Tips for Avoiding Some Common Order-Entry Problems

By Cathy Welsh, MS, RD

As a former patient services manager turned clinical informatics analyst, I would like to share some considerations when planning your diet database to help avoid some common order-entry problems.

1. Should you have a few subcategories of orders?

For flexibility, you should build in a few subcategories. The primary category of your food service orders is meals. These are continuing orders. Diet orders start when entered and do not end until discharge. Create another category for specialty or one-time orders, such as “Birthday Cake” or “Test Tray.”

Categories can determine access to enter, or even see, diet orders. You may decide that diet technicians can enter specialty items, but not meals.

Categories also are used to design reports. This reporting can take place in the medical record itself, such as a special page or view, or in a printout. You might want your diet census to print everything, but for a special view, such as a nursing Kardex in the electronic medical record, you might want to only display meals.

2. How are clinicians going to find your diets?

Orders have primary descriptions or synonyms. To ease order entry, make a synonym for each diet order that begins with the term “Diet,” as in “Diet, Regular.” With one word, the user can easily review your diet list for as many orders that fill the order window. If you have more diets than that, that is another story!

3. What does your diet order look like?
Consistency is the key. The basic style or format of each diet order should have common features—a description, a start and stop time, duration, special instructions, and comments. More new details mean more formats. From a maintenance perspective, the fewer formats the better. How do you decide what kind of field to use?

Pick list (codeset or drop-down fields): These lists of values are used again and again. A good example is the values of calorie levels in your diabetic diets, such as 1200, 1500, and 1800. Having a free-text or even numeric field could lead to order entry errors and take more time, such as a 1408-calorie diet. Make you pick lists short enough, so you can see them without scrolling.

Numeric fields: A good use is for sodium restriction. Numeric fields can have decimal values, but for simplicity’s sake, stick with integer (whole number) fields to avoid 2.75-milligram sodium diet orders.

“Yes” or “No” fields: Choose labels for Yes/No fields carefully. On calorie-restricted diets, add a “Diet Snack Needed at Bedtime” order detail as a Yes/No field. If the clinician selects “Yes,” then the order says that. If “No” is selected, then the order details could say “No Diet Snack Needed at Bedtime” or nothing.

Free text: You want to give the clinicians some flexibility, so the best approach is to keep it standardized. Offer a “Special Instructions” field on each diet-order format. A common free-text order field size is 255 characters. If more space than that is needed, the clinician should just order a consult!

4. How can you avoid having multiple active diet orders with clinician order entry?

This sometimes is challenging. The question is, whose job is it to reconcile orders? Use these tips to help minimize the situation.

Duplicate checking:  Put the “duplicate checking” settings on your meal orders to warn that the patient has a current active diet order, and present a window to cancel. Or set meal orders to reject when duplicated. This way you are unable to enter new diet orders until the other order is cancelled.

Combinations: Build all the standard combination combinations into one order, such as Low Protein, Low Sodium, Low Potassium, and Fluid Restricted.

Cancelling orders: Encourage staff to cancel orders that no longer apply.

Durations: Encourage the setting of “durations” on diet orders. For example you can build order sets for progressive diets, where you have a regular diet ending at midnight and the NPO order beginning just after midnight.

Suspending and resuming a diet: Train staff to use an order action to “suspend” a diet while the patient is away for a procedure and then to “resume” the diet when the patient returns.