DNR Orders, cont.
DNR Order Process, cont.
Step Action
3. Sign the PowerForm by clicking the green checkmark at the top left.
An alert presents when the PowerForm is signed.
4. Click OK to close the Alert window.
You are returned to the Orders for Signature window.
5. Sign the DNR Order.
Note: The Code Status Order From must be manually forwarded to the designated attending physician to be cosigned.
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DNR Orders, cont.
DNR Order: Resident Forward
Step Action
1. Open the 2 Year Clinical Notes folder and locate the Code Status Order Form you just completed.
2. Click the Code Status Order Form so that the note is displayed in the view pane.
3. Right-click within the note and select the Forward option.
4. Change the Additional Forward Action option to sign.
5. Insert the name of the attending physician into the To: section of the window.
6. Click OK to send the request.
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DNR Orders, cont.
DNR: Attending Staff
When a resident places a DNR order, the Code Status Order Form must be cosigned by the designated attending physician. The Code Status Order Form is cosigned in the Message Center.
Step Action
1. Within the Documents folder located in the Message Center, identify any documents requiring cosignature.
2. Highlight the correct document for cosignature and double-click to open the note.
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DNR Orders, cont.
DNR: Attending Staff, cont.
Step Action
3. Review the document and click OK to cosign the note.
4. If you need to modify the note, right-click and select Modify to make changes.
5. When the modification is complete, sign the note.
Medication Special Alerts/
Communication Step Action
1. To enter exception orders (i.e., No Heparin, No IM Injections, No ACE Inhibitors, No Aspirin, etc.), search for the MEDICATION SPECIAL ALERTS Order Set in the catalog.
2. Select the appropriate exception order(s) from the list displayed.
3. Verify start date and time in the Details tab.
4. Click OK.
Note: By entering the exception order in the Order Set noted above, you enable the correct Alerts to display that effectively alert clinicians to avoid the exception medication.
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Transfer Order Review Note
This facilitates review of orders upon transferring the patient from one level of care to the next.
Note: The transfer order review note is currently not used at all IUH facilities. Please check its use with your facility.
Open Transfer Order Review Note
Step Action
1. In the open chart, click the PowerNotes band.
2. Click + Add.
3. For *Doc Type, select Orders Reconciliation.
4. Select the Transfer Order Review template from the IUH Inpatient Catalog.
Hint: Add this template to your Favorites.
5. Click OK.
Complete Transfer Order Review Note
Step Action
1. To review the patient’s orders, click Click here to make changes to orders.
The Order Profile opens.
2. Review all the current orders. If no changes to orders are needed, click Done.
3. To discontinue an order, click the checkbox to deselect the order.
4. Click Orders for Signature, then click Sign.
5. Click to refresh.
6. To list orders to be continued in the note along with a statement that all orders have been reviewed, click Include Transfer Order Summary Report.
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Transfer Order Review Note, cont.
Sign Transfer Order Review Note
Step Action
The electronic Discharge Instructions application is a secure electronic form used for documenting custom patient discharge instructions.
• You can contribute to the patient discharge document during the entire course of the inpatient stay.
• Vaccinations & TB testing information and Allergies &
Sensitivities flow into the Discharge Instructions automatically from Cerner.
• In addition, all caregivers can access the information after discharge to determine what information was provided to the patient.
There are three tabs in the discharge instructions form:
• Discharge Instructions
• Medication List
• Sign & Print
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Discharge Instructions
(eDI), cont. Step Action
1. Click the band to access
the eDI form.
2. Scroll down to complete the following sections or click each link to move to the desired section of the form.
• Patient Data
• Physicians to contact for
• Discharge Instructions Distribution
• Follow Up Visits
• Follow Up Tests
• Activity Limitations or Restrictions
• Treatment/Procedure/ Equipment
• Dietary Requirements
• Additional instructions
• Vaccinations & TB Testing
• Allergies & Sensitivities
• Final Release Info
3. Click + Add or + Edit to initially enter or edit information.
A window pops up to allow you to enter data.
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Discharge Instructions
(eDI), cont. Step Action
4. After you have entered or edited data, click Save prior to moving to the next screen.
5. If a change must be made to an existing section, click to make changes to the information.
6. If you place orders for tests or labs, you must click eSign to electronically sign the orders.
7. If you need to add more than one test order, click Save and Add for efficiency.
Caution: If orders for future tests or services are placed in eDI, they will NOT result in the scheduling of the tests or studies.
A requisition prints for each lab order when the Final Sign & Print is completed.
Medication List
The medication list tab is used to evaluate and reconcile current home and inpatient medications in order to create a complete list of home medications for the patient after discharge. When completed and printed, medications listed on the patient instructions will be grouped into the following categories:
• Take these medicines at home
• STOP taking these medicines
• DO NOT TAKE these medicines until instructed by your Doctor
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Discharge Instructions (eDI), cont.
Medication List, cont.
Step Action
1. Verify that:
• The home medication list in Cerner PowerChart is updated and accurate
• All new prescriptions that the patient will be discharged with have been entered in the orders or medication list tab (CPOE facilities)
2. Click the Discharge Instructions band.
3. Click Medication List.
4. Move through the Home Meds list on the left side of the screen first, marking each medication according to the following guide:
Home Medication List Options
Action Result
Continue • Places medication into the Take these medicines at home section of the instructions
• Choose this option if the patient was NOT taking this medication as an inpatient
Modify • Click Modify if medication details must be modified
• Changes made here DO NOT change the medication details in PowerChart
• Changes made here file into the Take these medicines at home section of the instructions
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Discharge Instructions (eDI), cont.
Home Medication List Options, cont.
Action Result
D/C • This option places the medication into the STOP taking these medicines section of the patient instructions
• DO NOT D/C and then reenter an order for the same medication; use modify and then enter any additional comments or instructions.
Hold • Selecting Hold requires that additional instructions be entered in a pop-up window
• Medications that have a Hold status display in the DO NOT TAKE these medications until instructed by your Doctor section of the patient instructions
Reviewed • Click for those home medications that you do not want to display on the home medication list
• If this medication is being given as an inpatient medication and will be continued as a home medication, click Continue on the inpatient medication list in order to pull in the date and time of the last medication dose, and click Reviewed on the home medication list.
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Discharge Instructions (eDI), cont.
Medication List, cont.
Step Action
5. Move through the Inpatient Meds list next, marking each medication according to the following guide:
Inpatient Medication List Options
Action Result
Continue • Places the medication in the Take these medicines at home portion of the medication instructions
• The date and time of the last
medication dose will be pulled into the discharge instructions
• Medications can be modified in the lower portion of the window using the Edit icon
Hold • Holding a medication places it in the DO NOT TAKE these medications until instructed by your Doctor section of patient instructions
• Additional details must be entered Reviewed • Use this for inpatient medications that
will not be taken at home
• Medications will not display in the patient instructions
6. Add any additional medications in the Add Medication link under the appropriate section (non-CPOE facilities only).
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Discharge Instructions (eDI), cont.
Medication List, cont.
Step Action
7. Enter comments to clarify any med orders.
Note: Comments in the existing medication list displayed in blue font will not populate the discharge instructions and must be added in the comments area.
Note: The Add Medication link under Continue these meds should be used to enter a home medication for which the patient will be given a handwritten prescription (non-CPOE facilities).
8. When all medications have been addressed, click Patient Version to view the patient copy of the discharge instructions and ensure that the medication list is accurate and uses patient-friendly language.
Note: Medication orders may change frequently and changes made earlier in an admission may change prior to discharge and must be reviewed.
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Discharge Instructions (eDI), cont.
Step Action
9. You can click X to “reset” a medication and remove it from the lower portion of the screen to the home medication or inpatient medication list in the original state.
Note: Modifications and new medication orders entered in the eDI form do not flow to PowerChart; therefore, it is best to enter modifications on the medications list tab prior to reconciling on discharge instructions. At non-CPOE facilities new prescriptions must be entered in both places.
Sign & Print
The Sign & Print section is used to electronically sign the patient discharge instructions when the patient is ready to be released.
Step Action
1. Click the Sign & Print tab
2. Click Physician eSign to sign your name (the person currently logged in).
3. The nurse will click Nurse eSign to sign the RN’s name.
Note: All three sections of the discharge instructions must be signed in order to save and distribute the note.
4. Click Final Sign & Print.
Note: If there are medications still to be reviewed, you must go back and address them before you will be able to Physician eSign.
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Discharge Instructions (eDI), cont.
Sign & Print, cont.
Step Action
5. If you make any changes or corrections after the Physician or Nurse eSign, click Unsign and make the necessary changes.
6. Return to the Final Sign & Print page and click the Physician eSign.
Note: The Nurse eSign must also be completed.
7. If you are completing the entire eDI yourself, you can click both Physician eSign and Nurse eSign.
8. Click Final Sign & Print.
The name of the user currently logged in populates the Final Sign & Print signature box.
The patient version of the discharge instructions automatically open.
9. Click to print two copies:
• One for the patient, and
• One for the medical record
Note: The copy of the discharge instructions for the medical record must include the physical signature of the patient/family and the health professional reviewing the instructions.
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Discharge Instructions (eDI), cont.
Sign & Print, cont.
Step Action
10. A requisition prints for each test that was ordered. Give these to the patient or family.
Note: It is the physician’s responsibility to review the discharge medication instructions with the patient/ family.
Safeguard Printed Patient Information
Follow these guidelines for printing discharge instructions:
You Are Printing Discharge Instructions
You Find Printed Discharge Instructions Carefully select the correct
printer from the drop-down menu.
If you find discharge instructions containing patient information on a printer, contact the person who printed the material.
Retrieve the printed material from the printer immediately.
If unable to contact the discharge instruction owner, place the material in the shred box.
If the discharge instructions did not print, reselect the correct printer and attempt to print the material again.
If the material prints a second time, contact the Service Desk at 962-2828 and report the computer name, location, and the name of the printer where the material printed.
If the material does not print after a second attempt, contact the Service Desk at 962-2828.
Place the material in the shred box.
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Discharge Instructions (eDI), cont.
Favorites: Discharge Instructions
• Areas where Favorites can be added or changed are denoted by a
• You can view current Favorites by hovering your mouse over the
Add Favorites
Step Action
1. Click .
2. Enter the appropriate information in the form.
Note: The descriptive title is for your use and does not display on the patient copy of the instructions.
3. Click Save when completed.
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Discharge Instructions (eDI), cont.
Modify a Favorite
To modify a Favorite, click beside the Favorite name.
Delete a Favorite
To delete a Favorite, click beside the Favorite name..
Replace a Favorite
To replace a Favorite that was entered into the Discharge Instructions, select Replace.
Select Favorites
To select more than one Favorite choice, select Append.
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Glossary
Clinical Notes Band
A viewer for scanned, dictated, or other documents sent to or generated within the Cerner system. (e.g.
operative or progress notes).
ClinDoc The application used by nursing to document patient care data and assessments. It can be launched from PowerChart and is the recommended view for I/Os where implemented.
CPOE An acronym for Computerized Provider Order Entry.
Encounter A single patient interaction, such as an inpatient admission or an outpatient visit.
Filter A filter allows the user to manipulate data views so that only the desired groups of data display, based on the user’s preference.
Flowsheet An electronic spreadsheet of a selected patient’s clinical results. Within the results Review Band, any single result can be opened to view additional details.
Examples: Lab Results, Results-72hr.
General View Bands
Views in PowerChart containing information displays, pulling together information posted in a variety of Cerner locations. Differ from flowsheets (defined above) in that these bands are static displays with limited to no capability for manipulating views.
Refresh must be done manually. Examples: Diagnosis Summary, Micro, ED Summary.
MAR Summary Band
An acronym for Medication Administration Record, which serves as a record of the drugs ordered for/and administered to a patient. This is where documentation of medication administration is found. MAR Summary is an abbreviated view-only version of the MAR.
Message Center
The Physician default view when opening PowerChart, allowing for management and processing of orders and documents.
155 Order
Sentence
Provides ordering efficiency by allowing the user to select in one click the pertinent medication order details, including dose, route and frequency that reflect most commonly ordered medication details.
Order Set Contains groups of orders that are related by process or function so as to increase ordering efficiency and support ordering best practices.
Patient List Allows the tracking of patients and can be filtered by several criteria, including inpatient/outpatient status, unit/location, provider relationship, and discharge status.
PowerChart Cerner view that supports inpatient and outpatient workflow.
PowerNote Structured clinical note created from a pre-defined template. Allows for auto-populating, select data within the note to expedite documentation.
PowerPlan Groups of condition-based or admission-specific orders that allow for standardized orders based on specialty, ordering efficiency and ease of
discontinuing orders.
Relationship The association between a healthcare provider and a patient. Relationships can be visit-specific (such as an admitting physician) or lifetime (such as primary care physician). A relationship must be established electronically with a patient before you can open his or her chart.
Results Clinical data entered via PowerChart directly or from an ancillary or departmental system.
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