Order Medications

1. Select the patient.

2. Click Write (ALT+W).

3. Click Medications (ALT+M).

Medications on the PAML with planned action on admission to continue or substitute should be included in the active medication orders. Active meds are listed on the left.

1. If the PAML is not displayed, click the vertical + PAML Meds + button to the right of the list.

2. To display details of a PAML medication record:

• Click the line for the order to see details in the summary area beneath the lists.

• To view details in a larger area, click Zoom (ALT+Z). Click Close (ALT+C) to return to the list.

3. For more information, hold the mouse pointer over the object for a moment:

• To display the entire text of a line

• To display the full text of an abbreviated Planned Action on Admission (PAA)

• To display a key to all of the PAA abbreviations (PAA column heading)

4. Click for the medication in the PAML to start the order.

Parameters for the new medication are carried forward to the medication order form as available from the PAML source and applicable to the planned action on admission. Depending on the situation, you may have to search for the medication, and include all of the parameters for the order. If possible, the medication name, route, dosing, and frequency of administration may be pre-filled. You can edit as needed.

5. Complete the order—see following procedure.

Medications that have been added to the active medications list from the PAML on the right are displayed with a checkmark.

"Order Initiated From PAML Medication" is included in the detail information of the order.

• To change the drug itself, discontinue the order, then write an order for the new medication.

• To write a new order, click Add (ALT+A).

• To edit an existing order, click to select its line, then click Edit (ALT+E).

• When editing, to change the administration route and other parameters, click Change (ALT+H). You must then look up the medication again, using the name as entered already. See below, Specifying the medication.

• If you have a medication in the med name field, KnowledgeLink will search for that name automatically. Hold the mouse pointer over the to display the search criteria that would be used.

• Click to access KnowledgeLink..

• Click Exit (ALT+E) to close KnowledgeLink.

• Click Pop Out (ALT+P) to open KnowledgeLink in a separate window from the CAS.

• Toggle between Order Entry and KnowledgeLink by clicking the icons in the taskbar.

• Click to close the KnowledgeLink window.

To access MGH Lexicomp Online, click the button in the Clinical Link tab at the botton of the form. This reference opens in a separate Internet window.

1. Select the drug and delivery route.

   1. Type all or part of the name of the medication in the Med name field.

   • For patient-controlled analgesia, you can type "PCA" without selecting a route.

   • For epidurals, you can type "EPI" (at least the first 3 letters, or more, of "EPIDURAL").

   • For patient-controlled epidural analgesia, you can type "PCEA" or "PCE."

   2. To edit the administration route for a completed medication order, click Change (ALT+H), then continue as follows.

   3. Select an administration method from the Route list to narrow the list of results.
      Multiple routes—for example, PO/PR—are not allowed.

   4. Click Search (ALT+S) or press ENTER.

2. Select from the search results, then click OK (ALT+O).

   The initial medication search is based on the parameters you entered for the med name and route (if any) AND the age group of the selected patient. Dosing, frequency of administration, pharmacy-recommended dose instructions, and other information may differ based on the age group.

   • Expanding or changing the search: Click to select another age group option at the bottom of the display: Adult, Pediatric, or Neonate. The search begins automatically.

   • Misspelling? If you did not get a result you expected, the med name entry may be misspelled. Click the Sounds like search checkbox to see if that helps. The search begins automatically.

   • Non-formulary: If none of the search results matches your entry, you do have the option to select "take as typed." Be sure that spelling is not the problem. Ordering non-formulary medications is not optimal. Safety-related decision support is NOT triggered for non-formulary medications, including allergy and drug-drug interventions, dosing and substitution recommendations, and bar-coding for administration. Delivery can be delayed up to three (3) days. You must verify that you do want to order a non-formulary medication—see Respond to interventions, non-formulary, below.

   • To access KnowledgeLink, click

   • Click Exit (ALT+E) to close KnowledgeLink.

   • Click Pop Out (ALT+P) to open KnowledgeLink in a separate window from the CAS.

   • Toggle between Order Entry and KnowledgeLink by clicking the icons in the taskbar.

   • Click to close the KnowledgeLink window.

   • Choosing a medication:

   1. Click to select a medication/route combination.

   Chemotherapeutics that can be administered in non-oncology treatments are available through this medications order form. Scroll down the search results list and select a "non-chemo use" option to order either cytoxan and methotrexate, for example.

   2. Click OK (ENTER).

   3. If you selected the incorrect drug, click Cancel (ALT+C), then start again.

   • Non-formulary: If none of the search results matches your entry, you do have the option to select "take as typed." Be sure that spelling is not the problem. Ordering non-formulary medications is not optimal. Safety-related decision support is NOT triggered for non-formulary medications, including allergy and drug-drug interventions, dosing and substitution recommendations, and bar-coding for administration. Delivery can be delayed up to three (3) days. You must verify that you do want to order a non-formulary medication—see Respond to interventions, non-formulary, below.

3. For certain med/route combinations, specify type as prompted.

   • For meds with IV an route that can be administered as a bolus, continuous infusion, or both together, click to select an option when prompted, then click OK (ALT+O).

   • For a continuous infusion medication that could be administered on a sliding scale, click an option when prompted, then click OK (ALT+O). If you select Sliding Scale, click to select a blank or pre-filled scale, then click OK.

Drug-drug interactions are not checked in all circumstances. See Overview of DDIs.

• Messages—Food-Drug Interactions (FDI), Pharmacy dose instructions

  • This message is for your information. Click OK (ALT+O) to continue.

  • The information in the message is displayed in the appropriate tab at the bottom of the medication order form, and in the zoom detail of the completed order.

• Allergies

  • To stop writing the new medication order, click Cancel (D/C) order (ALT+C). Select another medication or cancel out of the medication order form.

  • To override the intervention and order the medication, click Keep (override) order (ALT+K). Type a reason for the override in the field provided, then click Close (ALT+C).

• Duplicate Therapies

  The top section of this alert displays the medication order you are currently writing, and the bottom lists all active medication orders that triggered the duplicate therapy alert. You can keep all, one, some, or none of the orders. You must provide a reason for ordering a new mediation that is a duplicate therapy. See Overview of Duplicate Therapy Interventions.

  • To stop writing the new order without affecting the existing active orders, click Cancel OR:

  1. Click to select the Do Not Order option in the top section.

  2. Click OK.

  • To continue the new order without duplicate therapies:

  1. Click to select the Order option in the top section.

  2. Click to select D/C order for all of the active orders in the bottom section.

  3. Click OK (ALT+O).

  • To stop writing the new order and discontinue one or more existing duplicate therapies:

  1. Click to select the Do Not Order option in the top section.

  2. Click to select D/C order for one or more of the active orders in the bottom section.

  3. Click OK (ALT+O). The summary views of the orders for duplicate therapies are flagged with <DuTx>, and the intervention and override are documented in the order details.

  • To continue the new order AND one or more existing duplicate therapies:

  1. Click to select the Order option in the top section.

  2. Click to select a reason for ordering these treatments together. For Other, type a reason (limited to the number of characters displayed).

  3. If there is more than one active order in the bottom section, click to select D/C order for any that you do not want to keep.

  4. Click OK (ALT+O). The summary views of the orders are flagged with <DuTx>, and the intervention and override are documented in the order details.

• Duplicates

  • To erase the new medication order, click Cancel (D/C) order (ALT+C). Select another medication or cancel out of the medication order form.

  • To continue ordering a duplicate medication, click Keep all (ALT+K).

• Drug-Drug Interactions Level 1

  1. Click an option to either cancel the new order you started, or discontinue the existing active medication order.

  Some orders cannot be canceled or discontinued—see Overview of DDIs regarding chemotherapy.

  2. Click Continue.

  3. For medications that are required as part of a chemo regimen or protocol, you will be prompted to indicate the reason for omitting the med. "DDI" is entered by default; type additional information as required, then click OK.

• Drug-Drug Interactions Level 2

  • To stop writing the new order, click Cancel Name of Med Order.

  Some orders cannot be canceled or discontinued—see Overview of DDIs regarding chemotherapy.

  • To continue the new order:

  1. For each medication listed, D/C the order or override the intervention:

  • To the D/C active medication, click the discontinue option.

  • Alternately, to override the warning, click one or more checkboxes to indicate your reasons for doing so. If Other, type an explanation.

  2. To order the lab when drug level monitoring is recommended, click the Order Medication Name level, next available checkbox.

  3. Click Continue Name of Med Order.

• Epoetin/Darbepoetin SC Decision Support

  • See Overview of Epoetin/Darbepoetin Decision Support.

  Clicking Cancel (ALT+C) at any point in the data entry and evaluation step clears the Medication order.

  1. Click to select a single reason for placing this order, then click OK (ALT+O).

  2. If you select Other, no additional information is needed. Continue with the dosing needed.

  3. If a hemoglobin (HGB) result less than 7 days old is available from the Clinical Data Repository (CDR) at Partners, this is automatically used for evaluation. Otherwise, provide the information as follows:

  1. Type the patient's last known hemoglobin (HGB) result.

  2. Type the date the specimen was collected, or select the date from the calendar.

  3. Type the location of the lab that ran the test.

  4. Click OK (ALT+O).

  If the HGB result was not pulled from the CDR, a CBC Next Draw will be included automatically in this order session. Likewise, a Ferritin Next Draw is automatically included if this level is not available. The lab orders are displayed in the Current Lab Orders list, as well as the Order For This Session.  If you cancel the original medication order, you must manually delete the lab order(s) if you don't want them. See Deleting Orders.

  4. If the most recent HGB is over 10 mg/dl, treatment with epoetin or darbepoetin is not warranted. Click OK (ALT+O). You will have to select a different medication or cancel out of the medication order form.

  5. Click to select a diagnosis, then click OK (ALT+O).

  6. Click to indicate which phase of epoetin/darbepoetin treatment the patient is undergoing, then click OK (ALT+O).

  7. Guidelines for ordering the selected medication for the stage of treatment you indicated are displayed.

  1. To change the order specifications from the selected default, click another option.

  2. Click OK (ALT+O).

  The parameters as selected for dose, frequency, and duration are entered on the med order form. These parameters cannot be edited.

  8. Select the dose and frequency (see next, for repetitive order medications).

• Height and Weight for Creatinine Clearance—Adults (19 or older)

  • See Overview of Nephros/Gerios Administration Adjustments and Substitutions

  This prompt is triggered by ordering a nephros medication for a patient with a recent (1 calendar year) serum creatinine result in the CDR.

  1. Type a value in either the kg (kilograms) or lb (pounds) field. Alternate units are calculated automatically.

  2. Type the patient's height, in inches.

  3. Click OK (ALT+O).

  4. Click Correct (ALT+C) at the Validation prompt. (To change the entry, click Incorrect repeat the process above.)

  5. Type your signing key, then click OK(ALT+O).

  • See also: Viewing and Editing the Weight and Height Record.

• Kayexalate Warning

  This prompt is triggered when you select Kayexalate (polystyrene sulfonate) on the Medications order form. There are several potentially fatal contraindications against the administration of this drug. To respond:

  • Read the warning.

  • To review current FDA safety information on Kayexalate, click Link to FDA Warning. To return to the decision support form, click OK.

  • To review the article on UpToDate on the treatment and prevention of hyperkalemia, click Link to UpToDate Article.  To return to the decision support form, click OK.

  • Review the list of absolute contraindications for Kayexalate (polystyrene sulfonate).

  • Click the Yes option to cancel the order because there is an absolute contraindication.

  • Click the No option if the patient has no absolute contraindications.

  • If you have not canceled the order due to absolute contraindications, review the alternative treatment recommendations.

  • Click the Yes option to cancel the Kayexalate order if an alternative is acceptable .

  • Click the No option if alternative treatments are not sufficient.

  • To return to the Medications Active Orders list without ordering, click Cancel Order (ALT+C).

  • If you do order Kayexalate, all of your selections are recorded for patient safety and quality assurance monitoring.

• Nephros/Gerios Substitutions

  • See Overview of Nephros/Gerios Administration Adjustments and Substitutions

  • To stop ordering, click Cancel Order (ALT+C).

  • To switch your order to a substitute:

  1. Select the substitute order from the drop-down list.

  2. Click Order Substitute. The intervention window closes, and the medication you chose is displayed in the Medication Order form.

  3. Complete the order as usual.

  • To keep the medication you started with:

  1. Click Continue Original Order.

  2. Set the dosing, frequency, and other parameters, then complete the medication form as described next.

• Non-formulary or Take-as-Typed

  If you select "no match found; press Enter to accept as typed" from the medication search results, you will be prompted to verify that you want to order a non-formulary medication.

  • To stop writing the new medication order, click No (ALT+N). Select another medication or cancel out of the medication order form.

  • To verify that you want to order the medication, click Yes (ALT+Y). You will have to complete the order using the Other option for most parameters.

  No safety-related decision support is available for non-formulary/take-as-typed medication orders. This includes drug/drug and drug/allergy checking, dosing recommendations, and bar-coding for administration verification.

• Fixed dose, adult (patient over 19 years old on admission)

  • See Overview of Nephros/Gerios Interventions.

  When used for treatment of adult patients with renal insufficiency, or elderly patients, some medications should be administered with adjustments to the dosing and/or frequency. These recommendations are displayed in the Nephros/Gerios tab at the bottom of the order form and in the detail of the order. The default dosing and frequency are set to the recommended dosing and frequency.

  1. Loading dose: If needed, see Ordering a Loading Dose.
     The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. Select a defined amount or Other from the Dose drop-down list.

  • Do not select the Other option when ordering chemotherapeutics, such as cytoxan or methotrexate, for non-oncology treatments.

  • For range doses, PRN (as needed) must be checked, and a reason entered. See below, Complete the order.

  3. Select a frequency value or Other.

  4. Insulin dosing for when patient is not eating: If needed, click to check NPO Dose (ALT+N), then type the units to be given. An order for hemoglobin A1c is added automatically. See Consequent Orders - Overview.

  In the ambulatory units, the frequency selection for defined medications determines whether the medication is handled as a repetitive order. The duration for repetitive orders is set automatically and cannot be edited.

• Fixed dose, non-adult (patient less than 19 years old on admission)

  1. Loading dose: If needed, see Ordering a Loading Dose.
     The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. Select a dosing/frequency combination from the Common Orders drop-down list.

  3. If the Common Orders do not include the dosing/frequency you want:

  1. Select a defined amount or Other from the Dosing drop-down list, then select a frequency value or Other.

  • Do not select the Other option when ordering chemotherapeutics, such as cytoxan or methotrexate, for non-oncology treatments.

  • For range doses, PRN (as needed) must be checked, and a reason entered. See Completing the Order, next.

  2. Select a frequency value or Other, then type an amount with appropriate units in the frequency field.

  The Dose field (actual dose for administration) is display only. To enter or edit the dose displayed in the Dose field, select Other from the Dosing drop-down list. See Ordering "Free-Text" Dosing.

  If the amount in the Dose field (actual dose for administration) is based on standardized dosing tables, the More Info button is displayed with the calculated results. Click to review the details for the selected medication.

  The following calculated results are displayed for your information:

  • Total daily dose = dose x frequency per day

  • Total daily dose per kg = dose x frequency per day per kg (patient weight)

  • Dose deviation = difference between rounded and non-rounded dose as a percentage of the rounded dose

  • Calculated dose = dose calculated without defined rounding (actual dose is rounded as defined for the selected medication)

• Continuous medicated drips, with or without bolus

  1. For applicable delivery routes such as IV Bolus Plus Infusion, the Loading Dose window opens automatically.  See Ordering a Loading Dose.

  The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. Type a value or range for the continuous dose.

  For range dosing, as needed PRN administration is not allowed, and a "Titrate to" description is required. See Completing the Order, next.

  3. If available, select a flow rate or Other.

  4. Select a fluid. If Other, press TAB and type a description, then click OK (ALT+O).

  5. Select a Start Time or Other.

  6. If needed, type a number for the duration (hours).

  7. If needed, select a line or Other for the site.

  8. To note reasons for holding the medications, type in the Hold if field.

  9. To describe parameters for titrating the administration for effect, type in the Titrate To / Therapeutic Goal field.

  10. Type instructions as needed.

  For selected intrathecal (IT) medications, the titrate to and instructions field are pre-filled with required information from the Chronic Pain Service.

  For selected anticoagulants, the therapeutic goal and instructions field are pre-filled with required information from the Thrombosis Service.

  11. Click OK (ALT+O).

• Patient-Controlled Analgesia (PCA)—Adult

  • Default values are available for some PCA meds. You can change these if needed.

  • The concentration for adult PCA is set when you select from the med search results. To order a different concentration, click Cancel (ALT+C) and repeat the medication lookup.

  • Press TAB to move through the fields quickly.

  • Click the tabs on the index card display in the upper right to view the Dosing Guide for PCA, Associated Orders, and the PCA Analgesia Scoring Guide. The associated orders and scoring guide information is included in the detail (Zoom) view of the order.

  1. If the concentration you selected is high and requires approval of an authorized provider from the Pain and Palliative Care or Anesthesia service, click Close (ALT+C) to acknowledge the message.

  • To select a lower concentration medication, click Cancel (ALT+C) to close the order form, then repeat the medication lookup. (See Specify the medication, above.)

  • To continue, complete the order, entering the name of the approving provider (see following).

  2. Type values (mg) for the start dose, lower and upper limits for the dose range, lockout time, continuous rate (day and night), and one-hour dose limit.

  3. Enter the name of the approving MD if the use of the medication is restricted (the Approval by field appears only when required):

  1. Type at least one letter of the last name. To include more information, follow this with a comma (,), and one or more letters from the first name (no spaces).

  2. Click Search Approval. The Providers list opens, displaying any names that matched your input.

  3. Click to select a name.

• Patient-Controlled Analgesia (PCA)—Pediatric

  • The concentration for pediatric PCA is set when you select from the med search results. To order a different concentration, click Cancel (ALT+C) and repeat the medication lookup.

  • Press TAB to move through the fields quickly.

  • Click the tabs on the index card display in the upper right to view the Dosing Guide for PCA, Associated Orders, and the PCA Analgesia Scoring Guide. The associated orders and scoring guide information is included in the detail (Zoom) view of the order.

  1. Type values for the start dose and PCA dose range.

  2. Type the number of minutes for the lockout time.

  3. Type the milligrams per hour for the continuous flow rate (day and night), and one-hour dose limit.

  4. Type additional instructions as needed.

• Patient-Controlled Epidural Analgesia (PCEA)

  • Default values are available for some PCEA meds. You can change these if needed.

  • The concentration and ingredients for adult PCEA are set when you select from the med search results. To order a different concentration, click Cancel (ALT+C) and repeat the medication lookup.

  • Press TAB to move through the fields quickly.

  • Click the tabs on the index card display in the upper right to view the Dosing Guide for PCEA, Associated Orders, and the PCEA Scoring Guide. The associated orders and scoring guide information is included in the detail (Zoom) view of the order.

  • Click the ? button to display the recommended ranges for the associated parameter. Click OK (ALT+O) to return to the order form.

  1. Type values for the initial rate of infusion, titration rate range, demand dose, lockout interval, and one-hour volume limit.

  2. Instructions are included automatically. You can add to there or change them as needed.

  1. Loading dose

  • Loading dose is expected for infusions that include a bolus. (See Specify the medication > Selecting an Infusion Type, above.) Click Cancel (ALT+C) if no loading dose is needed.

  • If needed, see Ordering a Loading Dose.
    The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. The argatroban and heparin sliding scale orders are offered as medication lookup results. If sliding scale parameters are not included in the instructions of the current form:

  • Click Cancel (ALT+C) to close the order form.

  • Repeat the medication lookup (see Specify the medication, above).

  3. If needed, type to change the values in the dose field (range dosing required), select a different fluid option, and/or select a different start time.

  4. If needed, type the number of hours for the duration.

  5. If needed, select the site of the infusion.

  6. If applicable, click the checkbox to indicate that the patient will use medications from home.

  7. If needed, type to change the start rate (the units are defined automatically).

  8. If needed, type to describe reason(s) for holding the order.

  9. Titrate To and Instructions include sliding scale parameters for the selected treatment (IV Cardiac or DVT/PE for heparin, or the specific doses of argatroban). Type to change as needed.

• Epidurals

  • Click the tabs on the index card display in the upper right to view the Dosing Guide, Associated Orders, and the Epidural Analgesia Scoring Guide. The associated orders and scoring guide information is included in the detail (Zoom) view of the order.

  • Click the ? button to display the recommended ranges for the associated parameter. Click OK (ALT+O) to return to the order form.

  1. Type the initial infusion rate, then the upper and lower limits for titration.

  2. Click OK (ALT+O).

  3. Associated orders for epidurals are listed in the consequent orders display.

  • To view additional information, click More Info (ALT+M).

  • To skip all consequent orders, click No (ALT+N).

  • Click to check or uncheck one or more of the orders as applicable. Only checked orders are added.

  • To add the selected consequent order(s) to your session, click Yes (ALT+Y).

  • See also: Overview of Consequent Orders.

• Loading Dose

  The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  1. Select a dose from the list.

  2. If Other:

  • Type a dose in the amount field, then select units from the drop-down list.

  • If the units needed are not listed, click the Other Unit checkbox and type a description.

  • Click OK (ALT+O).

  3. Click OK (ALT+O).

  4. To change the settings, click Loading Dose.

  5. Complete the maintenance dosing portion of the order. See above, Setting the Dosing, Frequency, Infusion Rate, and Other Parameters.

• Taper dose (sequential days, applicable meds only)

  1. If needed, order a loading dose. See Ordering a Loading Dose.

  The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. Click to select Taper from the Dose drop-down list.

  3. For each dosage (up to 7), select a value or Other for the dose.
     Order the doses chronologically. The order reads "#1 dose for x total doses then #2 dose for y total doses then #3 dose for z total doses."

  4. For each dosage (up to 7), select a value or Other for the frequency.

  5. Type a number for the total number of doses for each dosage.

  6. Click OK (ALT+O).

  • Taper dosing is not available for neonates.

  • Taper doses cannot be edited or put on hold. You must discontinue the order to stop the administration, and write a new order if changes are needed. See Discontinuing Orders.

• Sliding scale (applicable meds only)

  1. If needed, order a loading dose. See Ordering a Loading Dose.

  The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. Click to select Sliding Scale from the Dose drop-down list.

  3. For Insulin Regular or Insulin Lispro orders with defined dosing sliding scales (Usual Dose, Low Dose, or High Dose), the dosing is locked; edits are not allowed. If changes are needed, click Cancel (ALT+C), then search for insulin. Select Insulin Regular Custom or Insulin Lispro Custom as needed.

  4. For some medications, the values for a routine scale are already entered. If editing is available:

  • To enter a tighter sliding scale, click Clear Scale (ALT+C), then update the fields (see next step).

  • To restore default values, click Default Scale (ALT+D). If more than one default is available, click an option when prompted, then click OK.

  5. If needed, type a value or range for the dose-determining test result in the left field of a line, and the responding dose in the right field. Complete as many lines as needed to designate the entire scale.

  6. By default, the instruction to call the responding clinician is selected, and the blood sugar limits are set to below 50 mg/dl or above 400 mg/dl.

  • To remove the instruction from the order, click to uncheck the item.

  • To change the lower or upper limits, type different values.

  7. Click OK (ALT+O).

  8. Select a frequency or Other.

• Insulin Pump

  Insulin pump orders are needed to alert nursing and other providers that patients are self-managing their Insulin.

  1. By default, insulin pump orders are defined as Patient to Use Home Supply; the checkbox is checked automatically.

  2. The range for the dose defaults to 0 - 25 units/hour.

  For range dosing, as needed PRN administration is not allowed, and a "Titrate to" description is required. Insulin pump orders are automatically set to titrate to "Blood Sugar Goal." See Completing the Order, next.

  3. The default Start Time is Today.

  4. If needed, type a number for the duration (hours).

  5. To note reasons for holding the medication, type in the Hold if field.

  6. Type instructions as needed.

  7. Click OK (ALT+O).

• Insulin Algorithm

  1. Select Insulin Algorithm from the Dose drop-down list.

  2. Complete the algorithm:

  1. Type values for the patient's carbohydrate ratio (grams of carbohydrate per one unit), target blood sugar (mg/dl), and sensitivity or correction factor per one unit (mg/dl).

  2. The dose is rounded down to the nearest whole unit by default. To round down to a half (0.5) unit or a tenth (0.1) unit, select from the Round Down to the Nearest drop-down list.

  3. By default, the instruction to call the responding clinician is selected, and the blood sugar limits are set to below 50 mg/dl or above 400 mg/dl.

  • To remove the instruction from the order, click to uncheck the item.

  • To change the lower or upper limits, type different values.

  3. To generate a chart from the Department of Endocrinology, displaying insulin doses based on the patient's carbohydrate intake and glucose level, click View Algorithm (ALT+V).

  • The default example does not use the entries made for the current order. To update the chart, click the field, then backspace or delete to erase the default value, and type:

  1. To reflect the order for the patient, update the Target, Carbohydrate Ratio, Sensitivity, and Round Down to values.

  2. To set the carbohydrate intake amounts for which you want to display doses (column headings in the chart), update the Carbohydrate Intake, Values 1 through 4, in grams.

  3. To set the blood sugar levels for which you want to display doses (rows in the chart), update the Blood Sugar range minimum, maximum, and intervals (mg/dl).

  4. Click Re-Calculate.

  5. To generate a paper copy of the completed chart, click Print.

  6. Click Ok to return to the algorithm entry form.

  4. Click OK (ALT+O) to return to the medication order form. Reselect Insulin Algorithm from the Dose drop-down list to change the data for the calculations.

  5. Select a frequency.

  6. Click OK (ALT+O).

• Heparin (IV Cardiac or DVT/PE) or Argatroban or Bivalirudin sliding scale

  1. Loading dose

  • Loading dose is expected for infusions that include a bolus. (See Specify the medication > Selecting an Infusion Type, above.) Click Cancel (ALT+C) if no loading dose is needed.

  • If needed, see Ordering a Loading Dose.
    The loading and maintenance dosing for a single medication can be ordered on the same form. The two are separated for transmission to the pharmacy system, with a one-time (x1) frequency for the loading dose. You must delete both orders before signing to prevent ordering the medication. See Deleting Orders.

  2. The argatroban and heparin sliding scale orders are offered as medication lookup results. If sliding scale parameters are not included in the instructions of the current form:

  • Click Cancel (ALT+C) to close the order form.

  • Repeat the medication lookup (see Specify the medication, above).

  3. If needed, type to change the values in the dose field (range dosing required), select a different fluid option, and/or select a different start time.

  4. If needed, type the number of hours for the duration.

  5. If needed, select the site of the infusion.

  6. If applicable, click the checkbox to indicate that the patient will use medications from home.

  7. If needed, type to change the start rate (the units are defined automatically).

  8. If needed, type to describe reason(s) for holding the order.

  9. The Therapeutic Goal and Instructions include sliding scale parameters for the selected treatment: IV Cardiac or DVT/PE per nomogram for heparin, or the specific doses of argatroban or bivalirudin. Type to change as needed.

• Repetitive Order Medications (predefined)

  1. Select a defined amount or Other from the Dose drop-down list.

  2. Select a frequency value.

  The frequency selection defines whether the medication is handled as a repetitive order.

  Duration for defined Repetitive Order medications is set automatically, and cannot be edited.

• Alternating (odd and even days) doses

  The alternating dosing option is not accepted in Pharmacy and cannot be written for inpatients. To order different dosing on alternating days, write two (2) orders with QOD frequencies, one for each dose, and set the start dates and times as appropriate. See Defining Custom Times For Orders.

  For outpatients and discharge, alternating dosing can only be written on free text medications—that is, when you choose “none of the above” from the medication search results.

  1. For both odd and even days, select a value or Other for the dose.

  2. For both odd and even days, select a value or Other for the frequency.

  3. Type a number for the duration, then click Total Doses, Days, or Hours.

  4. Click OK (ALT+O).

• Variable sequential dosing

  The variable dosing option is not accepted in Pharmacy and cannot be written for inpatients. To order different dosing on sequential days, write one order for each dose,  with QD frequency, and set the start dates and times as appropriate. See Defining Custom Times For Orders.

  For outpatients and discharge, variable dosing can only be written on free text medications—that is, when you choose “none of the above” from the medication search results.

  1. For each dosage (up to 5), select a value or Other for the dose.
     Order the doses chronologically. The order reads "#1 dose for x total doses then #2 dose for y total doses then #3 dose for z total doses."

  2. For each dosage (up to 5), select a value or Other for the frequency.

  3. Type a number for the total number of doses for each dosage.

  4. Click OK (ALT+O).

• Patient-Controlled Analgesia and Epidurals: Type instructions as needed, then click OK (ALT+O).

• Continuous medicated drips (IV and IT): No additional information needed once dosing and other parameters are completed. See Ordering continuous medicated drips, with or without bolus.

• All other routes:

1. For inpatient orders, if the order does not have to be filled by pharmacy because the patient will be using medications from home, click to check Use Home Supply; May Self Admin; May Require Form.

If this medication is available on formulary at the MGH pharmacy, you must provide a reason for using a supply from outside the hospital. Allowing patients to take medications brought from outside of MGH bypasses all bar code based safety checking, which is used by the MGH electronic Medication Administration Record (eMAR). You may be contacted by a pharmacist to re-order the medication if it is available from MGH formulary.

1. if prompted, type your reason for allowing the patient to take a medication from outside the hospital.

2. Click OK (ALT+O).

Orders with Use Home Supply; May Self Admin; May Require Form are flagged <POM>.

2. To indicate as needed medication (not available for taper or sliding scale administrations):

1. Click to check PRN (ALT+P). To edit , click .

2. When prompted for a reason, for MGH sites only, click More Info to access the MESAC site for information on effective and safe medication management.

3. Click the associated checkbox to select one or more reasons. Reasons are listed alphabetically.

4. For reasons needing delimiting values (such as temperature), type to describe the clinical requirements. Less than (<) and greater than (>) symbols are allowed.

5. For Other, type a description. Use pre-defined reasons rather than the Other option whenever appropriate.

6. Click OK (ALT+O).

3. Select a Start Time (Routine, Today, Stat, In AM, Specific Date/Time, On Call to OR/CATH, On Discharge—for new discharge meds only—or Other).

• The time of first dose for the Routine start time is based on the time the order is written, the frequency, and the MGH pharmacy 50% rule for Standard Medication Administration Time (SMAT). For inpatient orders only, the start time based on the current time is displayed to the right of the field. Because the start time for special orders (pre-admission, post-op, transfer, new inpatient chemo) is based on the time of activation, this information is not available when writing this type of order. The start time is also not available when writing medication orders for discharge.

• Specific date and time is offered for inpatient non-chemo medications only.

• To order scheduled days (chemo and chemo-related medications only), select Other and click to select the Scheduled Days option.

• For specific date and time, you can only select a future date, within the next 7 days.

• To change the specific date or time from the default, type over the entry or select from the calendar.

4. To note reasons for holding the medications, type in the Hold if field.

5. Type the number of days or total doses in the Duration field, then click an option to select the units.

• Duration is not definable for x1 medications.

• Duration for defined Repetitive Order medications is set automatically, and cannot be edited. The options of Weeks/Months is available only for these medications.

• Total doses are calculated automatically from the selected frequency and number of days when provided.

6. Type instructions as needed.

Do not include hold conditions or start/end times in the instructions. See steps above for setting the start time, for indicating reasons to hold the medication, and for limiting the number of days or doses to give.

Include the treatment plan for pain management if you selected the PRN option to do so.

7. Enter the name of the approving MD if the use of the medication is restricted (the Approval by field appears only when required). See as appropriate:

• Infectious Disease Approval of Restricted Antibiotics

  If you are awaiting approval of nighttime orders (written between 8 pm and 8 am):

  • Click OK to acknowledge the message that you must contact Infectious Disease by 10 a.m. for approval to continue the treatment.

  • Will Contact ID in AM is added to the ID Approval field automatically.

  Once you obtain approval, edit the order to enter the name of the approving MD as follows:

  1. Type at least one letter of the last name. To include more information, follow this with a comma (,), and one or more letters from the first name (no spaces).

  2. Click Search Approval. The Providers list opens, displaying any names that matched your input.

  3. Click to select a name.

  4. Click OK.

• Thrombosis Service

  If you are awaiting approval of nighttime orders (written between 8 pm and 8 am):

  • Click OK to acknowledge the message that you must contact the Thrombosis Service by 10 a.m. for approval to continue the treatment.

  • Will Contact Hematology in AM is added to the Thrombosis Service field automatically.

  For orders in surgery that meet the criteria for emergent orders set by the Thrombosis Service:

  1. Type any letter in the Thrombosis Service field.

  2. Click Search Approval.

  3. Select the appropriate option: Cardiac Surgery Temporary Approval or Vascular Surgery Temporary Approval.

  4. Click OK.

  Once you obtain approval, edit the order to enter the name of the approving MD as follows:

  1. Type at least one letter of the last name. To include more information, follow this with a comma (,), and one or more letters from the first name (no spaces).

  2. Click Search Approval. The Providers list opens, displaying any names that matched your input.

  3. Click to select a name.

  4. Click OK.

• Approval of Restricted Medications: Heart Failure Group, EP (Electrophysiology), Restricted Mediations For Neonates, Pain and Palliative Care, GI (Gastrointestinal), DEA X

  You must obtain approval from an authorized provider to order the medication. Once you obtain approval, enter the name of the approving MD as follows:

  1. Type at least one letter of the last name. To include more information, follow this with a comma (,), and one or more letters from the first name (no spaces).

  2. Click Search Approval. The Providers list opens, displaying any names that matched your input.

  3. Click to select a name.

8. Click OK (ALT+O).