The Physician Entered Orders Report includes verified medication, ancillary, and nursing orders placed via Order Entry and identifies who verified the orders. For Nursing, the report may serve as the physician order sheet. Please see the Order Entry and Verify Orders user guide for more information on Nursing order entry and the nursing order verification processes.

 

Data included on the Physician Entered Orders Report is outlined below:

•Patient Information

▪Patient's name

▪Account number

▪Medical record number

▪Date of Birth

▪Age

▪Sex

▪Room number

▪Any drug allergies documented through the TruBridge EHR system

•Medication Information

▪Date/Time of order placement

▪Medication description, dosage, frequency, route, duration, priority and instructions*

▪Flow rate and components for IV medications

▪Physician’s electronic signature with credentials

•Ancillary Order Information

▪Date/Time of order placement

▪Ancillary order description, quantity, frequency, duration, days, and priority.

▪Physician’s electronic signature with credentials

•Nursing Order Information

▪Date/Time of order placement

▪Description of Nursing Order - up to three lines of up to 75 characters each will display

▪An Action if taken (Discontinue)

▪Physician’s electronic signature with credentials

 

NOTE: Renewed medication orders should display the instructions and/or comments from the original order.