Placing orders

General principles

  • Most lab tests can be done on the first floor (no lab slip needed, it’s all electronic).
  • Some are done in the clinic (eg urine dip, urine pregnancy test).
  • Most x-rays and some CT/US can be done same day (2nd floor radiology).
  • X-rays can usually be done as a walk-in, other imaging needs to be scheduled (give your patient the number for radiology so that they can call and schedule, or if you are worried about their ability to schedule, put on the red light and your MA can help the patient).

Special Lab tests

Add on labs (to a prior blood draw) “LADDON” and free text the lab, select your name from the provider list, your contact number in case it cannot be added. For micro: “MADDON”
ANA reflexive panel
  • Meds & Orders: “ANA” or find it in the Browse section of Meds & Orders. This lab panel (ANARC) includes:
    • Initial screen includes ANA screen by IFA and by multiplex. The multiplex screen detects the following antibodies: anti chromatin, ribosomal P, Sm, Sm/RNP, RNP, SSA/Ro, SSB/La, Centromere B, Scl70, and Jo1.
    • If either screening test is positive, identification panel ANARC2 will be performed at an additional charge.
Cort stim:
  • Let your team RN know; he/she will arrange with the patient—usually best to pick the dat ahead of time (makes the lab and med orders easier)-order cortisol twice (at 0 and 60 minutes) – can future order it for the day the test will be done
  • order cosyntropin injection (250 mcg IM x 1):
  • Meds & Orders: “cosyntropin” and you should see the order with the bed icon on the left and “FAM”, which stands for Facility Administered Medication”. Select “intramuscular”. Choose the date (easier if you know this ahead of time).
Celiac testing
  • Meds & orders: “Celiac”> Celiac serology reflexive panel (Lab code CELRP). Components:
    • Anti Tissue Transglutaminase, IgA (ATTGA)
    • Anti Deamidated Gliadin, IgG (ADGPG)
    • Reflex testing (anti endomysial [CELRP1] . . . or IgA level [CELRP3] . . . ) with additional charges, will be ordered as indicated based on the results of the IgA anti tTG and the IgG anti-DGP.
    • Note the deamidated gliadin is a newer generation test, better than the older gliadin test which is no longer used.
    • If the Anti-deamidated gliadin is positive but the anti-TTG IgA is negative, they will check the total IgA level, as it might be low.
Stat basic panel Meds & Orders: Search for “R2 BMP w/ICA (STAT ONLY)”
Stool test for colorectal cancer screening Meds & Orders: “FIT” or “FOBT” will default to “SFOBG” which is Fecal Immunochemical Test (FIT). Red light in exam room and the MA will give the patient the kit with instructions.

Cardiology Orders

Cardiac stress test: Meds & Orders > “Cardiac stress test” > select “Referral to Cardiac Stress Test”. You will have the option to order a Treadmill-ECG, Treadmill-perfusion, Treadmill-EchoPharmacologic stress perfusion, pharmacologic stress echo
Event monitor / holter monitor: Meds & Orders: type “Holter” or “Event Monitor” or “ECAT” and you should select the one with CAR0001 or CAR0002 or CAR0003 codes.  (Do NOT select the external referral to ECG services).  This will bring up a clarification screen and you should choose one of:

  • “Referral for Holter Monitor and Interpretation Order”
  • “Referral for Event Monitor and Interpretation Order”
  • “Referral for ECAT and Interpretation Order”

For Holters the patient can usually pick it up at the regional heart center the same day–it is still best to have the MA discharge the patient to give them the right instructions. For event monitors, they can also usually pick up same day but also better to have the MA discharge the patient so they can give them the right information.  There is a fair amount of teaching for these so the regional heart center may start having appointments for the set up.

Holter monitors are for 24 hrs and are best for detecting ectopy burden.

King of Hearts and ECAT are actually the same device.

The difference is that ECAT is programmed differently and considered “mobile telemetry” and covered much less frequently by insurance.

ECAT includes a daily trend report (like you might see on our inpatient tele units) while KOH does not.

KOH and ECAT are both patient AND auto-triggered:  Either records when triggered by the patient (transmits the previous 2 minutes and subsequent 3 minutes) or when preset alert criteria are detected (eg bradycardia <30 or < 40 with symptoms, tachycardia > 200 or > 150 with symptoms, afib/flutter, > 6 beat VT, pauses > 3.5 sec, etc).

Both KOH and ECAT send the signals through a cell phone that is given to the patient.

significant findings are sent from the company to the ordering provider during the weekday, and to the cards fellow after hours (who will then find you or the on call provider)

The Heart Card is a small card that is placed on the chest when a patient has symptoms, only records when put in place–only use this if the convenience is worth it for patients with infrequent episodes which are sustained and in which the patient is awake and symptomatic.  The tracings are not as good, so for the most part we will be doing KOH/ECAT.

See preclinic conference for more details on when to order which device.

Orders and interactions with outside agencies

Home Health Home health: Post hospital d/c: check with your team RN to see if the hospital already took care of the initial paperwork and orders.

New start from clinic: Meds & Orders: “home health”, select “Referral to Home Health Services”. Discuss with your attending as will need to make sure patient meets criteria. If so, will need to complete “Face to Face” form.

For other home health orders, usually done via fax and telephone encounters.

Route a TE to your team RN pool for assistance with arranging Home Health once orders have been placed.

Home oxygen
  • Home oxygen: Usually work with your clinic RN.
  • New referral:
    • Medicare requires:
    • Step 1: Resting sats on room air
    • Step 2: Exertional (ambulatory / walking) sats on room air
    • Step 3: Exertional sats on Oxygen. (they want to see evidence that sats come up on O2).
    • Generally 88% or less for step 1 or 2, with improvement in step 3, will meet coverage requirements for Medicare.
    • Can order pulse oximetry in clinic, and if confirmed to meet criteria, discuss with your team RN.
    • This will generate a form that your mentor attending will need to sign later, so do get the documentation correct!
Orders to a SNF Usually done via fax or RN telephone call.If new orders, can write the order in a telephone note, route to your RN.
Iron infusion This is still done on paper.  Ask your team RN for the Iron Infusion orders for 4 South.  Your team RN will work with 4 South and with the patient to arrange.  You will need to discuss with the patient the risks/benefits, and decide on the dose, etc.
IV fluids for contrast nephropathy prevention This is still done on paper. Ask your team RN to assist with orders for 4 South.  You should write the paper orders for fluids (eg UpToDate recommends 3 mL/kg over one hour prior to the procedure, and 1 – 1.5 mL/kg/hour during and 4-6 hours afterward) and give it to your RN to coordinate for when the test is scheduled.
IV fluids in clinic Under Meds & Orders type in the fluids you would like to order eg “Normal Saline” – should display as an Immunization. Write the amount and rate in the order. Inform your clinic RN, who will move the patient to the treatment room.(Or: Meds&Orders–> New Order–> Browse –> Imm/Inj (on left) –> find under Injections)

TBA: conscious sedation (eg for MRI), open MRI, walkers and DME, injections in clinic, induced sputum, transfusions on 4S, admitting a patient from clinic…