SN Problem List Interventions In Allscripts That Initiate Orders

Transcription

1 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order General I01 DO NOT REUITATE Y General I02 Assess body systems/vital signs/complications General I03 Assess/instruct patient/caregiver on signs/symptoms of infection and infection control methods General I04 Assess/instruct patient/caregiver on signs/symptoms to report to nurse/physician General I10 Pulse Oximetry General I11 Notify MD when O2 saturation levels less than General I05 Notify physician if blood pressure is outside of the range of General I06 Notify physician if pulse is outside the range of General I07 Notify physician if respirations are outside the range of General Notify physician if temperature greater than General I09 Notify physician of the following changes in clinical findings General I12 May accept order from General I13 Administer influenza vaccine Medication Management I01 Assess/instruct patient/caregiver on medications, route, dosages, use, actions, side effects, and response to medications/side effects to report Medication Management I02 Assess/instruct patient/caregiver on administration of injectable medications Medication Management I03 Assess/instruct patient/caregiver on use of medication planner Medication Management I05 Assess/instruct patient/caregiver on use of automated medication dispenser Medication Management I07 Assess/instruct patient/caregiver on anticoagulant use/management including when/what to report to physician/nurse Medication Management I08 N to administer injectable medications Medication Management I10 Assess/instruct patient/caregiver on over the counter medications, herbal remedies, and supplement use, dosages, actions, side effects, and interactions with prescribed medications/side effects to report Lab I09 Finger stick for glucose Y Lab I01 Finger stick for PT/INR Y Lab I71 Perform Venipuncture for PT/INR if fingerstick INR is greater than 4.0 Y Lab I14 UA Y Lab I15 UA with & Y Lab I67 Vaginal Pathogen creen Y Lab I16 Wound & Y Lab I13 May draw lab from venous access device Y Lab I66 Venipuncture for 25-Hydroxy Vitamin D Level Y Lab I22 Venipuncture for Albumin Level Y Lab I24 Venipuncture for Ammonia Level Y Lab I25 Venipuncture for B12 Level Y

2 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Lab Venipuncture for BMP Y Lab I26 Venipuncture for BUN Y Lab I32 Venipuncture for reactive protein RP Y Lab I27 Venipuncture for alcium Level Y Lab I28 Venipuncture for arcinoembryonic Antigen Y Lab I05 Venipuncture for B Y Lab I70 Venipuncture for B with Differential Y Lab I29 Venipuncture for hlamydia Y Lab I04 Venipuncture for MP Y Lab I31 Venipuncture for reatinine Y Lab I20 Venipuncture for ulture Aerobic Y Lab I21 Venipuncture for ulture Anerobic Y Lab I30 Venipuncture for ytomegalovirus Y Lab I10 Venipuncture for digoxin level Y Lab I33 Venipuncture for Dilantin Level Y Lab I11 Venipuncture for electrolytes Y Lab I36 Venipuncture for Ferritin Level Y Lab I08 Venipuncture for glucose Y Lab I45 Venipuncture for Guiacic Blood Y Lab I38 Venipuncture for Hepatic Function Panel Y Lab I06 Venipuncture for Hgb / Hct Y Lab I07 Venipuncture for HgbA1 Y Lab I39 Venipuncture for HIV Y Lab I68 Venipuncture for INR Y Lab I41 Venipuncture for Lipid Panel Y Lab I43 Venipuncture for Lithium Y Lab I44 Venipuncture for Magnesium Y Lab I46 Venipuncture for Phenobarbital Y Lab I47 Venipuncture for Phosphorus Y Lab I40 Venipuncture for Potassium Y Lab I23 Venipuncture for Pre-albumin Level Y Lab I48 Venipuncture for PA Y Lab I02 Venipuncture for PT/INR Y Lab I49 Venipuncture for PTT Y Lab I50 Venipuncture for Rheumatoid Factor Y Lab I35 Venipuncture for edimentation Rate ER Y

3 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Lab I52 Venipuncture for GOT erum glutamic-oxaloacetic transaminase Y Lab I53 Venipuncture for GPT erum glutamic- pyruvic transaminase Y Lab I51 Venipuncture for ickle ell creen Y Lab I54 Venipuncture for tool ulture Y Referrals I01 PT evaluation and treatment for Referrals I02 OT evaluation and treatment for Referrals I03 T evaluation and treatment for Referrals I04 MW evaluation for Referrals I06 Dietitian/nutritionist consult for Referrals I11 ertified diabetic educator for Referrals I10 Psychiatric Nursing evaluation and treatment for Neurological I11R Perform neurological check at each visit Neurological I01R Assess/instruct patient/caregiver on neurological disease management/complications and appropriate Neurological I02 Assess/instruct patient/caregiver on signs/symptoms of aspiration and prevention measures Neurological I03 Assess swallowing ability Neurological I04 Assess/instruct patient/caregiver on seizure activity and appropriate actions Neurological I05 Assess/instruct patient/caregiver on short-term memory deficits, progressive nature of disease, depression symptoms, reaction to environmental stimuli, and aggressive/abusive behavior Neurological I09 Assess/instruct patient/caregiver on restricted activities Y Respiratory I01R Assess/instruct patient/caregiver on respiratory disease management/complications and appropriate Respiratory I06 Assess/instruct patient/caregiver on oxygen use/safety Respiratory I08 Assess/instruct patient/caregiver on use of inhalers/nebulizers/incentive spirometry Respiratory I09 Assess/instruct patient/caregiver on use of Positive Pressure Breathing equipment Respiratory I10 Assess/instruct patient/caregiver on respiratory treatments and assess response Respiratory I11 Assess/instruct patient/caregiver on pursed lip breathing Respiratory I12 Assess/instruct patient/caregiver on chest physiotherapy-postural drainage/cupping/percussion Respiratory I13 Assess/instruct patient/caregiver on trach/laryngectomy care Respiratory I14 Provide Trach are Respiratory I16 Assess/instruct patient/caregiver on care/maintenance of pleural catheter Respiratory I17 Provide pleural catheter care Respiratory I18 Asses/instruct patient.caregiver on diaphragmatic breathing ardiovascular HF I01R Assess/instruct patient/caregiver on cardiovascular disease management/complications and appropriate

4 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order ardiovascular HF I02 Assess/instruct patient/caregiver on cause of HF, common symptoms and potential complications ardiovascular HF I03 Assess cardiovascular status/identify complications ardiovascular HF I04 Assess/instruct patient/caregiver on taking/recording pulse ardiovascular HF I05 Assess weight every visit ardiovascular HF I06 Assess/instruct patient/caregiver on recording daily weights ardiovascular HF I07 Assess/instruct patient/caregiver on diet and fluid restrictions ardiovascular HF I08 Assess for orthostatic hypotension ardiovascular HF I09 Apply anti-embolytic hose/instruct patient/caregiver on use ardiovascular HF I11 Assess/instruct patient/caregiver on energy conservation/cardiac rehab activities/restrictions ardiovascular HF I12 Assess/instruct patient/caregiver on measures to avoid exacerbation of cardiovascular symptoms ardiovascular HF I25 Assess/instruct patient/caregiver on oxygen use and safety precautions ardiovascular HF I26 Assess/instruct patient/caregiver on proper surgical wound care ardiovascular HF I27 Assess surgical wound location, size, drainage, wound bed and periwound care ardiovascular HF I32 Patient/caregiver unable to perform surgical wound care due to ardiovascular HF I33 N to perform surgical wound care at nursing visits and patient/caregiver to perform in absence of nurse ardiovascular HF I34 Perform Incision care ardiovascular HF I35 Perform suture removal ardiovascular HF I36 Perform staple removal and apply steri strips ardiovascular HF I37, I38, I39 Wound are Y ardiovascular HF I40 Assess/instruct patient/caregiver on cardiac medications, route, dosages, use, actions, side effects, and response to medications/side effects to report ardiovascular HF I43 Assess/instruct patient/caregiver on anticoagulant use/management including when/what to report to physician/nurse ardiovascular HF I47 Perform PT/INR as ordered Y ardiovascular HF I49 Perform phone calls to patient/caregiver to assess compliance with treatment plan ardiovascular HF I51 Instruct patient on use of HELP unit ardiovascular HF I52 Perform programming of HELP unit reminder prompts ardiovascular HF Perform and monitor Oxygen saturation levels. Notify MD of level less than Y ardiovascular HF Perform percussion and postural drainage on patient OPD I01 Assess/instruct patient/caregiver on respiratory disease management/complications and appropriate OPD I04 Assess/instruct patient/caregiver on oxygen use/safety/storage. ee medication list for O2 OPD I06 Assess/instruct patient/caregiver on use of inhalers/nebulizers/incentive spirometry OPD I07 Assess/instruct patient/caregiver on respiratory treatments and assess response OPD I08 Assess/instruct patient/caregiver on pursed lip breathing and diaphragmatic breathing

5 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order OPD I11 Assess/instruct patient/caregiver on taking/recording pulse OPD I12 Assess weight, weight diary, intake and symptom log at each visit OPD I13 Assess/instruct patient/caregiver on proper technique for weighing and recording daily weights OPD I15 Assess/instruct patient/caregiver on energy conservation/cardiac rehab activities/restrictions OPD I16 Assess/instruct patient/caregiver on measures to avoid exacerbation of cardiovascular symptoms OPD Assess/instruct patient/caregiver on oxygen use and safety precautions OPD I24 Perform phone calls to patient/caregiver to assess compliance with treatment plan OPD I25 Instruct patient on use of HELP unit OPD I26 Perform programming of HELP unit reminder prompts OPD I27 Perform and monitor Oxygen saturation levels. Notify MD of level less than Y OPD I28 Assess/instruct patient/caregiver to report changes in sputum color, consistency, amount OPD I29 Assess/instruct patient/caregiver to report increased OB, increased/change in cough, wheezing/rhonchi OPD I30 Assess/instruct patient/caregiver on importance of adequate fluid intake to thin secretions, decrease fluid in lungs Gastrointestinal I01R Assess/instruct patient/caregiver on gastrointestinal disease management/complications and appropriate Gastrointestinal I04 Assess for impaction/remove impaction if present Gastrointestinal I06 Assess/instruct patient/caregiver on increased fiber, fluids, fruit in diet, and foods/fluids to avoid Gastrointestinal I08 Assess/instruct patient/caregiver on bowel regimen Gastrointestinal I09 Assess/instruct patient/caregiver on suppository administration, stool softeners, enemas, and anti-emetics. ee Medication Profile. Gastrointestinal I10 Assess/instruct patient/caregiver on recording intake & output, noting frequency, color, consistency, amount, mucous, and bleeding Gastrostomy-Enteral I01R Instruct patient/caregiver on enteral feeding management/equipment, complications and appropriate Gastrostomy-Enteral I03 Instruct patient/caregiver on checking for placement/patency of tube Gastrostomy-Enteral I04 Assess skin integrity around stoma. Instruct patient/caregiver on site care Gastrostomy-Enteral I30 leanse feeding tube insertion site with: Gastrostomy-Enteral I31 Apply dry dressing: Gastrostomy-Enteral I08 Instruct patient/caregiver to report signs/symptoms of enteral feeding complications to nurse/physician Gastrostomy-Enteral I10 hange feeding tube Gastrostomy-Enteral I11 Discontinue feeding tube Gastrostomy-Enteral I12 Gravity feed Gastrostomy-Enteral I13 Type Gastrostomy-Enteral I14 Amount Gastrostomy-Enteral I15 Frequency

6 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Gastrostomy-Enteral I16 Water Flush Gastrostomy-Enteral I17 Hold feedings for residual greater than Gastrostomy-Enteral I20 Pump feed Gastrostomy-Enteral I21 Type Gastrostomy-Enteral I22 Rate Gastrostomy-Enteral I23 Frequency Gastrostomy-Enteral I24 Water Flush Gastrostomy-Enteral I25 Tubing hange Frequency kin I01 Assess/instruct patient/caregiver on precipitating factors leading to skin impairment kin I02 Assess/instruct patient/caregiver on methods to prevent pressure ulcers kin I03 Instruct patient/caregiver on adequate nutrition for prevention of skin breakdown kin I05 Instruct patient/caregiver on pressure relief/shearing reduction measures kin I06 Instruct patient/caregiver on use of pressure relieving devices Wound I01 Assess/instruct patient/caregiver on proper wound care Wound I02 Assess wound location, size, stage, drainage, wound bed and periwound care Wound I04 Assess/instruct patient/caregiver on risk factors causing skin breakdown Wound I05 Instruct patient/caregiver on measures to promote wound healing Wound I08 Patient/caregiver unable to perform wound care due to Wound I09 N to perform wound care at nursing visits and patient/caregiver to perform in absence of nurse Wound I10 Perform Incision care Y Wound I30 Perform suture removal Y Wound I31 Perform staple removal and apply steri strips Y Wound I25 Drain are Y Wound I26 Drainage system Location/type: Y Wound I28 Drainage system evacuation amount not to exceed Y Wound I27 Drainage system sterile dressing change at each fluid evacuation to include clean with alcohol, apply foam, cover with gauze dressing, sterile cap change, cover with transparent dressing and apply new clamp Wound I29 ompression therapy for venous stasis ulcers to include Y Wound I15 Wound are Y Wound I16 Wound are Y Wound I17 Wound are Y Wound I18 Wound are Y Wound I19 Wound are Y Wound I20 Wound are Y Wound I21 Wound are Y Y

7 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Wound I22 Wound are Y Wound I23 Wound are Y Wound I24 Wound are Y Neg. Pressure Wound I01 Assess wound for response to therapy, complications Neg. Pressure Wound I06 hange wound negative pressure wound therapy dressing 3 times/week and PRN negative pressure wound Y therapy/dressing problems. Location/type: Neg. Pressure Wound I07 Therapy setting: continuous Y Neg. Pressure Wound I08 Therapy setting: Intermittent Y Neg. Pressure Wound I09 Negative Pressure etting (mmhg.) Y Neg. Pressure Wound I10 lean with: Y Neg. Pressure Wound I11 Analgesia (prior to dressing change) Y Neg. Pressure Wound I12 kin barrier to periwound: Y Neg. Pressure Wound I14 Foam election: Y Neg. Pressure Wound I15 ontact layer: Y Neg. Pressure Wound Drape Y Neg. Pressure Wound I17 Bridge to Y Neg. Pressure Wound I13 Gauze Y Neg. Pressure Wound I22 hange wound negative pressure wound therapy dressing Frequency/Location/type: Y Neg. Pressure Wound I19 Teach negative pressure wound therapy maintenance: monitoring alarms, changing drainage canister, repair of air leaks. Neg. Pressure Wound I20 Perform/instruct on applying saline moistened gauze dressing when Negative Pressure Wound Therapy is interrupted for more than 2 hours Neg. Pressure Wound I21 Other Y Ostomy I01R Assess/instruct patient/caregiver on ostomy care management/complications and appropriate Ostomy I02 Assess gastrointestinal status/identify complications Ostomy I03 Assess skin integrity around stoma/instruct on site care Ostomy I04 Perform/instruct patient/caregiver on care of ostomy/change of bags/stoma care Ostomy I07 Instruct patient/caregiver on colostomy irrigations Ostomy I09 Instruct patient/caregiver on nutritional/hydration needs of ostomate Ostomy I10 Instruct patient/caregiver on avoiding gas producing foods Ostomy I11 Refer to WON Urinary I01R Assess/instruct patient/caregiver on urological disease management/complications and appropriate Urinary I02 Assess/instruct patient/caregiver on renal disease management/complications and appropriate

8 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Urinary I04 Assess/instruct patient/caregiver on reporting bladder spasms, frequency, hesitancy, force of flow, urgency, color, pain, odor, and burning to N/MD Urinary I05 Assess/instruct patient/caregiver on catheter care Urinary I07 Assess/instruct patient/caregiver on use of condom catheter (size) Y Urinary I08 Assess/instruct patient/caregiver on intermittent catheterization Y Urinary I09 Assess/instruct patient on self catheterization (frequency) Y Urinary I10 Insert catheter/change (specify cath/balloon size, type, and frequency) Y Urinary I11 Bladder training Urinary I12 Irrigate catheter with ml Normal aline PRN Y Urinary I13 Irrigate catheter with Y Urinary I15 Perform/instruct patient/caregiver on care of urostomy/change of appliance/stoma care Y Urinary I16 Perfom/assess/instruct patient/caregiver on nephrostomy tube site care: Y Urinary I17 Instruct patient/caregiver on proper handling/maintenance of catheter drain bag Musculoskeletal I01R Assess/instruct patient/caregiver on musculoskeletal disease management/complications and appropriate Musculoskeletal I09 Assess/instruct patient/caregiver on cast care Musculoskeletal I10 Assess circulation/movement/sensation Musculoskeletal I11 Assess/instruct patient/caregiver on anticoagulation administration, precautions and need for compliance afety I01 Assess fall risk and instruct patient/caregiver on fall and safety precautions afety I02 Assess/instruct patient/caregiver regarding safety of home environment/potential hazards and removal of hazards afety Instruct patient/caregiver on fall and safety precautions Nutrition I01 Assess nutritional status Nutrition I02 hange diet to Nutrition I03 Assess/instruct patient/caregiver on nutritional requirements/prescribed diet Nutrition I09 Assess/instruct patient/caregiver on use of dietary supplements Pain I01 Assess level of comfort/discomfort and identify comfort goal Pain I02 Assess location, intensity, duration, precipitating factors, and characteristics of pain Pain I03 Assess effectiveness of to mitigate pain Pain I04 Assess/instruct patient/caregiver on nonpharmacological methods of pain control Pain I05 Assess/instruct patient/caregiver on pain medication administration, actions, and side effects Pain I09 Instruct patient/caregiver on imagery, relaxation and distraction techniques Pain I11 Assess if bowel regimen is in place if patient taking opiod medications Diabetes-Metabolic I01R Assess/instruct patient/caregiver on diabetes management/complications and appropriate Diabetes-Metabolic I02 Assess/instruct patient/caregiver on metabolic disease management/complications and appropriate

9 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Diabetes-Metabolic I03 Assess/instruct patient/caregiver on signs/symptoms of hypoglycemia/hyperglycemia, causes, and treatment Diabetes-Metabolic I04 Assess/instruct patient/caregiver on prescribed diet, necessity of consistent meals, snacks, and sources of protein Diabetes-Metabolic I06 Assess/instruct patient/caregiver on use of blood glucose monitor, frequency, recording results, and management of equipment Diabetes-Metabolic I07 Report blood glucose reading to physician if outside the ordered parameter of Diabetes-Metabolic I08 Assess/instruct patient/caregiver on insulin Prep and storage/rotation of sites/administration/sliding scale/sharps management and disposal Diabetes-Metabolic I09 Assess/instruct patient/caregiver on proper diabetic foot, nail care and footwear Diabetes-Metabolic I10 Report blood glucose reading to physician if outside the range of mg/dl before meals Diabetes-Metabolic I11 Patient/caregiver verbalize understanding of importance of exercise Diabetes-Metabolic I12 Assess/instruct patient/caregiver on signs/symptoms of impaired circulation/neuropathic changes Diabetes-Metabolic I14 Assess/instruct patient/caregiver on care and management of insulin pump and needle changes Diabetes-Metabolic I15 Assess/instruct patient/caregiver on use/maintenance/care/storage of insulin pen Psychosocial I15 Assess/monitor patient's psychotropic medication compliance, effectiveness, and side effects Psychosocial I03 Assess psychosocial needs, implications Psychosocial I04 Assess mental/emotional status Psychosocial I07 Instruct patient/caregiver on options for life style changes Psychosocial I08 Identify/instruct patient/caregiver on problem solving skills Psychosocial Assess/instruct patient/caregiver on signs/symptoms of depression, disease progression, complications and what to report Psychosocial I24 Monitor effectiveness of for depression Psychosocial I25 Monitor effectiveness of for anxiety Psychosocial I06 Instruct patient/caregiver on relaxation and diversionary techniques Psychosocial I01 Assess/instruct patient/caregiver on signs/symptoms of dementia, disease progression, complications and what to report Psychosocial I02 Monitor effectiveness of for dementia Psychosocial I22 Assist/instruct patient/caregiver on home modifications to provide home safety and optimal function Infusion Therapy I01 Assess/instruct patient/caregiver on signs/symptoms of complications of infusion therapy Infusion Therapy I02 Administer parenteral nutrition. Include flow rate, bolus/pump; yclic or ontinuous. ee medication list Infusion Therapy I03 Assess/instruct patient/caregiver on administration of Parenteral Nutrition Infusion Therapy I04 Administer IV solutions/medications. ee medication list Infusion Therapy I05 Assess/instruct patient/caregiver on administration of IV solutions/medications Infusion Therapy I06 Instruct patient/caregiver on IV line maintenance/flush Infusion Therapy I07 hange IV tubing every 3 days

10 N Problem List Interventions In Allscripts That Initiate Orders Y- tart and top Order - ertification/ Recertification - tart upplemental Problem odes Intervention Order Infusion Therapy I08 Patient/caregiver unable to perform IV care due to Infusion Therapy I09 Discontinue infusion therapy Infusion Therapy I10 Discontinue infusion therapy access Infusion Therapy I13 Perform peripheral infusion site care: rotate site every 3 days and as needed for signs/symptoms infection/inflitration. Infusion Therapy I14 Maintain current peripheral infusion site unless infiltrates. Infusion Therapy Perform infusion site care Infusion Therapy I16 Assess/instruct patient/caregiver on infusion site care and precautions Infusion Therapy I19 Instruct in safe disposal of needles/sharps in home Infusion Therapy I20 Assess/instruct patient/caregiver on care of saline/heparin lock for intermittent infusion therapy Infusion Therapy I21 Assess/Instruct patient/caregiver on signs/symptoms of infection/infiltration and emergency procedures. Infusion Therapy I22 Instruct patient/caregiver on tapering/titration of TPN solutions when starting and discontinuing if not on continuous infusion. Infusion Therapy I23 Assess/instruct patient/caregiver on use of PA pump for pain management Infusion Therapy I24 Restart subcutaneous needle every 3-5 days, as needed and for signs/symptoms of infection. Infusion Therapy I25 Venous Access Dressing hange every 7 days if using transparent dressing; every 48 hours if using gauze dressing. Infusion Therapy I26 hange Huber needle using sterile technique every 7 days. Y Infusion Therapy I27 hange injection cap every 7 days, when leaking and after blood draw. Y Infusion Therapy I28 Access Port and flush port(s) after every medication infusion and every 30 days when the port is not used for Y meds. ee Medication List Infusion Therapy I29 Perform PI line site care: using sterile technique, cleanse with chlorhexidine scrub, apply transparent, occlussive dressing with no gauze weekly and as needed for loosening or soiling. Y Infusion Therapy I30 hange PI line cap every 7 days, as needed and after each blood draw. Y Infusion Therapy I31 hange PI line dressing change 24 hours after insertion and then weekly. Y Infusion Therapy I32 Apply lock to infusion device. Infusion Therapy I33 Assess/instruct patient/caregiver on care of infusion lock Y Resumption of are I01 Resume home care services per previous plan of care with changes as identified with these orders Discharge I01 Discharge from skilled nursing services Discharge I02 Discharge from home health services