| A | B |
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| Doctor’s orders | Directions that guide patient care, interventions, treatments, tests, medications, and activities in the hospital. |
| Order entry | The administrative process of putting doctor’s orders into action; may also be called transcribing or processing orders. |
| CPOE | Computerized provider/physician order entry; the physician enters orders directly into the computer. |
| Non-CPOE environment | A setting where orders may be handwritten or downloaded from order sets and then manually processed. |
| Admission orders | Doctor’s orders written before or at the time a patient is admitted to hospital. |
| Pre-admission orders | Orders completed before the patient is admitted, often for planned surgery or day procedures. |
| Emergentologist | The physician who commonly writes the initial orders for a patient admitted through the emergency department. |
| Most responsible physician (MRP) | The physician primarily responsible for coordinating a patient’s care and writing ongoing orders. |
| Hospitalist | A physician employed by the hospital to oversee and coordinate the care of hospitalized medical patients. |
| Intensivist | A physician who specializes in caring for critically ill patients, usually in an intensive or critical care unit. |
| When orders are commonly written | At admission, transfer, discharge, before or after surgery, during rounds, or when a patient’s condition changes. |
| Common content of doctor’s orders | Activity, diet, medications, IV therapy, nursing interventions, treatments, laboratory tests, and diagnostic tests. |
| Order set | A group of pre-established medical orders based on clinical guidelines and designed to standardize care. |
| Examples of order sets | Preoperative, postoperative, pre-admission, and diagnosis-specific order sets such as pneumonia or heart failure. |
| Flagging | A method used to indicate that a new written order is present and needs to be reviewed or processed. |
| Unsigned written order | An order that should not be transcribed; the clinical secretary should notify the patient’s nurse. |
| Duplicate orders | Repeated orders that may occur when more than one provider writes orders or when order sets overlap. |
| Clinical secretary response to duplicate orders | Do not delete them independently; notify the nurse so the situation can be clarified. |
| Stat order | An order that must be carried out immediately (Urgent medications, IV therapy, blood work, or diagnostic tests.) |
| Priority when processing orders | Stat and urgent orders are handled first, followed by the remaining orders according to urgency and patient needs. |
| First step in order entry | Identify the orders that need to be processed. |
| Second step in order entry | Review the orders for anything urgent or stat and notify the nurse as needed. |
| Third step in order entry | Process the remaining orders in order of priority. |
| Fourth step in order entry | Identify each order as completed to avoid duplication or omission. |
| Fifth step in order entry | Check your work carefully and sequentially. |
| Sixth step in order entry | Have the orders checked by the designated nurse. |
| Seventh step in order entry | Sign off according to facility policy after confirming the orders are complete. |
| Eighth step in order entry | Send medication-related orders to pharmacy when required by the facility process. |
| Ninth step in order entry | Return the pChart to its proper place and remove any order flag. |
| Why completed orders are marked | To keep track of what has been processed and prevent duplication or omission. |
| R identifier | A symbol that may indicate a requisition has been completed and sent. |
| K, C, or A identifier | A symbol that may indicate a nursing-related or direct-care order has been entered or activated on the eKardex. |
| Patient access list (PAL) | An electronic list of registered patients used by authorized staff to support workflow and access patient information. |
| Patient list/organizer | A customizable view that displays selected patient information without opening each full chart. |
| Examples of PAL information | Patient name, location, admission date, physician, allergies, diet, fall risk, VIP status, resuscitation status, and order alerts. |
| Disclosure status | Indicates whether patient information such as location or condition may be released in response to inquiries. |
| Fall risk | Identifies patients who may be at increased risk of falling because of mobility or cognitive concerns. |
| VIP status | A designation used when a patient requests additional privacy controls; any patient may request it. |
| Advance directives | Instructions about a patient’s wishes for care, including resuscitation status such as DNR. |
| Do Not Resuscitate (DNR) | a resuscitation-status order recorded under advance directives or level of intervention. |
| eKardex | A centralized patient database that provides a summary or profile of important information from the patient’s eChart. |
| Situation/background view | An eKardex view containing key current patient information, including medications and background details. |
| Assessment view | An eKardex view showing current assessments such as lab results, vital signs, and intake and output. |
| Recommendation view | An eKardex view containing the plan of care, discharge planning, and follow-up needs. |
| Activities of Daily Living (ADL) | An eKardex category that may include orders such as bathroom privileges or assistance with mobility. |
| Clinical parameters | An eKardex category that includes monitoring information such as vital signs. |
| Advance directives/level of intervention | The eKardex category where resuscitation status and related care decisions are recorded. |
| Lab and diagnostic test requisition | A request for a laboratory or diagnostic test; in many CPOE systems the doctor’s electronic order serves as the requisition. |
| Clinical secretary role with a paper requisition | Complete required administrative details, fax/send it to the appropriate destination, and scan it into the eChart if required by protocol. |
| Medication order components | Drug name, dose, frequency, route, administration times, start date, and stop date. |
| Routine or scheduled medication | A medication taken on a regular schedule at specified times. |
| PRN medication | A medication given only as needed, usually to relieve a symptom. |
| Stat medication | A medication that must be given immediately. |
| Single-dose medication | A one-time medication order; often used for preoperative or other specific one-time needs. |
| Loading dose | A higher-than-usual initial dose given to rapidly increase the therapeutic level of a medication in the bloodstream. |
| Sliding scale drug order | A medication order in which the dose is adjusted according to test results, such as blood glucose. |
| Anticoagulant | A medication that helps prevent new blood clots from forming or existing clots from progressing. |
| Anticoagulants as prophylactic medications | Anticoagulants may be ordered to prevent blood clots, such as in some postoperative patients. |
| Warfarin monitoring | INR is used to monitor the effect of warfarin. |
| Heparin monitoring | PTT or aPTT is used to monitor unfractionated heparin therapy. |
| Medication order related to lab values | An order in which medication dosing or continuation depends on laboratory results. |
| Patient’s own medications in hospital | They must be ordered by the attending provider before the patient can take them in hospital. |
| Clinical secretary response to pills at the bedside | Notify the patient’s nurse because patients should not self-medicate without an order. |
| Hospital pharmacist’s role | Processes medication orders, updates eMARs, and ensures medications are available on the unit. |
| Automated Dispensing Unit (ADU) | a computerized cabinet used to store and dispense medications. |
| Electronic Medication Administration Record (eMAR) | record used to document medication orders and administration. |
| Nothing by mouth (NPO) | the patient should not eat or drink for the specified period |
