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| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| Computerized physician order entry | 1/3 | https://en.wikipedia.org/wiki/Computerized_physician_order_entry | reference | science, encyclopedia | 2026-05-05T07:27:20.608307+00:00 | kb-cron |
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. The entered orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE reduces the time it takes to distribute and complete orders, while increasing efficiency by reducing transcription errors including preventing duplicate order entry, while simplifying inventory management and billing. CPOE is a form of patient management software.
== Required data ==
In a graphical representation of an order sequence, specific data should be presented to CPOE system staff in cleartext, including:
identity of the patient role of required member of staff resources, materials and medication applied procedures to be performed operational sequence to be obeyed feedback to be noted case specific documentation to build Some textual data can be reduced to simple graphics.
== CPOE related terminology ==
CPOE systems use terminology familiar to medical and nursing staff, but there are different terms used to classify and concatenate orders. The following items are examples of additional terminology that a CPOE system programmer might need to know:
=== Filler === The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
=== Order === A request for a service from one application to a second application. In some cases an application is allowed to place orders with itself.
=== Order detail segment === One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.
=== Placer === The application or individual originating a request for services (order).
=== Placer order group === A list of associated orders coming from a single location regarding a single patient.
=== Order Set === A grouping of orders used to standardize and expedite the ordering process for a common clinical scenario. (Typically, these orders are started, modified, and stopped by a licensed physician.)
=== Protocol === A grouping of orders used to standardize and automate a clinical process on behalf of a physician. (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.)
== Features of CPOE systems ==
Features of the ideal computerized physician order entry system (CPOE) include:
Ordering Physician orders are standardized across the organization, yet may be individualized for each doctor or specialty by using order sets. Orders are communicated to all departments and involved caregivers, improving response time and avoiding scheduling problems and conflict with existing orders. Patient-centered decision support The ordering process includes a display of the patient's medical history and current results and evidence-based clinical guidelines to support treatment decisions. Often uses medical logic module and/or Arden syntax to facilitate fully integrated Clinical Decision Support Systems (CDSS). Patient safety features The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction reviews, and checks on allergies and test or treatment conflicts. Physicians and nurses can review orders immediately for confirmation. Intuitive Human interface The order entry workflow corresponds to familiar "paper-based" ordering to allow efficient use by new or infrequent users. Regulatory compliance and security Access is secure, and a permanent record is created, with electronic signature. Portability The system accepts and manages orders for all departments at the point-of-care, from any location in the health system (physician's office, hospital or home) through a variety of devices, including wireless PCs and tablet computers. Management The system delivers statistical reports online so that managers can analyze patient census and make changes in staffing, replace inventory and audit utilization and productivity throughout the organization. Data is collected for training, planning, and root cause analysis for patient safety events. Billing Documentation is improved by linking diagnoses (ICD-9-CM or ICD-10-CM codes) to orders at the time of order entry to support appropriate charges.