hl7 version 3 diet orders - health level seven...

HL7 Version 3 Diet Orders

Domain Analysis Model Use Cases and Storyboards

Draft v 1.105/14/2011

Authors:

Members of American Dietetic Association Nutrition Informatics Committee:

Elaine Ayres Joan Hoppe Bill Swan Trudy Euler

Curt Calder Amy Miller Anne Lougher

Margaret Dittloff Marty Yadrick Mary Jane Rogalski

Lindsey Hoggle Jessie Pavlinac Nisha Jain

1

Table of ContentsIntroduction...............................................................................................................................................4

Storyboard Sample Format........................................................................................................................7

Storyboard Topic................................................................................................................................... 7

Storyboard Actors and Roles.................................................................................................................7

Pre-Condition.........................................................................................................................................7

Sequence of Events, Storyboard, Activities...........................................................................................7

Post Condition....................................................................................................................................... 7

Diet Order Storyboards and Use Cases......................................................................................................8

Use Case 1: Order New Diet—General/Healthful (unrestricted) Diet....................................................8

Use Case 2: Order New Diet with Quantitative, Nutrient-based Modifications...................................11

Use Case 3: Texture/Consistency Modifications.................................................................................13

Use Case 4: Diet Order change to ‘NPO for Tests’...............................................................................15

Use Case 5: Pediatric Specialty Orders – NEED TO DOCUMENT..........................................................17

Use Case 6: Order Oral Nutritional Supplement.................................................................................19

Use Case 7: Order Enteral Nutrition (Tube Feeding)...........................................................................22

Use Case 8: Meal/Special Service Designation Order.........................................................................26

Use Case 9: Request RD/Nutrition Consult.........................................................................................28

Glossary................................................................................................................................................... 37

References and Acronyms.......................................................................................................................39

Appendix: Storyboard naming standards...............................................................................................40

2

Introduction

Computerized Food and Nutrition Service Management Systems (FNMS) used by dietetics and

foodservice departments in hospitals and long-term care facilities depend on HL7 interfaces to

exchange data with hospital information systems (HIS), electronic health records (EHR) and

computerized physician order entry (CPOE) systems. The core function of these interfaces is the

electronic transmission and exchange of medically-based diet orders, tube feeding and nutritional

supplement orders, dietary intolerances and food allergies along with patient/resident food preference

information required to provide inpatients with nutritionally/culturally appropriate meals. The orders

interface capabilities of different FNMS varies by vendor; the majority support one-way, inbound

messages while some may support bi-directional interfaces. The procedure for acknowledging

nutrition orders also varies among institutions; for instance, in many institutions the order is verified by

nursing prior to transmission to the FNMS.

Diet and nutritional supplement orders are an important part of the medical nutrition therapy. This

coded information is used by nutrition software systems to control and customize the foods that get

offered and served to patients/residents as part of their plan of care. A hospital or long-term care

facility Food & Nutrition Services department needs a diet order to notify them that a patient is able

and allowed to eat. A diet order is comprised of one or more diet specifications (often called diet

codes, modifications or restrictions). A patient can have only one effective diet order at a time. The

composite list of diet specifications in a diet order indicate what foods a patient should or should not

receive. This may involve controlling the type, texture and/or quantity of foods and nutrients that the

patient should receive. Often a complete diet order consists of a single diet code, such as ‘General

Healthy/Standard’ which is unrestricted in the amount or type of foods offered.

Diet codes can govern foods in a number of ways. In some cases, such as a gluten-free diet or a diet

code representing a food allergy, certain foods are contraindicated. In other cases, the diet implies a

recommended amount of one or more nutrients. “Some diet codes can combine to make a single diet

order. A 1500-Calorie restriction and a 2-gram sodium (NA2GM) restriction can coexist since they do

4

not address the same nutrient.” Certain kinds of diet codes cannot be combined with other codes, such

as NPO (Nothing by mouth) or use of more than one code for a given quantity of a nutrient, e.g., 1500-

Calorie and 2000-Calorie. It is impossible to feed a patient at two different calorie levels at the same

time. “These constraints are not defined in the table, but rather are implied by the semantics of the

codes.”(Chapter 4: Order Entry Page 4-98 Health Level Seven, Version v2.5.1 © 2007.)

A recognized standard or controlled vocabulary of diets or diet codes does not currently exist. Each

hospital institution or group will define a list of diet codes for use at their facility. However, most

localized diet descriptions or codes can be categorized as requiring either qualitative adjustments such

as texture modifications to assist a patient with chewing or swallowing disorders; or quantitative

modifications to control the amount of certain nutrients per day. Nutrient-based diets are ordered in

amounts per 24 hours and may then be arbitrarily divided up among multiple meals and/or between

meal snacks according to the patient’s typical eating behavior or the operational processes of each

medical facility. A dietitian may recommend that a patient receive a nutritional supplement or protein

sandwich between main meals to help the patient meet the daily nutrient totals for a diet. Suggested

diet taxonomy (see appendix #) compiled by the Nutrition Care Process/Standardized Language

Committee of the American Dietetic Association includes the following basic categories of diets:

Oral Dietso General/Healthful (to include age-appropriate modifications, e.g., toddler)o Texture/Consistency Modifiedo Allergy/Intolerance – to eliminate or limit foods with specific ingredients i.e. gluten-free o Quantitative Nutrient-based Modifications

Energy Modified Carbohydrate Modified Protein & Amino Acid Modified Fluid Modified (Restricting or limiting consumption of total fluids) Mineral Modified (sodium, potassium, phosphorus, etc.)

Medical Nutritional Supplementso Ordered b y Generic Description of Product Formulation, e.g., High Protein/2.0 Kcal formula o Ordered by Specific Product/Manufacturer ID

Enteral Nutrition (for tube feedings) Parenteral Nutrition (as these are generally pharmacy orders, they will not be addressed here)

5

Diets are typically ordered by a physician (or other licensed independent practitioner – LIP) or in some

cases by a licensed dietitian/nutritionist with clinical privileges, delegated authority or per established

protocols. Diet orders should designate a start time or meal for which the new diet order is to take

effect. This start time may be a specific time (either now or in the future) or for a designated meal or

snack period. Under certain circumstances, a diet order will have a specified end date/time or

expiration time if it is part of transitional orders for diet progressions or required for certain medical

procedures or tests. More often a diet order will have no end or stop date/time and will continue so

the patient is fed until the order is cancelled, revised or a replaced by a new order.

The intent of this document is to describe the diet and nutrition order storyboards, use cases and flow

of information needed to model nutrition orders in HL7 version 3.

6

Storyboard Sample Format

Storyboard TopicThe purpose of the story board is to illustrate the communication flow and documentation of a . . .

Storyboard Actors and RolesTriage Nurse

Trauma Physician

Etc.

Pre-ConditionTo be inserted

Sequence of Events, Storyboard, ActivitiesTo be inserted

Post ConditionTo be inserted.

7

Diet Order Storyboards and Use Cases

Use Case 1: Order New Diet—General/Healthful (unrestricted) Diet

Use Case Description

The purpose of this use case is to illustrate a physician or LIP ordering a diet in the patient record. This

diet order information needs to be shared with other care providers and hospital departments which

have specialized computer systems. Typically a physician will order a diet by selecting from a list of

diet modification codes defined at each hospital facility. The addition of a diet order is the trigger

event that will initiate meal service for a patient who is admitted to the hospital. The Food & Nutrition

Services department needs a diet order to notify them that a patient is able and allowed to eat. The

order should designate a start time or meal at which the new diet order is to take effect. This start

time may be a specific time (now or in the future) or meal. Upon receipt of the diet order information,

the Food & Nutrition Services operation will prepare and serve the patient diet-appropriate foods

according to the facility’s meal service policies. A diet order may have an expiration or end point time

such as a special diet needed for a specific test, but this is not common.

Conditions

This use case applies to the entry of any new diet order for a patient. The order should take effect at

the designated start time or meal specified in the order and should remain in effect until it is cancelled,

suspended, or superseded by a subsequent new diet order.

Preconditions

1. The patient has been admitted to an inpatient nursing unit of an acute care hospital

2. Admission nutrition screening has already been completed on the patient

3. The acute care hospital uses an electronic health record (EHR)

4. The acute care hospital uses CPOE

5. The acute care hospital uses an electronic food and nutrition management system (FNMS)

6. The acute care hospital EHR and FNMS share information via HL7 interface, either one-way or bi-

directional.

8

7. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)), registered dietitian

or (Healthcare Provider (PROV-RD)) and the diet clerk all have access to the EHR. The diet clerk

(DC) and the registered dietitian also have access to the FNMS.

Actors/RolesAaron Attending (Attending Physician - LIC/Author)Adam Everyman (Patient)Nancy Nightingale (Registered Nurse - PROV-RN)Connie Chow (Dietitian - PROV-RD)Diet Clerk (Need a name to assign)Foodservice Worker (Need a name to assign)

Use Case Sequence of Steps

1. Physician enters an order into CPOE system for a new diet selecting ‘General/Healthful’ diet code for patient Adam Everyman that is to begin immediately.

2. The Diet Order is sent to Food & Nutrition Services via HL7-compliant interface to the department’s food & nutrition management software system (FNMS).

3. FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to the CPOE sending system) and the FNMS patient record for Adam Everyman is updated with the new diet order details.

4. Food & Nutrition department prepares a meal tray with foods appropriate for the ordered diet for the patient according to the facility’s meal service procedures, which may be at the next scheduled meal service or for on-demand hotel-style meal delivery.

5. Meal tray is delivered to the patient.

Use Case Scenario

Adam Everyman, a 40-year old male with a fractured femur, is admitted to room 234 of GHH Inpatient

(orthopedic) Unit at Good Health Hospital at 16:30. Adam Everyman tells nurse Nancy Nightingale he

is hungry and wants to know when he can eat. Dr. Aaron Attending assesses the patient and

determines that he has no other medical conditions or complications at this time. Dr. Aaron Attending

enters a new diet order for a ‘General/Healthful’ diet without any therapeutic modifications to start

now (16:30) and to continue with no end date/time specified into the CPOE system of Good Health

Hospital. The diet order information is electronically transmitted to the Nutrition Services

department’s computerized food and nutrition management system (FNMS) which automatically

9

ITG, 04/28/11,

They need names too

ITG, 05/14/11,

We are assuming no room service? MKD: Don’t really know how or if we need to elaborate on the type of meal service operation that may be in use at the facility unless that changes the structure or transactional behavior of the diet order itself.

acknowledges receipt of the order transaction at 16:45 and updates the patient record for Adam

Everyman matching the diet code for ‘General/Healthful’ diet and sets that start time of that diet order

as of 16:30, which will allow Adam Everyman to receive a dinner meal tray. A diet clerk in the Nutrition

Services department uses the FNMS to generate tray tickets for dinner. Foodservice trayline workers

assemble a meal tray for Adam Everyman that includes food appropriate for General/Healthful dinner

meal. Adam Everyman receives his dinner meal tray according to the department’s meal service

delivery schedule.

10

ITG, 05/14/11,

Some interfaces are not real time. It could be delayed 15 minutesMKD: True –edited to indicate start time of the order that was sent.

Use Case 2: Order New Diet with Quantitative, Nutrient-based Modifications


The purpose of this use case is to describe the flow of information that will initiate meal service for an

admitted patient who requires a diet with multiple quantitative nutrient modifications such as that

required for a diabetic patient undergoing renal dialysis treatment.

• Example: 80 gm Protein + Consistent Carb + 2g Sodium + 2g Potassium + 800-1000 mg

Phosphorus + 1500 mL Fluid Restricted

Conditions

This use case applies to the entry of any new diet order for a patient requiring one or more diet

modifications that specify a quantity or range of a given nutrient. The order should take effect at the

designated start time or meal specified in the order and should remain in effect until it is cancelled,

suspended, or superseded by a subsequent new diet order.

Preconditions

Same as previously stated

Actors/Roles

Harold Hippocrates (Physician - Author)Eve Everywoman (Patient)Nancy Nightingale (PROV-RN)Connie Chow - Dietitian (PROV-RD)Diet ClerkFoodservice Worker


1. A patient with diabetes and chronic kidney disease (CKD) on dialysis (stage 5) is admitted to the hospital with edema. The patient weighed 72 kg at admission.

2. Registered Dietitian (RD) completes a nutritional assessment documenting the patient’s usual weight as 69 kg and a diet history that reveals that the patient’s typical food intake exceeds her recommended sodium, and potassium levels and her carbohydrate intake varies considerably contributing to uncontrolled blood glucose values. The RD calculates the patient’s protein needs given her dialysis treatments, e.g., 1.2 grams protein/kg body weight, and recommends a protein level diet of 80 gm protein/day. Protein level diets at Good Health Hospital are ordered in 10 gram

11

Margaret Dittloff, 05/14/11,

Per Anne Lougher: Use Case description - A diet order such as 1.2 gm/kg/day or 0.6 gm pro/kg/day is very difficult in the electronic medical record. For the order to be executed, the wt must be available. The wt must either be put into the system on the ordering side (many doctors are not likely to find the wt and put it into the order) or the wt must be put in on the FNMS side. In our system the doctor (or dietitian) calculates the pro needs prior to placing the order, then chooses from a list of pro restrictions such as 60 gm pro, 70 gm pro or 80 gm pro. That is the pro restriction order which interfaces to the FNMS. Step 6 that the RD reviews the patient's new order would not happen. First, with the direct interface the dietitian would not know the diet order was placed, and second, if the order came through in the evening, early morning or on a weekend, the dietitian would not be readily available.

increments, e.g., 60 gm pro, 70 gm pro, 80 gm pro, etc. The RD documents her nutrition recommendations in the EHR.

3. After reviewing the RD’s recommendations, the physician enters a new diet order for 80 gm protein + Consistent Carbohydrate + 2g sodium + 2g potassium + 800-1000mg Phosphorus + 1500 mL Fluid Restricted by selecting from the available diet codes in the CPOE system.

4. The diet order is sent to Food is sent to Food & Nutrition Services via HL7-compliant interface to the department’s FNMS.

5. FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to the CPOE sending system) and the FNMS inserts the new diet order details into the existing admission record patient record for Eve Everywoman.

6. Food & Nutrition department prepares a meal tray with appropriate foods to ensure that nutrients are within the prescribed quantities for the patient served according to the facility’s meal service operation procedures.

7. Meal tray is delivered to the patient.

Use Case Scenario

Eve Everywoman, a patient with diabetes and chronic kidney disease requiring dialysis is admitted to the hospital with an infection and edema. Eve’s usual weight is 69 kg and her admit weight was recorded as 70.5 kg. Connie Chow, the registered dietitian, completes a nutritional assessment for Eve including a diet history that reveals Eve has been eating foods high sodium and potassium while not controlling her carbohydrate intake. Connie documents her assessment findings and nutrition prescription recommendations in the EHR.

12

Use Case 3: Texture/Consistency Modifications


The purpose of this use case is to notify a Food & Nutrition Services department of an order that

relates to resident/patient texture modification. Texture modification is part of the diet order, and

may have different textures ordered for different food groups, e.g., ground meat, or individual foods

for one resident/patient. In addition, texture modification could include snacks and meals at different

consistencies recommended by the Speech and Language Pathologist (SLP) and/or the physician which

must be communicated to the Food & Nutrition Services department or resident/patient care staff.

Preconditions

1. The patient has been transferred from a nursing home and is admitted to an inpatient nursing unit

of an acute care hospital



4. The acute care hospital does not have a CPOE.


6. The acute care hospital EHR and FNMS share information via HL7 interface, either one-way or bi-

directional.


1. Resident/Patient swallowing status warrants a texture modification per the recommendations of the Speech/Language Pathologist.

2. The Speech/Language Pathologist per protocol writes an order for Puree diet. Since this particular order is not for a specific day or meal, it applies to all days and meals. Note: For multiple texture modifications for one resident/patient the SLP or authorized provider may write orders designating that the modification is for certain days, meals, or specific food groups/foods.

3. The written order is transcribed and entered into the EHR 4. Puree order is sent to Food & Nutrition Services via HL7-compliant interface to the department’s

food & nutrition management software system.

13

5. Once in the Resident’s/patient’s record, any tray ticket or snack/nourishment label printed from the FNSM for that patient will print with Puree listed.

Actors

Adam Everyman (Patient)Harold Hippocrates (Physician)Nancy Nightingale (Registered Nurse)Ellen Enter (Transcriptionist)Foodservice Staff Worker (need name)

Texture Modifications

Adam Everyman has been diagnosed with a Transient Ischemic Attack (TIA). Dr. Harold Hippocrates

writes an order for a Puree diet based on the recommendations of Speech Pathologist. Ellen Enter

transcribes the order into appropriate EHR screen where she selects Puree from a distinct drop-down

menu of Diet - Texture Modification options. When prompted for respective Days or Meals, Anne

enters ALL and ALL, since this order is not unique to a particular day or meal. Alternatively this could

be entered to begin now (0800) with no end or expire date-time. Once entered, this order is sent via

interface to the Food & Nutrition Services department’s nutrition management software system where

it automatically populates the appropriate area of the resident/patient record within that software

system.

As the next meal approaches, Joe Foodservice Worker executes functions in the department’s software

system that produces tray tickets for that meal. Smith Patient’s tray ticket prints with Puree the

designated area of the tray ticket. Joe’s co-workers who assemble resident/patient trays immediately

recognize that this order means that only puree items are to be served on the resident’s/patient’s tray.

14

Use Case 4: Diet Order change to ‘NPO for Tests’


The purpose of this use case is to describe the situation where a patient’s diet order must be changed

to ‘NPO’ to indicate that the patient is not allowed to eat or drink anything for a specified period of

time in preparation for medical tests that will be conducted. For patient safety reasons, this scenario

relies on entry of a separate, new diet order once the tests are completed indicating to foodservice

that the patient may resume eating rather than modeling this using an order with an explicit expire

time or suspending/holding the previous diet order.


1. Admitted patient, Adam Everyman, is transferred to the cardiac unit of the hospital and has an

active diet order for a ‘General/Healthful’ diet

2. Doctor orders lab tests (e.g., Lipid Profile) for tomorrow at 0600 that require an 8-hour fast.

Doctor changes the diet to ‘NPO for tests’ diet to be effective from 2200 after the evening meal

service. He also authorizes nursing to enter a new order diet order to resume the ‘General/Normal’

diet after tests are completed.

Orders are transmitted to FNMS of the Nutrition Services Department.

3. FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to the CPOE sending system) and the FNMS patient record for Adam Everyman is updated with the new diet order details.

4. The patient receives a meal service tray with appropriate foods according to the hospitals meal

service policies for the evening (dinner) meal.

5. The patient is not allowed to order any additional food or beverages after 2200 hours per the ‘NPO

for Tests’ diet order.

6. In the morning, the blood draw for the lab is delayed, so the patient should not be allowed to order

food until that is completed and the new diet order is sent. This is one reason food and nutrition

professionals responsible for patient meal do not want order to have a set expire time as many

15

7. Patient’s blood is drawn by the lab tech at 0735 and the patient is hungry, so per the physician’s

authorization the nurse enters a new diet order to resume the ‘General/Healthful’ diet effective

immediately.

8. FNMS receives the new diet order for ‘General/Healthful’ diet so the patient is once again allowed

to order/receive meals.

9. Nutrition Services department prepares and delivers a breakfast tray to the patient.

16

Use Case 5: Pediatric Specialty Orders – NEED TO DOCUMENT


The purpose of this use case is to describe the information required for typical pediatric diet orders.

Such orders will include orders for breast feeding and infant formulas including any necessary additives

or fortifiers.

Components of an infant formula order:

Infant formula and/or fortified breastmilk orders are placed by the physician or dietitian based upon

the nutrient and caloric density required by infant. The caloric concentration of standard

manufacturer infant formulas is 20 kcal/oz (0.67 kcal/mL). Hospitalized infants often require higher

caloric concentrations, so formulas are mixed using high-calorie concentrated liquids (40 kcal/oz or

1.33 kcal/mL) or high-calorie ready-to-feed (22- or 24-kcal/oz) formulas to prepare the total volume of

formula required.

Base Formula Product by caloric density in kcal/oz (US/Canada) or kcal/30mL (Australia/Canada) or kJoules/30mL(Australia) (Need to verify this with international representatives)

o Standard caloric densities – 20 kcal/oz (kcal/30mL), 22, 24, 26, 27, & 30 ProductA, 24 kcal/oz

Modular Additives – Additional components may be mixed with the base formula in specific amounts or to add a certain number of kcals, carbohydrate, protein, and/or fat, such as “plus Glucose Additive to 27 kcals/oz.”

Carbohydrate Additive (Liquid or Powder - 2 kcal/mL) Total caloric density (sum of base + additives) in kcals or kJoules per oz or 30mL or 100 mL

To total of 27 kcal/oz Feeding frequency – e.g. every 3 hours or 8 feedings/day Volume per feeding – 3 oz (90 mL)o Total volume of feeding required per day – 24 oz (720 mL)

Infant Formula Example:

Formula Product A (24 kcal/oz) + CHO Additive = 27 kcal/oz

60 mL x 7 feedings/day

17

ITG, 05/15/11,

Contact reviewers Pavlinac and Jain for review

Conditions

Preconditions

Same as previously stated

Actors/Roles

Karen Kiddler (Pediatrician)Kari Kidd (Patient)Nancy Nightingale (PROV-RN)Connie Chow - Dietitian (PROV-RD)Formula Room Technician


Use Case Scenario

Karen Kidd is a 2-week old infant in the Neonatal Intensive Care Unit (NICU) at Good Health Hospital.

18

Use Case 6: Order Oral Nutritional Supplement



relates to the provision of an oral nutritional supplement.

Conditions

This use case applies to oral beverage supplements including commercial products which are often

vitamin/mineral modified and house-made preparations such as shakes made from milk and ice cream

products. Specifications may be by name or by desired nutrient composition. Use of a supplement

may be in addition to other diet orders or be the sole source of oral nutrient intake.

Exclusions

This use case does not include use of commercial or house-made supplements for tube-feedings.

Products used may be identical, but this use case will only address those for oral consumption. The use

case does not address herbal or encapsulated dietary supplements dispensed by pharmacy or brought

by patients from home.

Preconditions




4. The acute care hospital uses CPOE


6. The acute care hospital EHR and FNMS share information via a one-way or bi-directional interface.

7. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)) and registered

dietitian or (Healthcare Provider (PROV-RD)) have access to the EHR. The diet clerk (DC) and the

registered dietitian have access to the FNMS.

Actors/Roles

Rachel Resident (Physician - Author)

Connie Chow (Dietitian – PROV(RD)

Nancy Nightingale – (Registered Nurse - PROV(RN)

19

ITG, 04/28/11,

I would differentiate between commercial products which are vitamin/mineral modified and a milkshake from milk and ice cream. The concern is the extra nutrient load

Adam Everyman (Patient – PAT)

DC – Chris Clerk (?role code for non-providers)

SDLOC – service delivery location


1. Trigger: Patient requires additional source of calories/protein/carbohydrate/fat.2. LIC (role) enters supplement (entity) as medical order (act) into EHR

a. (Alternative) RN or RD enter medical order into EHR and LIP countersigns orderb. (Alternative) RN or RD enter service order into EHR

3. Order sent to FNMS via interfacea. PAT roleb. Service location rolec. Act – diet code based on quantity, status, timing d. Entity – general statement about the supplement, material state

4. Order received and fulfilled by DC in FNMS5. Order fulfillment sent by FNMS to EHR6. Order resulted in EHR7. PAT receives supplement8. Alternate act states for cancellation, suspension

Use Case Scenario

Adam Everyman is admitted to Good Health Hospital with second degree burns. A high-calorie diet is

ordered but the RD notes that the patient is still not consuming adequate calories. The RD confers

with the LIP and they agree that a liquid oral supplement should be provided to Adam Everyman.

The LIC enters a supplement order into the EHR. The order contains the following information:

1. The patient name2. The patient identifier3. Prescriber4. Patient location5. Date/Time of order6. The name of the supplement (commercial canned or house-made) or the desired

nutrient composition of the supplement7. Start Date/Stop Date8. Start Time/Stop Time or meal/nourishment association9. Quantity per administration

20

ITG, 04/28/11,

This is usually not given

Sodexho, 05/03/11,

Following info is required for all diet orders also. Specified in this section only.

ITG, 04/28/11,

If an order needs to be resulted then there would be a delay in feeding the patient; we don’t require this

ITG, 04/28/11,

This seems very FNMS specific language; I don’t know what that is

The order is then electronically passed from the EHR to the FNMS. The FNMS acknowledges receipt of

the order. The FNMS places the new order information into its patient record. The RD (or DC) reviews

the order to ensure it is accurate and appropriate, or the FNMS has the ability to determine if the

supplement is appropriate based on other diet orders. The DC then utilizes the FNMS to issue the

desired supplement from inventory (or preparation instructions) and a delivery ticket to accompany

the supplement to the patient location. Once a delivery ticket is generated,, the FNMS then returns an

electronic message to the EHR to result the order with the following information:

1. The patient name2. The patient identifier3. Date/Time of order fulfillment4. The name of the supplement provided

Adam Everyman receives his supplement.

21

ITG, 04/28/11,

I would add consumption of the product in the Intake/Output section of the EHR

Margaret Dittloff, 04/17/11,

Ticket or label printing may not be enough evidence to signify that the supplement has been delivered to the patient. This might be enough to trigger a promise to deliver the supplement; however the initial acknowledgement of the order receipt would have done the same. Need to further flush out system roles and responsibilities in v3.

Use Case 7: Order Enteral Nutrition (Tube Feeding)


The purpose of this use case is to notify a Food & Nutrition Services department that a patient requires

an enteral tube feeding. ASPEN (American Society for Enteral and Parenteral Nutrition) defines

“enteral nutrition” as “nutrition provided through the gastrointestinal tract via a tube, catheter, or

stoma that delivers nutrients distal to the oral cavity.” Best practices for enteral nutrition (EN) orders

recommend that all of the following are documented in the EN order request: (1) patient

identifiers/demographics including age and weight, (2) formula and/or modular components required

to meet the patient’s specific nutritional needs, (3) identification of enteral access delivery site and

device (route and access), and (4) administration method and rate.

Conditions

This use case applies to enteral or tube feeding orders that require one or more products, whether

commercially pre-prepared formula or mixed on site to include modular components, for

administration through an enteral access device which is defined as a “tube placed directly into the

gastrointestinal tract for the delivery of nutrients or drugs” (ASPEN Enteral Nutrition Practice

Recommendations, JPEN 2009). Use of a tube feeding may be in addition to an oral diet order and/or

total parenteral nutrition; or EN may be the sole source of nutrient intake for an individual unable to

consume food or beverages by mouth.

Exclusions

This use case does not include nutritional supplements that a person would consume orally although

some products used for enteral/tube feeding formulas are also suitable as oral supplements; nor does

it include parenteral nutrition orders that require intravenous administration of nutrients. Note:

Infant enteral formulas are a special sub-case of this main enteral nutrition order use case (to be added

later).

Preconditions


2. Patient has had an enteral access device (tube) successfully placed and has been assessed and

deemed ready to initiate enteral feedings

22

3. The acute care hospital has established a formulary of available enteral formulas specific to the

institution based upon patient population needs


5. The acute care hospital uses CPOE (Computerized Provider Order Entry)


7. The acute care hospital EHR and FNMS share information via HL7-compliant interfaces

8. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)) and registered

dietitian/nutrition support specialist or (Healthcare Provider (PROV-RD)) have access to the EHR.

The Formula Room Technician (FT) and the registered dietitian have access to the FNMS..

Actors/Roles with class codes

Aaron Attending (Physician - LIC)Connie Chow (Registered Dietitian/Nutrition Support Specialist - PROV (RD))Nancy Nightingale (Registered Nurse - PROV(RN))Adam Everyman (Patient - PAT)FT – Francis Tech (What is the name and role code for non-providers?)SDLOC – service delivery location (patient’s admit location – unit-room-bed)

Use Case Sequence of Steps – New Enteral Nutrition Order

1. Enteral access device (Nasogastric tube) placement is confirmed and patient is assessed and ready to begin enteral nutrition feeding. (Pre-condition)

2. LIC (role) enters the enteral nutrition order (entity) as medical order (act) into CPOE/EHRa. LIP (or LIC as used her) would enter directly into EHRb. RN or RD/CNSD enter medical order into EHR as per hospital policy

3. EN order sent electronically to FNMS via interfacea. PAT roleb. Service location rolec. Entity – d. Act – status, timing, data about the entity

i. Mood – Request (RQO))e. Act Class – Substance Administration

4. Order is received by FNMS and order receipt is acknowledgeda. FNMS needs to correlate this EN tube feeding order with the medical diet order (Note: The FNMS

needs to be notified if this patient is to receive solely tube feedings or whether he also requires food; this needs to be communicated in conjunction with diet order information.)

23

ITG, 05/15/11,

Is this Mode? Also seems very specific to a FNMS brandMKD: Reference here is to HL7 Ref. Information Model

5. FNMS user (Formula Room Technician) prepares or assembles the required enteral products for delivery to the patient’s unit (service delivery location). FNMS generates patient-specific labels as required.

6. Enteral products for this patient are delivered to the unit to fulfill this order.7. Upon receipt of proper formula and at the designated order start time, PROV-RN (role) begins the enteral

feeding at the initial rate. 8. Initiation of EN is documented in the EHR.9. PROV-RN advances feedings (rate and/or volume increases) as directed by the EN order protocol and

documents each increase in EHR and any signs of feeding complications.a. (Is this Substance Admin or Observation?)

10. Adjustments to various components (rate, formula, etc) of enteral nutrition orders are very common as patients may experience complications or may not fully tolerate the feedings.

Use Case Scenario

Adam Everyman, a 55-year old male motor vehicle accident victim with multiple rib fractures, major

lung contusions and haemothorax that has been drained is admitted to the Intensive Care Unit of Good

Health Hospital from the Emergency Department for ventilator support. A nasogastric enteral access

device has been placed and radiograph (X-ray) has confirmed proper placement. The patient has been

assessed is now haemodynamically stable enough to begin enteral nutrition feedings while he awaits

further surgery. After consultation with the nutrition support dietitian, a standard, polymeric enteral

formula was selected from the hospital’s established formulary and a total energy target of 20-25

kcal/kg body actual weight with 1.2 – 1.5 grams protein/kg ideal body weight has been set. Aaron

Attending designates a diet order of NPO (no oral food intake) and the following enteral nutrition order

using City Hospital’s EN order set protocol that directs advancement of the feedings from initiation to

the target goal rate within the CPOE system (see sample Adult EN Order Form):

Name: Thomas Trauma MRN: 00999 DOB: 1/9/1956

Room: ICU – 10 Dosing Weight: 83.2 kg

Formula: Standard* * Could be generic description of types or product-specific e.g., Osomolite

Delivery Site Route: Gastric Access: Nasogastric

Method of Administration: Pump-assisted

Rate:_20__Initial mL/hour Advance by: 10 mL/hour every _4_hour(s) to goal of 70 mL/h

Order Start Date/Time: 20110109 @ 1400

The NPO diet and EN orders are received electronically in the FNMS. Francis Technician verifies the

orders received in the FNMS. She prepares and labels the required amount of enteral formula

24

products for transport to the unit. Upon receipt of the product at the unit, Nancy Nurse verifies the

formula against the enteral nutrition orders and starts the tube feeding at the initial rate of 20

mL/hour following normal administration protocols (sterile water for flushing the tube, elevated head

of bed, etc.) recording the date and time the formula is spiked/hung on the product label and in the

EHR. After 4 hours if there are no observed feeding complications or contraindications, Nancy Nurse

will increase the pump rate to 30 mL/hour and continue that process over the next 24 hours until the

goal rate is achieved or the EN orders are modified.

25

Use Case 8: Meal/Special Service Designation Order

(Note: Needs work – need to revise actor names and abbreviations and put into above format.)



relates to patient tray delivery. As opposed to a diet order, a Meal/Special Service Designation is a

message either about delivery time (eg, Hold Tray, Late Tray, Early Tray), adaptive equipment (eg,

Built-up Spoon, Plate Guard), staff assistance (eg, Cut Up Meat, Open Cartons), or isolation precautions

(eg, Isolation Tray, Disposable Dishes). In addition, a Meal/Special Service designation could include

messages such as Tray to Nurse’s Station, VIP, Suicide Precautions, or any other messaging relevant to

and desired by the Food & Nutrition Services department or patient care staff.


1. Patient’s diagnosis warrants isolation precautions; physician writes/enters order for Isolation Tray.2. Since this particular order is not for a specific day or meal, ALL is selected for Days and Meals.3. Isolation Tray order is sent to Food & Nutrition Services, either via HL7-compliant interface to the

department’s food & nutrition management software system, or via a printout in the department.4. Once in the patient’s record, any tray ticket or snack/nourishment label for that patient will print

with Isolation Tray listed.

For sensitive messages (eg, Suicide Precautions), rather than printing on the patient’s tray ticket as

such, either a departmentally-defined code could be used (eg, ******) or the particular services could

be set to not print on the tray ticket. Staff could instead obtain a list of respective patients via an on-

demand report and adjust trays accordingly.

Actors

Prescott PatientDaniel DoctorUma Unit SecretaryFrank Foodservice Staff Worker

26

Use Case Scenario for Meal/Special Service Designation

Prescott Patient has been diagnosed with H1N1 influenza. Daniel Doctor gives a verbal order for

Isolation Tray (Disposable Dishes) to Uma Unit Secretary. Uma Unit Secretary proceeds to the

appropriate EHR screen where she selects Isolation Tray from a distinct drop-down menu of

Meal/Special Service options. When prompted for respective Days or Meals, Uma enters ALL and ALL,

since this order is not unique to a particular day or meal (as opposed to, for example, Early Tray for

tonight’s dinner only). Once entered, this order is sent via interface to the Food & Nutrition Services

department’s nutrition management software system where it automatically populates the

appropriate area of the patient record within that software system.

As the next meal approaches, Frank Foodservice Worker executes functions in the department’s

software system that produce tray tickets for that meal. Prescott Patient’s tray ticket prints with

Isolation Tray in large font in the designated area of the tray ticket. Frank’s co-workers who assemble

patient trays immediately recognize that this order means that only paper or plastic dishes and utensils

are to be used for this patient’s tray.

Prescott Patient is served his tray on entirely disposable materials. After Prescott finishes consumption

of his meal, the staff member discards the entire tray and all its contents.

27

Use Case 9: Request RD/Nutrition Consult


The purpose of this use case is to place an order for a dietitian to consult on a hospital inpatient and

the subsequent fulfillment of that order request.

Summary:

1. LIC instantiates dietitian consultation order in the EHR.

2. Order is communicated to RD directly via EHR reports/alerts as well as via an interface to the

FNMS.

3. RD receives order, completes requested service and documents service.

Actors/Roles with class codes

LIC – Daniel Doctor

PROV-RD (Registered Dietitian/Nutritionist Healthcare Provider)

Hospital Unit Clerk (Data Entry)

Preconditions:


2. A need for RD consultation is determined by the LIC

3. The RD is authorized to provide all nutrition-related consultation services requested by the LIC

4. Nutrition-related consultation services include, but are not limited to: Patient nutrition

assessment, follow-up evaluation, education assessment, patient counseling, patient education,

discharge assessment, calorie count, TPN order recommendation, enteral feeding

recommendation.


6. The acute care hospital uses a electronic medical record or EHR.

7. The acute care hospital also uses an EOS

8. The LIC, RD and HUC are authorized users of the EOS

28

9. The acute care hospital also uses an EDS

10. The LIC, RD and HUC are authorized users of the EDS

11. The acute care hospitals EDS and EOS share information via a bi-directional interface (or may be

integrated as one EHR).

12. The acute care hospital does not use CPOE

Glossary:

Term Definition

AF1 Alternate Flow 1



CD

Communication Device: A regular telephone, cellular phone, pager, radio, or

other communication hardware by which one individual communicates a

message to another individual verbally or using readable text.

CO

Communication Output: A record by which the results of communication from

one individual can be viewed by another individual. May include, but is not

limited to: Automated computer print-out, computer report viewed on print

output or on-screen, or paper message delivered by hand/pneumatic tube

system or other means.

CPOE Computerized Physician Order Entry

EDS Electronic Documentation System

EHR Electronic Health Record

EOS Electronic Ordering System

HUC Hospital nursing Unit Clerk

LICLicensed Independent Practitioner: Physician, Physician Assistant, Nurse

Practitioner, or other licensed individual authorized to place patient orders.

NSD Nutrition Services Department

PMR Paper Medical Record

RD Registered Dietitian

29

Sodexho, 05/06/11,

Why LIC and not LIP

RDCO Registered Dietitian Consult Order

TPN Total Parenteral Nutrition

Basic Flow:

Line Actor Action System Response

1 LIC writes order in PMR for RDCO

2In reviewing PMR for orders, HUC finds

RDCO.

3 HUC logs into EOS HUC log-in authenticated

4 HUC enters RDCO into EOS EOS confirms entry of RDCO

5HUC initials PMR to affirm that RDCO

has been processed.

6 NDS receives RDCO via CO

7 NDS communicates RDCO to RD via CD

8 RD receives RDCO

9 RD completes requested service(s)

10 RD logs into EDS RD log-in authenticated

11RD selects patient for whom service(s)

was/were provided.EDS displays appropriate patient

12 RD documents service(s) provided

EDS prompts RD to affirm that

documentation is correct and to

electronically sign documentation.

13

RD clicks on appropriate button to

affirm electronic signature for

documentation.

EDS confirms signed documentation

14 EDS communicates completed RDCO to EOS

15 RD signs out of EDS

Post Conditions:

The requested service for the patient has been completed and the nutrition staff takes

30

this service into consideration in planning for any additional care for the patient.

Alternate Flows:

AF1 – EHR with Full CPOE

Preconditions:

1. Assume basic flow preconditions # 1-5

2. Acute care hospital has EHR with fully functioning CPOE

3. The LIC, RD and HUC are authorized users of the EHR

Line System Actor Action System Response

1 LIC logs into EHR LIP log-in authenticated

2 LIC selects appropriate patient EHR displays appropriate patient

3 LIC enters RDCO EHR confirms entry of RDCO

4EHR automatically communicates RDCO to

RD via CD.

5 RD receives RDCO


7 RD logs into EHR RD log-in authenticated


was/were provided.EHR displays appropriate patient

9 RD documents service(s) provided

EHR prompts RD to affirm that



10



documentation.

EHR confirms signed documentation

11 RD signs out of EHR

Post Conditions:


31


AF2 – EHR + Order Set

Preconditions:


2. Acute care hospital has EHR with CPOE that generates printed order sets

3. The LIC, RD and HUC are authorized users of the EHR


1 LIC logs into EHR LIP log-in authenticated

2 LIC selects appropriate patient EHR displays appropriate patient

3 LIC enters RDCO EHR confirms entry of RDCO

4 EHR prints copy of order set

5 LIC logs out of EHR

6 LIC places order set in PMR


RDCO.

8 HUC logs into EHR HUC log-in authenticated

9 HUC enters RDCO into EHR EHR confirms entry of RDCO

10EHR automatically communicates RDCO to

RD via CD.


has been processed.

12 RD receives RDCO


14 RD logs into EHR RD log-in authenticated


was/were provided.EHR displays appropriate patient

16 RD documents service(s) provided EHR prompts RD to affirm that


32


17



documentation.

EHR confirms signed documentation

18 RD signs out of EHR

Post Conditions:



AF3 – Simple PMR

Preconditions:



1 LIC writes order in PMR for RDCO


RDCO.

3HUC communicates RDCO to NDS via

CO or CD.


has been processed.

5 NDS receives RDCO via CO

6 NDS communicates RDCO to RD via CD

7 RD receives RDCO


9RD documents service(s) provided;

signs and dates documentation.

Post Conditions:

33



Questions:

What other use cases are connected to the RDCO? The calorie count service requires interim

work by diet technicians, nursing or others before the RD can document completion.

The TPN recommendation service requires assessment and calculation work on the part of the

dietitian as well as possible collaboration with pharmacy.

How many additional alternate flows are possible? Only 4 variations are shown in order to

highlight some of the most common situations, however numerous iterations are possible

based on the combination of systems and work flows available in different hospitals.

How would other task list, messaging and alerting functionality of systems affect the use case?

Many EHR’s available today offer more sophisticated work flow processing with these tools.

Story Board:

- Provider writes order for dietitian consult in paper medical record; signature and date/time written

by provider.

- While processing new patient orders from the paper medical record, unit clerk finds the dietitian

consult order, enters it in the ordering section of the electronic health record (EHR) and initials the

order in the paper medical record.

34

Sodexho, 05/06/11,

Task needs to be created for RD for assessment. Recommendations needs to be linked as communication to pharmacy and LIC.

Sodexho, 05/06/11,

Calorie count form needs to be created in HER. Task needs to be generated for nursing, diet tech etc as a continuos task for three days. Task needs to be created for RD every day for three days,

- The dietitian consult order is communicated through the EHR to the Nutrition Services Department

(print out, page, text message to cell, periodically printed report).

- The Nutrition Services Department contacts the dietitian responsible for the patient on which the

order was placed and communicates the details of the consult order.

- The dietitian completes the requested service, and then documents the care in the EHR with

appropriate signature, date and time.

35

Sodexho, 05/06/11,

OR task list is created in EHR

Sequence and Activity Diagrams

36

Glossary

(Need to merge with existing HL7 Glossary + EHR Functional Model + Nutrition CME sources)

Diet – (V3) A supply Act dealing specifically with the feeding or nourishment of a subject. The detail of the diet is given as a description of the Material associated via Participation.typeCode = “product”. Medically relevant diet types may be communicated in Diet.Code, however, the detail of the food supplied and the various combinations of dishes should be communicated as Material instances. Examples – gluten free, low sodium.

From HL7 Glossary: A diet consists of the diet codes, supplements, and preferences effective at a given time. These three specifications govern which foods a patient will receive. Diets generally do not have a stated ending time to ensure that the patient always receives food.Diet Code - A diet code defines which foods a patient may receive; a patient must have at least one diet code to receive food.Dietary Orders - An order for a patient diet. A patient may have only one effective dietorder at a time.Diet.energyQuantity (PQ): deprecated concept. Convey quantity using a content relationship with an attribute expressing “calories”. The physical quantity SHOULD be convertible to 1 kcal/d (or 1 kJ/d).Diet.carbohydrateQuantity (PQ): express content relationship to an entity with a code of “carbohydrate” and a quantity attribute on the content relationship e.g. the supplied amount of carbohydrates per day. Convey carbohydrate restriction in the carbohydrateQuantity. Use case in grams, but not constrained to this unit of measure.EHR – Electronic Health Record: A comprehensive, structured set of clinical, demographic, environmental, social, and financial data and information in electronic form, documenting the health care given to a single individual.(ASTM E1769, 1995) Various, including DC.1Material (MAT): A subtype of Entity that is inanimate and locationally independent. Example – food. ODS - (New with Version 2.2) Dietary orders, supplements and preferences segment.ODT - (New with Version 2.2) Diet tray instructions segment.OMD - Dietary order message.ORD - Dietary order - General order acknowledgement messageOrder - An order is a request for a service from one application to a second application. The second application may in some cases be the same, i.e., an application is allowed to place orders with itself. Usually orders are associated with a particular patient.Order Detail Segment - One of several segments that can carry order information. Examples are OBR and RXOSupply (SPLY): provision of a material by one entity to another. Provide Material classTrigger Event The event that initiates an exchange of messages is called a trigger event. The HL7 Standard is written from the assumption that an event in the real world of health care creates the need for data to flow among systems. The real-world event is called the trigger event. For example, the trigger event “a patient is admitted” may cause the need for data about that patient to be sent to a

38

Sodexho, 05/06/11,

One diet order will not cover diets such as renal, diabetic, pureed with nectar thick liquids.

number of other systems. There is a one-to-many relationship between message types and trigger event codes. The same trigger event code may not be associated with more than one message.

39

References and AcronymsHL7 Healthcare Development Framework Version 1.5 Release 1

Acronym Meaning Note

EHR Electronic Health Record

EMR Electronic Medical Record

HDF HL7 Development Framework The HL7 development methodology

PHR Personal Health Record

40

Appendix: Storyboard naming standardsTable 5: Patient Information for Storyboards

Cast Family Given MI Gender SSN

patient, female Everywoman Eve E F 444-22-2222

patient, male Everyman Adam A M 444-33-3333

patient, child Kidd Kari K F 444-55-5555

family, daughter Nuclear Nancy D F 444-11-4567

family, husband Nuclear Neville H M 444-11-1234

family, son Nuclear Ned S M 444-11-3456

family, wife Nuclear Nelda W F 444-11-2345

next of kin (parent) Mum Martha M F 444-66-6666

next of kin (child) Sons Stuart S M 444-77-7777

next of kin (spouse) Betterhalf Boris B M 444-88-8888

next of kin (other) Relative Ralph R M 444-99-9999

contact person Contact Carrie C F 555-22-2222

Table 6: Healthcare Staff for Storyboards


healthcare provider Seven Henry L M 333-33-3333

assigned practitioner Assigned Amanda A F 333-44-444

physician Hippocrates Harold H M 444-44-4444

primary care physician Primary Patricia P F 555-55-5555

admitting physician Admit Alan A M 666-66-6666

attending physician Attend Aaron A M 777-77-7777

referring physician Sender Sam S M 888-88-8888

intern Intern Irving I M 888-22-2222

resident Resident Rachel R F 888-33-3333

chief of staff Leader Linda L F 888-44-4444

authenticator Verify Virgil V M 999-99-9999

specialist Specialize Sara S F 222-33-3333

allergist/immunologist Reaction Ramsey R M 222-22-3333

HL7 Version 3 Domain Analysis Model: Diet and Nutrition OrdersDraft Release 1.0 – Use Cases and StoryboardsJanuary 2010 WGM

HL7 Version 3 Diet Orders 42


anesthesiologist Sleeper Sally S F 222-66-6666

cardiologist Pump Patrick P M 222-33-4444

cardiovascular surgeon Valve Vera V F 222-33-5555

dermatologist Scratch Sophie S F 222-33-6666

emergency medicine specialist Emergency Eric E M 222-33-7777

endocrinologist Hormone Horace H M 222-33-8888

family practitioner Family Fay F F 222-33-9999

gastroenterologist Tum Tony T M 222-44-2222

geriatrician Sage Stanley S M 222-44-3333

hematologist Bleeder Boris B M 222-44-3344

infectious disease specialist Pasteur Paula P F 222-44-5555

internist Osler Otto O M 222-44-6666

nephrologist Renal Rory R M 222-44-7777

neurologist Brain Barry B M 222-44-8888

neurosurgeon Cranium Carol C F 222-44-9999

OB/GYN Fem Flora F F 222-55-2222

oncologist Tumor Trudy T F 222-55-3333

ophthalmologist Vision Victor V M 222-55-4444

orthopedic surgeon Carpenter Calvin C M 222-55-5545

otolaryngologist (ENT) Rhino Rick R M 222-55-6666

pathologist Slide Stan S M 222-44-4444

pediatrician Kidder Karen K F 222-55-7777

plastic surgeon Hollywood Heddie H F 222-55-8888

psychiatrist Shrink Serena S F 222-55-9999

pulmonologist Puffer Penny P F 222-66-2222

radiologist Curie Christine C F 222-55-5555

rheumatologist Joint Jeffrey J M 222-66-3333

surgeon Cutter Carl C M 222-77-7777

urologist Plumber Peter P M 222-66-4444

physician assistant Helper Horace H M 222-66-5555

registered nurse Nightingale Nancy N F 222-88-8888



nursing assistant Barton Clarence C M 222-99-9999

chiropractor Bender Bob B M 222-66-6666

dentist Chopper Charlie C M 222-66-7777

orthodontist Brace Ben B M 222-66-8888

optometrist Specs Sylvia S F 222-66-9999

pharmacist Script Susan S F 333-22-2222

podiatrist Bunion Paul B M 222-77-2222

psychologist Listener Larry L M 222-77-3333

lab technician Beaker Bill B M 333-44-4444

dietician Chow Connie C F 333-55-5555

social worker Helper Helen H F 333-66-6666

occupational therapist Player Pamela P F 222-77-6666

physical therapist Stretcher Seth S M 222-77-8888

transcriptionist Enter Ellen E F 333-77-7777

Pastoral Care Director Sacerdotal Senior S M 333-77-7777

Chaplain Padre Peter P M 333-77-7777

Informal Career Comrade Connor C M 333-77-7777

Electrophysiologist Electrode Ed E M 333-77-7777

Laboratory Specimen Processor Spinner Sam S M 333-45-4545

IT System Administrator Admin I. T. M 333-33-3333

Table 7: Organizations for Storyboards


Organizational Roles

Role Name Phone Address City State

healthcare provider organization Level Seven

Healthcare, Inc.

555-555-

3001

4444

Healthcare

Drive

Ann Arbor MI

healthcare insurer #1 HC Payor, Inc. 555-555-

3002

5555 Insurers

Circle

Ann Arbor MI

healthcare insurer #2 Uare Insured, Inc. 555-555-

3015

8888 Insurers

Circle

Ann Arbor MI

employer Work Is Fun, Inc. 555-555-

3003

6666 Worker

Loop

Ann Arbor MI

Health Authority Health Authority

West

terminology provider Titan Terminology 555-555-

3099

22 Wordy Way Ann Arbor MI

Table 8: Facilities for Storyboards


healthcare provider Community Health

and Hospitals

555-555-

5000

1000 Enterprise

Blvd

Ann Arbor MI

hospital Good Health

Hospital

555-555-

3004

1000 Hospital

Lane

Ann Arbor MI

hospital unit (e.g., BMT) GHH Inpatient Unit 555-555-

3005 (ext

123)

hospital ward GHH Patient Ward 555-555-

3006 (ext

456)

hospital room GHH Room 234 555-555-

3007 (ext

789)

emergency room GHH ER 555-555-

3008 (ext

246)



operating room GHH OR 555-555-

3009 (ext

321)

radiology dept. GHH Radiology 555-555-

3010 (ext

654)

laboratory, in-house GHH Lab 555-555-

3011 (ext

987)

pharmacy dept. GHH Pharmacy 555-555-

3012 (ext

642)

outpatient clinic GHH Outpatient

Clinic

555-555-

3013 (ext

999)

urgent care center Community Urgent

Care

555-555-

4001

1001 Village

Avenue

Ann Arbor MI

physical therapy clinic Early Recovery Clinic 555-555-

4006

1010 Village

Avenue

Ann Arbor MI

home health care clinic Home Health Care

Clinic

555-555-

4008

1030 Village

Avenue

Ann Arbor MI

chiropractic clinic Bender Clinic 555-555-

4009

1040 Village

Avenue

Ann Arbor MI

optician clinic See Straight

Opticians

555-555-

4010

1050 Village

Avenue

Ann Arbor MI

pharmacy, retail Good Neighbor

Pharmacy

555-555-

4002

2222 Village

Avenue

Ann Arbor MI

laboratory, commercial Reliable Labs, Inc. 555-555-

4003

3434 Industrial

Loop

Ann Arbor MI

nursing or custodial care facility Green Acres

Retirement Home

555-555-

4004

4444

Nursinghome

Drive

Ann Arbor MI

residential treatment facility Home Away From 555-555- 5555 Ann Arbor MI



Home 4005 Residential

Lane

satelite clinic Lone Tree Island

Satellite Clinic

555-555-

5001

1001 Lone Tree

Rd

Ann Arbor MI

satelite clinic Stone Mountain

Satellite Clinic

555-555-

5002

1000 Mountain

Way

Ann Arbor MI

satelite clinic Three Rivers

Satellite Clinic

555-555-

5003

1000 River

Drive

Ann Arbor MI

satelite clinic Bayview Satellite

Clinic

555-555-

5004

1000 Lakeside

Drive

Ann Arbor MI

hl7 version 3 diet orders - health level seven...

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