How to Enter A Manual Order (v3)
Note: Not all roles will have the ability to enter orders in the system, your System Administrator will have to adjust your rights in the system if you are unable to add an order but need this ability.
Sign into ZenCharts and click into the appropriate client's chart
From the main navigation, click on 'Medical' , then click into the 'Orders' section
Click on the + plus sign and select 'Add Manual Order'
Page 1 of 3: Set Order Type
A. Select Order type (required field)
Taper/Titration:
This will allow you to build out taper or titration type orders based on days or dosages (it is best to have these types of orders pre-built in the saved order templates section)
Standard Types:
Consistent Dose (By Days) Will allow you to enter an order for a specific number of days, and then the system will auto-discontinue the order after the set number of days (e.g. an antibiotic order for 10 days)
Consistent Dose (By Dosages): Allows you to enter an order that is to only be given for a specific number of dosages, and then the system will auto-discontinue the order
One Time: Allow you to create a single dose order and select the time it should be completed
Open End: Will keep an order active until the order is manually discontinued by staff
STAT: Allow you to enter a one time order that is to be completed immediately
Upon Admission Will allow you to create one time orders that should be completed upon a client's admission to a facility. This order type will most frequently be utilized when creating order templates
B. Enter a Justification: the indication/ reason for this order
Click Save and Proceed
Page 2 of 3: Enter Order Specifications
C. Begin typing the first 3 or more letters into the 'Rx Norm Search' field and select the needed medication (medication/strength/form) from the drop down (required)
Additional Options:
PRN: Selecting this will make the order a PRN order
Psychotropic & Antibiotic: Select this for the appropriate medication orders (these two options have additional features if turned on)
Do Not Substitute - Dispense as written: Select if ordering a brand name drug, and the client needs to receive the brand and not the generic
Ride Along PRN: If this is a scheduled medication, but the client can have a PRN dose of this medication if needed (Example, client takes Clonidine 0.1mg QAM, but may also take an PRN Dose for high blood pressure during the day)
D. Set the Frequency from the 'Frequency' Drop Down (required field)
E. Dose type: Defaults to Consistent, but can be changed:
Consistent or Varied: If this medication is to be given multiple times a day, does the dosage vary each time, or does the dosage stay the same each time?
(Example 1: Gabapentin 100 mg TID, client is to receive 1 tab for the morning, noon and evening dose - this would be a consistent dose, dose does not change throughout the day.
Example 2: Gabapentin 100 mg TID, client is to receive 2 tabs for the morning, 1 tab at noon, and 2 tabs for the evening dose - this would be a varied dose, because the dosage changes throughout the day)
If the Dose is Varied, select 'Varied Dose'
Enter the frequency of Dosages to be given in a day in the 'Count of Dosages' field (BID = 2, TID = 3, QID = 4)
Enter the Quantity of tabs or pills to be given for each frequency
Additional options:
Conditional Dosage - Dose is dependent on another variable and the dose given is to be entered in the emar ( example, sliding scale insulin based on blood glucose)
Maximum Dosage - Utilized mainly for PRN's where the client should not receive more than x amount of the medication in a 24 hour window - emar/emor will display a notification if client has reached the maximum dosage allotted for the day
F. Set Requirements - Allows you to select certain assessments or tags that need to be completed or noted at the time of administration/observation of the med. You also have the ability to set parameters in this field, for example: Requirement: Blood Glucose, 'Give if greater than 200' or 'Give if less than 70'
Save & Proceed
Page 3 of 3: Preview and Add Order
Review your order
G. You May update the wording in the auto-generated Sig Field and save
H. May Enter Instructions to Staff that will display on the EMAR/EMOR
then click 'Save Instructions'
I. May Enter Instructions to Pharmacy (applicable for orders that are e-faxed),
then click 'Save Instructions'
J. Click 'Add Quantity and Refills' for Orders that are e-faxed to a pharmacy,
then click 'Save Quantity & Refill'
If you are only adding this single order:
Click 'Start Manual Order' and complete the 'Ordered By, Ordered Via' fields, you may also adjust the starts date if needed, then Click 'Add Orders'
If you have additional orders to add:
Click 'Save & Create Next' and follow the same steps to enter additional orders
When you have Entered all additional orders, from page 3 of the ordering wizard:
Select all orders to be added from the Pending Orders drop down, click 'Start Selected Orders', and complete the 'Ordered By, Ordered Via' fields, you may also adjust the starts date if needed, then Click 'Add Orders'