Template

Order Set & Clinical Pathway Review Template (Interactive)

An interactive, governance-ready review template for order sets and clinical pathways that captures checklist responses, version metadata, stakeholder sign-off, test and rollback plans, risk rating, and scheduled audits. Submissions are stored for auditability and follow-up.

Interactive Tool

Order Set & Clinical Pathway Review

This interactive template guides clinicians and informatics teams through a governance-ready review of an order set or clinical pathway. Complete required fields, answer checklist items, paste reference links, and capture stakeholder sign-off. Submissions are stored for audit and version control.

Use this form when proposing a new order set, updating an existing one, or during scheduled audits.

Clear, organizational name for the order set or pathway.
Local identifier or EHR order set code.
Clinical service responsible (e.g., Cardiology, Emergency).
Existing version identifier.
Version number to apply if approved.
Date of this review (YYYY-MM-DD).
Primary reviewer completing this form.
Person responsible for clinical content.
Person who proposed the change or owns the order set.
Select 'No' if literature review or guideline alignment is incomplete.
Summarize evidence, key references (paste URLs or citations), and date of last literature review.
Includes order triggers, contraindications, alerts, and dosing logic.
Describe any logic errors, needed rule changes, or performance concerns.
Include pharmacy review results and automated safety testing.
Describe identified safety risks and planned mitigations or monitoring.
Brief simulation or clinical workflow testing to identify workflow friction.
Summarize test approach, participants, and key findings.
Describe how the change will be validated in test environment and acceptance criteria.
Describe how to revert if adverse effects occur, including who has authority to rollback.
Team-assessed risk if the change were deployed without mitigation.
1.0 10.0
Provide links to guidelines, literature, or test results. Attachments should be stored in your document system with a link here.
Primary clinical reviewer.
Select 'Yes' to indicate approval.
YYYY-MM-DD
Secondary reviewer, e.g., pharmacy lead.
Optional executive or committee chair.
Describe required edits, owners, and timelines.
High-level validation steps and acceptance criteria.
Who can trigger rollback and what steps are required.
YYYY-MM-DD
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