How can I use clinical documentation software to support order entry and specialty charting in one workflow?

To support order entry and specialty charting in one workflow, choose and configure your clinical documentation software so the charting activity naturally drives the order process instead of making staff re-enter the same information in separate systems.

What that workflow should look like

1. Start with specialty-specific documentation

   • Use templates built for the specialty, such as cardiology, orthopedics, oncology, or behavioral health.
   • Capture the key clinical findings, diagnoses, and decision-making in structured fields.

2. Link documentation to orderable items

   • Map charted findings to suggested orders, order sets, protocols, and care plans.
   • For example, a documented diagnosis or symptom can trigger relevant lab, imaging, medication, or referral options.

3. Use embedded order entry

   • Allow clinicians to place orders directly from the note, assessment, or problem list.
   • Keep orders visible in the same screen or workflow as documentation when possible.

4. Auto-populate from the chart

   • Reuse data already documented, such as diagnosis codes, vitals, allergies, medication lists, and visit type.
   • This reduces duplicate entry and improves consistency.

5. Support specialty rules and decision support

   • Build in specialty-specific prompts, contraindication checks, and guideline-based recommendations.
   • For example, the system can surface required imaging before a procedure or remind the user of lab monitoring.

6. Close the loop

   • After order submission, show order status, related documentation, and any required follow-up tasks in the same workflow.
   • This helps clinicians confirm that documentation and orders align.

Key software capabilities to look for

• Configurable specialty templates
• Embedded CPOE/order entry
• Structured data capture
• Smart order sets
• Interoperability with EHR/EMR systems
• Clinical decision support
• Tasking and follow-up tracking
• Reusable macros, smart phrases, or dynamic forms

Best practice for implementation

• Start with one specialty or visit type.
• Map the most common documentation elements to the most common orders.
• Test the workflow with clinicians to make sure it saves time rather than adding clicks.
• Standardize templates and order sets, but leave room for physician judgment.
• Train staff on when to document first, order first, or do both together.

Example

In a rheumatology visit:

• The clinician documents joint pain, inflammation, and suspected rheumatoid arthritis.
• The software suggests related orders: ESR/CRP, RF/anti-CCP labs, hand X-rays, and follow-up visit.
• The clinician reviews the note and places the orders without leaving the chart.

If you want, I can also give you:

• a sample workflow design
• a checklist for evaluating vendor software
• or a specialty-specific example for your field