ORDERS TO FLOWSHEETS
By Donna Jackson, RNBC
Sunrise Clinical Manager 4.5 allows orders to be linked to flowsheets, observations, or observation sets. For
example, if an order is placed for restraints, then the restraint flowsheet will open automatically. Another
example: orders for tube feedings can automatically add those observations to the intake and output flowsheet.
For this to work, the order must be set up for tasks and have a task form attached.
Setting up the medication drips is more challenging, since generally these observations should appear on both
the vital signs and the I&O flowsheet. On the I&O flowsheet, the row will be used to track intake for that
medication. On the vital sign flowsheet, this same observation will allow for drip calculation. The user can
enter the amount infusing and the row below will display the dose (10 ml/hr = 5 mcg/kg/min) – or the user can
enter in the desired dose and the infusion rate that should be set on the pump will be displayed. It is very
convenient when it works, but there is a lot that must be set up.
The building blocks for medication observations are the Intake subtype and the ObsComponent tables.
Unfortunately, these tables can only be express loaded and unloaded. The medications need to be built as an
intake type of “drips”. If this is not seen in the list, it will need to added via an express load. The
components – additive and solutions – come from the ObsComponent table. There should be content from a starter
set, but in case there is not, here are some rules.
If inputting data into the dictionary for these values, be aware that the name placed in the first column can
never be edited (Well actually you can edit it in the dictionary, but it is not reflected in config!) If
something needs to be renamed a new item must be built. If there are items that are not wanted, than unload and
make them “inactive” and then reload the dictionary. The good thing is, if you only want to add something, you
only need to add the new item. It will not change the items that are there – unless you happen to use the same
unique number (a number only used for the express load and unload) as another item in the table. I would
recommend that what is currently there is unloaded so there are no overlaps. Also, the unit of measure utilized
in this build must be an Eclipsys core UOM. For example, one site wants to run Oxytocin in milliunits/min and
this cannot be done because milliunits is not a core UOM.
Once all the intake types, additives and observations created, items can be built. Once the observation type
of “drips” is selected, some auto formatting of observation takes place. The second tab (Data Definition), has
been formatted. Consider changing the decimal to 2 digits for some of the drips that may need more granularity.
Go to the “Row Label Description” tab and add the solution and additive. The amount of the medication added
and the volume in the IV bag can be edited. On this tab, there is a second subtab called “Generic”. Click on
this to enter the initial dose units and the unit of measure to be used for the drip. In order for your drip to
calculate correctly, the medication UOM must match the initial dose units. For example, if you add 2 grams of
Lido to a bag, then the initial dose units must be grams/ml- not mg/ml. However, if you add 2000 mg of Lido, then
the initial dose unit is mg/ml. The desired dose unit for the drip should be mg/min, mcg/kg/min, units/hr, etc.
There is an alternative. You can build an observation as an “order based drip”. When this is finished, there
is very little to configure in SCM. The admixture selected on the order form controls the drug admixture for the
observation. The disadvantage of this is that the user can never add this to their flowsheet themselves. Before
a medication drip will appear on a flowsheet, the order must have been verified. A user may want to add the drip
themselves before it is verified by pharmacy so they can take advantage of the drip calculator and they cannot do
this with order based drips. Of course, this depends on where pharmacy orders are being verified. In order for
the order based drip to fan out to the vital sign flowsheet, there is a defect and a workaround. On the
medication order, on the Ordering Information 2, the “is large volume parental” must be off-checked. This may be
something for which there is a hot fix in the future, but at the time of this writing, that is the only way to
make this work.
If a site is using SMM for their pharmacy system, additional configuration for “order based drips” must be
done. There are certain fields that must be on the pharmacy form: calculatedDose, UOM, DrugConcentration,
DrugConcentrationUOM, DrugAmount and DrugAmountUOM. Additionally you must build a class type called ECLP-SMM
Drips (Code) and map it to the ECLP-SMM TPN type (User dictionary code). This class type must be added in the
OrderingInformation2 to the class type list. Additionally there are four places in SMM that this same class type
must be added. If you don’t already know, Eclipsys can help you find those four places in SMM config tools.
Once all observations are built they can be added to the flowsheets. Be sure that suppress fan out is not
checked for any of these items or it will not fan out to both the vital signs and I&O flowsheets. I generally
have the height and weight displayed on the vital sign flowsheet. Notice that medication drips will display as
two lines on the vital signs flowsheet, while the order based drips will display as one line and it will be grayed
out.
Once your orders and flowsheets are built, then you are ready to link the items. To do this, open the
“orders + flowsheets” icon. Enter the name of the order, flowsheet, observation or observation set to be linked.
Click search. Select the item and choose “manage links” and then “add”. Now you will need to enter the order,
flowsheet, observation or observation set to which you want the link. Once this is found, then click “select” and
the system will find all the matches. Find the link you want and check the appropriate boxes and click “apply”.
Follow this procedure for all of the items you want to link.
You are now ready to test – and it should work as long as someone has turned on “orders to flowsheet services”.
Yes, this must be turned on, just like order generation services.
Good luck. The users will love it, when done right.