What are Prebuilt Order Sets?
Order sets are collections of steps that can be found in a single location in the EHR. They are based on specific conditions, processes or tasks (e.g. hospital admissions or new patient intake).
Prebuilt order sets play a vital role in clinical charting while documenting in an electronic health records (EHR) system. They enable clinical quality as well as charting efficiency. It includes all components of the treatment plan based on chief complaints, active problems, and/or diagnosis.
How Do Prebuilt Order Sets Save Time?
Your assessments and plans are the components of clinical charting which may be the most time consuming to include all aspects at the granular level of documentation. By integrating order sets, the provider streamlines a labor-intensive processes, and optimize order set management with evidence-based clinical content. In this manner, it serves the feature of Clinical Decision Support System as well.
This functionality enhances the finer details of orders and supports consistent terminology. The prebuilt sets provide structured data across the care setting which is incredibly beneficial regarding data analytics when integrated with your EHR
Prebuilt order sets have been shown to decrease keystrokes and mouse clicks when working in an EHR. OmniMD EHR, with its exclusive clinical charting feature, gives the provider an exceptional experience with prebuilt order sets that ensures clinical quality improvement and quick documentation.
Can Prebuilt Order Sets Lead to Better Patient Outcomes?
A 2013 study in Chest looked at previously available literature on the use of prebuilt order sets. One study cited in the Chest article found that using a prebuilt order set led to an increase in early aspirin ordering for patients with a suspected heart attack (aspirin acts as an anticoagulant that can help prevent blood clots that cause heart attacks from worsening).
Another study suggested that using prebuilt order sets increased asthma treatment adherence in pediatric patients. When healthcare providers used an order set, 94 percent of their patients used their steroid inhalers appropriately, compared to 74 percent of patients whose doctors did not use a prebuilt order set.
Manual documentation of processes may lead to unintended omissions and medical errors. Thankfully, this can be prevented by integrating prebuilt order sets for CPT and ICD codes. It should go without saying, but physicians need to review the note and make any necessary minor edits based on an individual patient basis in a few instances. Physicians may also build their own customized order sets based on their unique requirements.
Prebuilt Order Sets Best Practices
Specific guidelines should be followed while preparing the order sets; this ensures that the provider does not miss any critical element of the note. Based on standard guidelines, studies and analysis, OmniMD builds order sets for specialty-specific CPT and ICD codes.
One of our customers’ favorite features of the OmniMD EHR system is the ability to create their own order sets. When building custom order sets or customizing OmniMD’s, ask yourself—and answer—these questions:
- What are the goals of developing this order set?
- Who controls the content, design, distribution to the rest of the practice, maintenance and revision of the order set? Who is the point person for the creation of the order set?
- What problem will this order set solve?
- How will success be measured?
When combined with physician expertise and efficient processes, prebuilt order sets can help medial practices save time, cut down on medical errors and ultimately serve their patients more effectively. Schedule a demo with OmniMD today.