order-sign

The order-sign hook fires when a clinician is ready to sign one or more orders for a patient (medications, procedures, labs, and others). It is among the last workflow events before an order is promoted out of a draft status. The context contains all order details (dose, quantity, route, etc.), although the orders are still in draft.

Defined by the CDS Hooks order-sign specification. Implemented by Payerbox for CRD per the Da Vinci CRD IG.

Endpoint

POST <base>/cds-services/order-sign-crd

Auth

SMART Backend Services. See Authentication.

Context

Field	Optionality	Prefetch Token	Type	Description
userId	REQUIRED	Yes	string	The id of the current user (e.g., `PractitionerRole/123` or `Practitioner/abc`)
patientId	REQUIRED	Yes	string	The FHIR `Patient.id` of the current patient in context
encounterId	OPTIONAL	Yes	string	The FHIR `Encounter.id` of the current encounter in context
draftOrders	REQUIRED	No	Bundle	A Bundle of FHIR request resources with a `draft` status, representing orders that aren't yet signed

Request Parameters

Field	Optionality	Type	Description
hook	REQUIRED	string	Must be `order-sign`
hookInstance	REQUIRED	string	A universally unique identifier for this particular hook call
context	REQUIRED	object	Hook-specific contextual data (see Context table above)
fhirServer	OPTIONAL	URL	The base URL of the CDS Client's FHIR server
fhirAuthorization	OPTIONAL	object	OAuth 2.0 bearer access token for FHIR server access
prefetch	OPTIONAL	object	FHIR data that was prefetched by the CDS Client

Response

Coverage determinations are delivered as systemActions[] — one update action per evaluated order, carrying the draft order with the ext-coverage-information extension appended. Cards are informational only (summary, indicator, detail, links, source). See CRD / System actions for the extension's sub-extensions and the DTR launch mechanism.

order-sign is a primary CRD hook: when the decision service cannot evaluate an order present in the hook context, the response still carries a coverage-information system action for it — covered = conditional, info-needed = OTH, and a human-readable reason, with no pa-needed claim — alongside an explanatory card.

Example

The response content depends on the external decision-making service configured via CDS_DECISION_SERVICE_URL. The example below shows a typical response structure, but actual determinations and links are generated by your decision service based on coverage requirements and prior authorization rules.

POST /cds-services/order-sign-crd
Content-Type: application/json
Accept: application/json

{
  "hook": "order-sign",
  "hookInstance": "d1577c69-dfbe-44ad-ba6d-3e05e953b2ea",
  "fhirServer": "https://ehr.example.com/fhir",
  "fhirAuthorization": {
    "access_token": "some-opaque-fhir-access-token",
    "token_type": "Bearer",
    "expires_in": 300,
    "scope": "user/Patient.read user/Observation.read",
    "subject": "cds-service"
  },
  "context": {
    "userId": "PractitionerRole/123",
    "patientId": "1288992",
    "encounterId": "89284",
    "draftOrders": {
      "resourceType": "Bundle",
      "entry": [
        {
          "resource": {
            "resourceType": "MedicationRequest",
            "id": "smart-MedicationRequest-103",
            "status": "draft",
            "intent": "order",
            "medicationCodeableConcept": {
              "coding": [{ "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "617993", "display": "Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" }]
            },
            "subject": { "reference": "Patient/1288992" },
            "dosageInstruction": [
              {
                "text": "5 mL bid x 10 days",
                "timing": { "repeat": { "frequency": 2, "period": 1, "periodUnit": "d" } },
                "doseAndRate": [{ "doseQuantity": { "value": 5, "unit": "mL", "system": "http://unitsofmeasure.org", "code": "mL" } }]
              }
            ]
          }
        }
      ]
    }
  },
  "prefetch": {
    "patient": {
      "resourceType": "Patient",
      "id": "1288992",
      "name": [{ "given": ["John"], "family": "Doe" }],
      "birthDate": "1970-01-01",
      "gender": "male"
    },
    "coverage": {
      "resourceType": "Coverage",
      "id": "cov-001",
      "status": "active",
      "beneficiary": { "reference": "Patient/1288992" },
      "payor": [{ "reference": "Organization/insurance-company-789" }]
    }
  }
}

{
  "cards": [
    {
      "uuid": "7b0b3f7a-8d2b-4d8b-a6e4-8cb4d3f2a6c1",
      "summary": "Documentation and policy resources",
      "indicator": "info",
      "source": {
        "label": "CRD Decision Service",
        "topic": { "code": "external-reference", "system": "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp" }
      },
      "links": [
        { "label": "Documentation Requirements", "url": "https://example.org/documentation-requirements", "type": "absolute" }
      ]
    }
  ],
  "systemActions": [
    {
      "type": "update",
      "description": "Update the draft MedicationRequest with CRD coverage information.",
      "resource": {
        "resourceType": "MedicationRequest",
        "id": "smart-MedicationRequest-103",
        "status": "draft",
        "intent": "order",
        "medicationCodeableConcept": {
          "coding": [{ "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "617993", "display": "Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" }]
        },
        "subject": { "reference": "Patient/1288992" },
        "extension": [
          {
            "url": "http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information",
            "extension": [
              { "url": "coverage", "valueReference": { "reference": "Coverage/cov-001" } },
              { "url": "covered", "valueCode": "covered" },
              { "url": "pa-needed", "valueCode": "auth-needed" },
              { "url": "date", "valueDate": "2026-09-03" },
              { "url": "coverage-assertion-id", "valueString": "3f8d2c1a-6b7e-4a2f-9c0d-1e2f3a4b5c6d" },
              { "url": "doc-needed", "valueCode": "clinical" },
              { "url": "questionnaire", "valueCanonical": "https://example.org/fhir/Questionnaire/medication-pa" }
            ]
          }
        ]
      }
    }
  ]
}