicktheRadiologyOrder/ActivityCountcolumn.TheOrderInformationdialogboxisdisplayed.
3.IfaradiologytesthasaDepartmentStatusorOrderStatusofCompleted,+Add isdisplayedundertheWetReadcolumnintheOrderInformationdialog box.
4.Click+Add.TheWetReaddialogboxisdisplayed.
5.Selectapositiveornegativeinterpretationofthex-ray.
a)Ifyouwanttomakeapredefinedinterpretationofthex-ray,makeaselectionfromthePredefinedInterpretationlist.
b)Ifyouwanttoenterafree-textinterpretationofthex-ray,enterthetextinthebox.
6.ClickOK.AredexclamationmarkisdisplayedundertheWetReadcolumn.Thisindicatesthatawetreadexists.Tovieworaddanotherwetread,clicktheexclamationmark.PreviouscommentsaredisplayedinthePreviousCommentsbox.
Additionally,awetreadcommentcanbeenteredfromPowerNote ED.
CompletethefollowingstepstoenterawetreadcommentfromPowerNoteED:
1.FromPowerNoteED,clickLaunch WetReadintheRadiologyResultssectionoftheMedicalDecisionMakingencounterpathway.
2.EnterthewetreadinformationandclickSave.WetReadtextispulledbackintothenote.
Consults
In the Quick Orders page, go to the “Other,” then the “Consults” subfolder. Choose the consult order, then sign the order. This will generate an icon for the consult on the tracking board. You will also need to separately page the consultant. (FirstNet does not have paging capabilities yet…).
Blood Transfusions
Blood transfusion consentsare now in iMed Consent. Log in to iMed Consent. Search for “Transfusion” via the “Search” field at the top. Double click on “Blood Transfusion”. Choose “LADHS English Consent WITH Blood”. It may list “Cardiac Surgery” next to it as the specialty. That is fine, as the consent is just for blood. Click OK.
How to Order Blood Transfusions:
1)Search for the appropriate ‘Blood Transfusion Order Set.’
2)Select which orders you would like. Right click on orders that have a blue X, then choose Modify to fill out the required details.
TIP: Be sure to click “Initiate” then “Orders For Signature.”
FYI - There is NO TYPE & CROSS order anymore! If there is not a T&S already done, the order set will automatically prompt you to order one. Be sure to choose Continue & STAT!
3)Remind the nurse that they will need to order the “Pick Up Slip” from the Quick Orders Page under “Nurse Triage Protocol Orders” when the blood product is ready. This slip will automatically print out for them to bring to the Blood Bank.
Finishing Notes / End of shift
Signing Notes and Requesting Co-Signature
Interns: Once you have completed your provider note, “forward” it to the senior resident to sign.
Residents: Once you have completed your provider note, click on “Sign/Submit.” A new window will pop up. Click on “Request endorsement.” Then click inside the yellow area under “Endorser” and click the binoculars icon to search for the attending you would like to co-sign your chart. Click OK. Under “Type” make sure that “sign” is selected (not reviewed). Then click sign to close the window.
Attendings and Residents supervising notes: In “Message Center” you can view the notes needing your signature in the “Documents.” Choose the “Correct” icon to change a note and write an addendum. If you want to write a separate note before the intern/resident has completed their note, you can do so using the “Note” function (rather than Provider Note).
Selecting the Correct Attending to Sign:
1. With few exceptions, you should select the attending who is on the same shift with you. For Peds overnight, select the Peds attending coming on in the AM, unless you presented the patient to an AAED attending overnight. Do not select more than one attending without discussing it with your attending.
Pickups and Follows
2. For patients signed out at rounds and not discharged by previous team: Oncoming resident should write a brief note using the Notes functionality (not Provider Notes) subject “ED Signout Note”. This should contain, at a minimum:
a. Acute problem list
b. Plan from rounds for each acute problem (whether changed or not)
This addendum will be signed by the second attending coming on shift with you.
3. On the less common occasion that you present a case to the attending on the shift before or after you – ask them if you can assign them to sign your note, (E.g. for patients seen near the end of shift that were not staffed with the attending on your shift).
4. On days where attending and resident shifts are different (12 hour coverage for ACEP, etc) – assign the attending you presented the case to initially. Sign-outs should get the same addendum by the oncoming resident as for regular shifts.
Medical Student Notes
Medical Students will document with the same reason for visit templates or brief notes as residents. When completed, the student will save their note (not sign). They will then forward it to the resident with whom they worked for signature. The resident will correct / or modify (addend) as necessary, sign, and send to the attending to sign.
NP cases
If a NP staffs a case with an attending physician, the workflow will be same as for resident cases. The NP will sign their note and send to the attending to co-sign. The attending should co-sign the note before the patient is discharged from the ED. The attending will place his or her name in the attending column and write an ED Attending Supervisory Note. If the NP dispositions a patient independently, he or she will leave the Attending column blank and will not request a cosignature on their note.
Admissions
Requesting Interqual
From the tracking board, click “Events”, “Request Event”, “Interqual Request”. An orange “REQ” icon will appear in the ADT column. This will change to yellow “IP” when it is in progress, and then green “MET” if approved or red “DEN” if denied.
Attending Admit Notes
In the Notes function, add a new note, subject as ED Attending Admission Note, using the autotext below.
.edattadmit
ED Attending Admission Note
Reason for admission: _
Admit team: _
Level of care: _
Attending Override Notes
Documented in a brief ED Note, titled “Interqual Override”.
Running the admission
Multi-Step process:
- From the tracking list, click “Admit/Discharge”. Click the pencil next to “Diagnosis”. Click the blue “+ Add” in the upper half of the window “Diagnosis (Problem) being Addressed this Visit”. Search for and select the main diagnosis then click “OK”. You must then click “OK” again. Then click close. If you did it correctly, you will see your diagnosis under the corresponding band on the left.
- From the tracking list, go to “Place Orders”. Click “Request For Admit” in the “Top Other” Section. Click the green folder and click “Modify”. Fill in the bed type, service, and admitting MDs. In the “special instructions” area put in the name and contact info for the admitting team. Click Sign.
The ED order"Request for Admit" will trigger Bed Control to change the patient from an Emergency Patient to an Inpatient and moves the patient into a Virtual ED bed, indicated on the track with an "A" next to the room number. Bed Control will also switch the ED attendings name to the Inpatient attending's name on the banner bar.
Once the patient is in a virtual bed, the inpatient teams will use "Admit to Inpatient" in their admit orders, which allows the patient to physically leave the ED.
There are 4 Bed Types: Medical/Surgical Unit = Ward; Telemetry; Stepdown/PCU, and ICU.
The inpatient teams will assign themselves to the patient in the "Primary Contact" on the banner bar. For now only names will be listed, and staff will need to go to Amion.com to search for the pager numbers. In the future, pager numbers will be incorporated into this field. They are also writing "communication orders" to list their contact info as well.