Write Routine Orders

This function adds orders to the current active inpatient orders record. It does not add orders to sessions pending activation—pre-admission, post-operative, transfer, inpatient chemotherapy, and discharge orders.

See also: Writing Specialized Orders for Future Activation.

If you haven't already:

Select the patient.
Click Write (ALT+W).

Prompts for inpatients only:

If the patient has been admitted from the ED without pre-admission orders, and there are still active orders from the ED, you will be prompted to inactivate the ED orders before continuing. Click Inactivate ED orders (ALT+I).
If the allergy record was updated in the ED, the order must be resigned. MDs, NPs, PAs, and CNMs are authorized to resign; click Continue (ALT+C), type your signing key when prompted, then click OK (ALT+O). RNs and other staff, who are not authorized to resign, must click OK (ALT+O) and notify an authorized provider that the resign is required.
For patients over 65 years old on admission, MDs, NPs, PAs, and CNMs are prompted to determine the need for a pneumococcal vaccine if this hasn't already been done. See Responding to the Pneumovax prompt.

Prompts for ambulatory clinics only:

Type or select the visit date. Click OK (ALT+O).
Click to select the clinic the patient will visit. Click OK (ALT+O).

Writing an order:

Click the button for the type of order you want.
Click Add (ALT+A) or the appropriate order button in the Add New Order section to open the order form.
Complete the order form:

Medications and lab orders (which are too numerous to list) must be selected by searching. See Writing Medication Orders and Writing Orders for Laboratory Testing for details.
Click to select from drop-down lists .
Type over, delete, or add to text entries.
Click to select different options . These are mutually exclusive; selecting one in a group automatically deselects the others.
Click to check or uncheck items .
For checkbox or drop-down list selections with additional information, click the button to the right to display the entry form.
For certain orders, click the labeled button—clinical history, reasons, or restrictions, for example—to open the form for editing. Click OK (ALT+O) to continue.

Click OK (ALT+O).

Consequent orders and interventions:

Depending on the order, you may be prompted to include other orders. See Overview of Consequent Orders.
New orders are checked against each other as well as existing orders for conflicts and potential adverse reactions. See Responding to Interventions.

Complete the order session:

Repeat the process for additional orders of that type.
Click Close (ALT+C). Your orders are listed in the Orders For This Session scratch pad.
Add orders from all types as needed.
Sign the orders. See Finding Your Clinical Signing Key.

See Procedures for Specific Orders