Documentation/Clinical Decision Support

Module guide · Clinical

Clinical Decision Support

The hospital's automated safety net: rules that watch orders and results, guidelines clinicians can look up, and an inbox where every alert gets reviewed.

Overview Dashboard Rules Guidelines Order checks Critical labs Alerts inbox Risk assessments Good practices

What this module is for

Clinical Decision Support (CDSS) is the system that quietly checks orders, labs and vitals against known safety rules, and speaks up, an alert, when something looks wrong.

Who uses it

Clinical informaticists and pharmacy/quality staff configure the rules. Prescribers and pharmacists run order checks and review alerts. Safety officers watch the dashboard and audit overrides.

Where to find it

Open Decision Support from the sidebar. Seven screens, a dashboard plus six tools.

1
Dashboard
A health-check of the whole system, alert volume, fatigue rate, pending critical labs.
2
Rules
The library of automated safety tripwires.
3
Guidelines
A searchable reference library of evidence-based clinical guidance.
4
Order Checks
Manually run a safety check on a proposed order before signing it.
5
Critical Lab Alerts
The worklist for panic-value lab results awaiting provider notification.
6
Alerts Inbox
Where every fired alert gets acknowledged or overridden.
7
Risk Assessments
Standardized clinical risk scores, sepsis, falls, pressure injury, and more.

Dashboard

A quick health-check of the whole CDSS system, and the hub to every other screen.

Field	What it means
Active Rules / Guidelines	How many safety rules are currently live, and how many guideline documents are in the library.
Alerts Today / Pending / Critical	How many alerts fired today, how many nobody has acted on yet, and how many are the highest severity.
Overridden	Alerts a clinician chose to bypass with a documented reason.
Alert Fatigue Rate	The percentage of alerts overridden vs. acted on. Over 50%, shown in red, is a warning that alerts may be too frequent and staff are starting to tune them out.
Critical Labs Pending	Panic-value lab results still awaiting the required phone call to the provider.

Critical lab banner

If any critical labs are pending, a red banner appears at the top, click it to jump straight to the Alerts Inbox.

Rules

The library of automated safety tripwires, e.g. 'if a patient is on Drug A and Drug B together, warn the prescriber.'

Search & filter

Field	What it means
Search	By rule name.
Category	Drug Safety, Lab Monitoring, Vital Signs, Risk Stratification, Preventive Care, Infection Control, Order Management, Clinical Pathway, Antibiotic Stewardship, or Quality Measure.
Status	Draft, Active, Retired, or Testing.

Create / edit a rule

Field	What it means
Name, Description*	The rule's display name and what it checks for.
Category, Alert Type	What kind of clinical concern this addresses, and the specific trigger (e.g. Drug-Drug Interaction, Critical Lab Value, Fall Risk, Sepsis Risk).
Severity	Low, Moderate, High, or Critical.
Condition Expression	The underlying logic that decides when it fires, a technical field for informaticists, not typical end users.
Action / Recommendation Text	The guidance shown to the clinician when it fires.
Overridable / Requires acknowledgement	Checkboxes controlling whether a clinician can dismiss the alert with a reason, or must actively confirm they saw it.
Refire Interval	Minutes to wait before showing the same alert again, to avoid repeating it needlessly.

Deactivate turns a rule off instantly. Delete permanently removes it and asks for confirmation first, everything else saves immediately.

Critical — red

High — amber

Moderate — blue

Low — gray

Guidelines

A searchable reference library of evidence-based clinical guidance, separate from the automated rules, this is knowledge to consult, not a live alert.

Field	What it means
Search	By title or content.
Source	The issuing organization, e.g. AHA, IDSA, USPSTF, CDC, TJC, and others.

Each card shows source, version, evidence grade if present, and a summary. Opening one shows the full content, key recommendations, a link to the original publication, and any linked ICD-10, LOINC, or CPT codes. New Guideline adds one, there's no edit or delete from this screen.

Order Checks

A manual safety check a prescriber or pharmacist can run before finalizing an order, checking it against the patient's medications, allergies and history.

Field	What it means
Patient*	Search by name or MRN.
Order*	One of the patient's active orders, only enabled once a patient is picked.
NDC Code / LOINC Code	Optional, check a specific drug or lab test directly.

Run Order Checks is read-only, it doesn't sign anything. Results show a pass/fail banner and five counts: Drug Interactions, Allergy Alerts, Dose Checks, Duplicate Orders, and Formulary Substitutions. If a hard-stop rule blocks the order, a red notice explains why.

What these terms mean

A drug interaction means two medications could react badly together. An allergy alert flags a documented allergy to something in the order. A dose check flags an unusually high, low, or unsafe amount given the patient's age or organ function. A duplicate order means the same or similar item is already active. A formulary substitution suggests an equivalent the hospital stocks or prefers.

Critical Lab Alerts

The worklist for lab results so abnormal they're a life-threatening emergency, and the required proof that the ordering provider was called.

Why this screen exists

A "critical" or "panic" lab value could indicate an immediate threat to the patient's life. Hospital accreditation rules (TJC NPSG.02.03.01) require calling the ordering provider right away, reading the value back to confirm it was heard correctly, and documenting that it happened, this screen is that record.

Field	What it means
Pending / Overdue tabs	Pending shows every unacknowledged critical result; Overdue narrows to those past a time threshold you can adjust (default 60 minutes).
Acknowledge form	A read-only summary of the test and result, plus a checkbox: "I read back the critical value to confirm accuracy" (checked by default), the actual safety requirement behind the read-back rule.

Each card shows how long it's been since the result was recorded, turning red once past the overdue threshold.

Alerts Inbox

The action center: every alert fired by a rule, an order check, or a risk assessment lands here for review.

Filters

Field	What it means
Patient	Narrow to one patient.
Severity	Low, Moderate, High, Critical, or All.
Status	Pending, Acknowledged, Overridden, Acted Upon, Expired, Cancelled, or All, defaults to Pending so the actionable queue shows first.

The two responses

Field	What it means
Acknowledge	"I saw this and I'm continuing." A green button with an optional note, no justification required, meant for lower-stakes or informational alerts.
Override	"I saw this safety warning and I am consciously choosing not to follow it." A red button that requires a written reason, it won't submit without one, and the action is logged for compliance review.

Every alert has an audit history icon showing who did what and when, useful for reviewing a pattern of overrides.

Pending — needs review

Acknowledged — seen, proceeding

Overridden — bypassed with a documented reason

Acted Upon — the recommendation was followed

Expired / Cancelled — no longer relevant

Risk Assessments

Standardized clinical risk scores, recorded here so the whole care team can see the trend.

Field	What it means
Patient*	Search by name or MRN, nothing else works until one is picked.
Assessment Type*	Sepsis qSOFA/SOFA, Fall Morse/Hendrich, DVT Caprini/Wells, Braden Pressure, LACE Readmission, NEWS2 Deterioration, MEWS, Stroke NIHSS, or APACHE II.
Score / Max Score*	The number from doing the assessment, and, optionally, the scale's highest possible score for context.

The risk level is calculated for you

Risk level, interpretation, and recommended interventions (e.g. "Initiate fall precautions") are computed automatically from the score, you enter the number, the system does the judgment call. There's no edit or delete, each entry is a permanent point-in-time record so trends stay accurate.

Low — green

Moderate — blue

High — amber

Very High / Critical — red, escalate

Good practices

An override always needs a real reason

It's logged and reviewed for patient safety, write what actually justifies proceeding despite the alert, not a placeholder.

Watch the Alert Fatigue Rate

If it's climbing past 50%, that's a signal a rule may be firing too often or too broadly, worth flagging to whoever maintains the Rules library rather than just clicking through overrides.

Critical lab read-back isn't optional

The confirmation checkbox exists because misheard values over the phone are a real, documented source of medical error, always actually read the value back before checking it.

Back to all guides Book a live demo