Physician Reference Guide

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Physician Reference

Guide

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Important Numbers

Support Resources

The IU Health Service Desk is available 24/7 to assist you with computer related issues, including password resets.

317-962-2828 [email protected]

The Center for Physician Education provides computer application instruction and educational services.

317-962-2222 [email protected]

The Center for Physician Education website, located on the Pulse page of the IU Health network, or via the link below:

http://www.clarian.com/informatics/active/ physician_education/ v2/index.php

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Table of Contents

Overview... 9

Introduction ... 9

Cerner Password ... 9

Security ... 9

Log On and Off... 10

Introduction ... 10

Remote Log On Procedure... 10

Downtime Procedures ... 11

Log On Procedure ... 13

Log Off Procedure ... 13

Change Your Password... 14

Introduction ... 14

Procedure... 14

Access Other Clinical Systems ... 15

Introduction ... 15

Available Systems... 15

View Surgical Schedules ... 16

Procedure... 16

Utilize Message Center ... 17

Introduction ... 17

Sign Single Telephone and Verbal Orders... 17

Sign a Group of Telephone and Verbal Orders17

Forward Orders for Signature... 18

Refuse Orders for Signature ... 19

4

Create and Maintain Patient Lists ... 20

Introduction ... 20

Lists Used ... 20

Create a Relationship List ... 20

Add Patient to Relationship List... 23

Remove Patient from Relationship List ... 23

Create a Query List (Report) ... 24

Modify a Query List... 25

Safeguard Printed Patient Information ... 26

Search for a Patient ... 27

Introduction ... 27

Procedure... 27

Multiple Encounters... 27

Locate the Correct Patient Encounter ... 28

Document Chart Access... 30

Introduction ... 30

Procedure... 30

View and Add Allergies... 31

View Allergies... 31

Add Allergies ... 31

Navigate to Sections of the Chart ... 33

Introduction ... 33

Manage Search Criteria on the Results Review Band 36

Move Forward or Back by One Day ... 36

Navigate to Results ... 36

View Result Details ... 36

Set View Format for Current Session... 37

5

Four Bands ... 38

Procedure... 38

Navigate Scanned Documents ... 39

Create a Free-Text Clinical Note ... 40

Write Notes ... 41

Set Up Personal Document Types as Defaults 41

Suggested Content... 41

Procedure... 41

Create New PowerNote ... 43

PowerNote Views... 46

Modify PowerNotes ... 47

Advanced PowerNote Functions ... 50

Computerized Provider Order Entry (CPOE) ... 59

Customize Views ... 59

The Orders Window ... 67

Order Entry Basics ... 69

Specialty Clinical Folders... 69

Set Your Clinical Specialty Folder as Your Home

Folder ... 69

Basic Order Search ... 70

Search for Orders ... 70

Enter Single Orders ... 71

Modify Orders ... 73

Favorites Folders... 74

Medication Order Frequencies ... 77

Standard Schedules for IU Health... 78

Order Entry Tools ... 79

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PowerPlans... 79

Medication Order Entry ... 87

IV: Titratable Drip... 88

IV – Heparin Nomogram and

Thrombo-stabilizer Infusions ... 89

IV – TPN Adult ... 89

IV – TPN Pediatric and Neonatal... 94

Medications: Dose Range Orders ... 96

Medications: Hold a Single Dose... 97

Medications: Irrigation Orders ... 98

Medications: Multiple PRN Reasons... 98

Medications: Multiple Route Orders ... 98

Medications: Non-Formulary/ ... 99

Substitution... 99

Alerts ... 99

Medications: One-time STAT Doses... 101

Medications: STAT Doses with Ongoing Orders

... 101

Medications: Patches... 102

Medications: Taper Doses... 102

Medications: Taper Dose, No Existing Taper

Order ... 103

Medications: Prescriptions ... 104

Dosage Calculator ... 112

Introduction ... 112

Where to Find the Dosage Calculator... 112

Calculation Options by Weight ... 113

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Pediatric Antimicrobial Stewardship ... 116

Introduction ... 116

Orders ... 116

Program Goals... 116

PowerPlans... 117

Organization of Antimicrobial Agents... 117

Place Orders from a Subphase... 118

Locate an Antimicrobial Agent PowerPlan ... 122

Restricted Agents... 123

Medical Student Orders ... 126

Overview: Medical Student Orders ... 126

Medical Students: Order Processes ... 126

Other Order Entry Processes... 136

DNR Orders ... 136

Medication Special Alerts/... 140

Communication... 140

Transfer Order Review Note ... 141

Discharge Instructions (eDI)... 142

Glossary ... 154

Frequently Used Phone Numbers ... 156

IU Health Ball Memorial... 156

IU Health Methodist ... 156

Riley Hospital for Children at IU Health ... 157

IU Health University ... 158

Richard L. Roudebush VA Hospital... 159

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9

Overview

Introduction Cerner is the vendor name of the EMR system used at IU Health. Cerner is a fully integrated EMR that is being introduced throughout IU Health.

Cerner Password

Your Cerner password:

• Must be 6-8 alpha-numeric characters

• May contain special characters (#, &...)

• Must be changed every 90 days

• May not be the same as your previous three passwords

Security There are strict regulations that govern the use and protection of patient information. Certain measures have been put into place at IU Health that protects patient data in the EMR.

• Cerner automatically logs out after 15 minutes of no

activity; however depending on the location, certain areas may have a different automatic logout time

• Do not share passwords

• Do not allow another person access under your ID and

password

• Log out of the EMR when walking away from the

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Log On and Off

Introduction SSL is a browser-based connectivity solution that allows credentialed physicians to access Cerner remotely. SSL works on Windows Vista, XP, and Windows 7 operating systems as well as on Mac operating systems.

Remote Log On

Procedure Step Action

1. Open your web browser.

2. In the address locator bar, enter

https://sragate.clarian.org

3. Click Yes to install Juniper on your system.

4. Enter your IU Health Network ID and

password.

5. Click Enter or Sign In.

Available roles in the secure gateway display.

6. Click the Tier0 link.

The Secure Access SSL – Home page displays.

7. In the Web Bookmarks section, click the

Cerner link.

The CernerWorks applications portal displays.

8.

Click to launch Cerner PowerChart.

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Log On and Off, continued

Procedures

Downtime Report Access

• During a downtime period, downtime reports may be

used to view and print patient data from a designated workstation

• Information available in the Downtime Reports folder

will display the most current patient data and will be from 1-12 hours old, depending on the report. The unit secretary or charge nurse will be your resource and will be able to provide the forms and information that you will need.

Downtime Reports Content

• The Downtime Reports folder will not contain your

personal patient list

Documentation During Downtime

• Locate paper forms for documenting during downtime

by asking the unit secretary or nurse where these forms are kept on the unit

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Log On and Off, continued

Procedures, cont.

Safeguard Printed Patient Information Follow these guidelines for printing reports:

You Are Printing a Report You Find a Printed Report Carefully select the correct printer

from the drop-down menu.

If you find a report containing patient information on a printer, contact the person who printed the report.

Retrieve the printed report from the printer immediately.

If unable to contact the report owner, place the report in the shred box.

If the report did not print, reselect the correct printer and attempt to print the report again.

If the report prints a second time, contact the Service Desk at 317-962-2828 and report the computer name, location, and the name of the printer where the report printed.

If the report does not print after a second attempt, contact the Service Desk at 962-2828.

Place the report in the shred box.

13

Log On and Off, continued

Procedure _{Step Action}

1.

Double-click on your computer desktop.

2.

Click displayed in the Applications

window.

3. Enter your user ID (usually your dictation

number) and password into the respective fields.

4. Click OK.

Log Off Procedure

Step Action

1. Close all open patient charts.

2. _{Click to immediately disconnect from}

the server.

The Exit Application window displays.

3. Select Exit and shut down the application.

Note: To suppress this message in the future, place a checkmark in the box.

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Change Your Password

Introduction You can change your password at any time using the following procedure.

Procedure

Step Action

1. When logged onto Cerner, click Task on the

toolbar.

2. Select Change Password from the drop-down

menu.

3. Enter your old password in the Old Password

field.

4. Enter a new password in the New Password

field.

5. Re-type your new password in the Retype

Password field.

6. Click OK.

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Access Other Clinical Systems

Introduction Within Cerner, you can access other clinical systems used at IU Health.

Available

Systems _{System Description}

INPC Data repository that includes:

• Labs and documentation created

prior to the Cerner implementation

• Current information from other

health care sites around the state of Indiana

ClinDoc • Electronic nursing flowsheet contains

data entered by nursing

• Data flows into Cerner

• It can be viewed from either ClinDoc

or Cerner

ClinSuite Tool used to facilitate the patient

handoff process between physicians

UpToDate IU Health’s source for evidence-based

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View Surgical Schedules

Step Action

1. _{Click in the links within Cerner.}

2. Click the appropriate surgical area.

3. _{Click to begin the print process.}

4. Place a checkmark in the Preview box.

5. Click Print.

6. In the next box, click Print.

The surgical schedule displays.

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Utilize Message Center

Introduction Cerner always initially opens to the Message Center where you can:

• Sign single or a group of telephone and verbal orders

• Forward orders for co-signature

• Refuse to sign orders

• Cosign notes Sign Single Telephone and Verbal Orders Step Action

1. Click the Orders, Cosign Orders or Med

Student Orders folder.

2. Review order details for accuracy.

3. Right-click the order.

4. Select Approve from the menu.

Sign a Group of Telephone and Verbal Orders

Step Action

1. Click the Orders, Cosign Orders or Med

Student Orders folder.

2. Review order details for accuracy.

3. Hold the Control key down while clicking on

multiple orders.

4. Right-click anywhere WITHIN the highlighted

orders.

5. Select Approve from the menu.

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Utilize Message Center, continued

Orders for

Signature Step Action

1. Select the order(s).

2. Click Forward Only.

3. Select Sign from the Additional Forward Action

list.

4. Find the provider by:

• Typing the name of the intended recipient

provider, or

• Click Search and look for the provider

5. Enter comments (up to 120 characters,

including spaces) if necessary. Note: Comments become part of the permanent patient medical record.

6. Click OK.

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Utilize Message Center, continued

Orders for

Signature Step Action

1. Click the Message Center Orders, Cosign

Orders or Med Student Orders folder.

2. Double-click the order you wish to refuse.

3. Click Refuse.

4. Select a reason.

5. Type a comment (up to 120 characters) if

needed.

6. Click OK or click OK and Next if you need to

refuse additional orders.

The order is routed to the refusal admin.

Cosign a

Note _{Step Action}

1. Click the Documents folder.

2. Double-click the note requiring cosignature.

3. Review the note for accuracy.

4. Click OK to sign the note.

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Create and Maintain Patient Lists

Introduction Patient lists use defined criteria to organize patient charts. Each patient list displays on a separate tab.

Lists Used Lists commonly used at IU Health include:

Type Description

Provider Group

Provider Group lists are helpful if you and your colleagues share a list of patients.

Provider Groups can be created by contacting the Help Desk at 317-962-2828.

Relationship Relationship lists display those

patients you already have a relationship with, such as attending or resident.

Query Query lists display the patients of

another physician.

Create a Relationship List

Relationship lists are encounter or visit-based. An outpatient relationship does not carry over into a new inpatient encounter.

Step Action

1. _{Click (List Maintenance) in the Patient}

List window.

2. Click New.

3. Select Relationship.

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Create and Maintain Patient Lists, continued

Relationship

List, cont. Step Action

4. Click Next.

5. Click + to the left of Visit Relationships.

6. Click Next.

7. Place a checkmark in the box to the left of

the appropriate type of physician relationship(s).

8. Enter a name for your new list.

9. Place a checkmark in the box to the left of

Encounter Types.

10. Place a checkmark in the boxes to the left of:

• Emergency

• Inpatient

• Observation

• Outpatient in a Bed

11. Click + to the left of Location, then click + to

the left of each appropriate location.

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Create and Maintain Patient Lists, continued

Relationship

List, cont. Step Action

12. Place a checkmark in the box to the left of

each location.

13. Click to the left of Discharged Criteria.

14. Select discharged criteria.

15. Click Finish.

16. Highlight the new list in the Available lists

pane.

17. _{Click to move the list to the Active lists}

pane.

18. Click to move your Relationship list to the

first position in the Active lists pane.

Your list is moved to the first tab in the patient list window.

19. Click OK.

23

Create and Maintain Patient Lists, continued

to

Relationship List

Step Action

1. Click the patient list tab where you need to

add the patient.

2. _{Click (Add Patient).}

3. Enter the patient’s last name or MRN (medical

record number).

4. Click Search.

5. Select your patient from the search results list.

6. Select the appropriate encounter from the

lower pane. 7. Click OK. 8. Click to refresh. Remove Patient from Relationship List Step Action

1. Click the specific patient list tab where you

need to remove the patient.

2. Click the patient’s name.

3. _{Click (Remove Patient).}

4. Click Yes to confirm.

If you have only one relationship with the patient, the patient drops off your list. But if you have more than one relationship with the patient, the patient does not drop off.

5. Select the appropriate relationship.

6. Click OK.

7. Click to refresh.

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Create and Maintain Patient Lists, continued

Create a Query List (Report)

Step Action

1. Click ..

2. _{Click (List Maintenance).}

3. Click New.

4. Select Query.

5. Click Next.

6. Select Physician List Query.

7. Change the name of the query to reflect the

physician names and locations.

8. Click Next.

9. Type the first few letters of the physician’s

name to move quickly to that area of the physician list.

10. Place a checkmark in the box to the left of the

desired physician’s name.

11. Click Next to select locations from within the

Organizations window.

12. Place a checkmark in the box to the left of each

location.

13. Click Next.

14. Click Finish.

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Create and Maintain Patient Lists, continued

Query List (Report), cont.

Step Action

15. Highlight the new list in the Available lists

pane.

16. _{Click to move your new list to Active Lists.}

17. Click OK.

18. _{Click (Execute Query) to activate the}

list.

Note: Each time you use the Query list, you must click the Execute Query icon to refresh the report results.

Modify a

Query List _{Step Action}

1. Click .

2. _{Click (Modify Parameters).}

3. Modify the parameters for a query list (add or

remove a physician or location).

4. Click OK.

5. _{Click (Execute Query) to implement}

your changes.

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Create and Maintain Patient Lists, continued

Printed Patient Information

While printing of patient lists is discouraged at IU Health, please follow these guidelines if you will be printing a patient list:

You Are Printing a List You Find a Printed List Carefully select the correct printer

from the drop-down menu.

If you find a list containing patient information on a printer, contact the person who printed the list. Retrieve the printed list from the

printer immediately.

If unable to contact the list owner, place the list in the shred box. If the list did not print, reselect the

correct printer and attempt to print the list again.

If the list 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 list printed. If the list does not print after a

second attempt, contact the Service Desk at 962-2828.

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Search for a Patient

Introduction You can search for a patient by name or by medical record number (MRN).

Procedure

Step Action

By Name

1. Type the last name of the patient in the Name

search field.

2. If multiple names display when using the name

search, highlight the correct patient name.

By MRN

1. Click the arrow to the left of the patient search

field.

2. Select MRN.

3. Enter the MRN into the search field.

Multiple Encounters •

You may find that the patient has multiple encounters that are displayed in the lower pane. Certain types of patients may have multiple Active encounters.

• You must identify and select the correct patient

encounter. If the improper encounter is selected, your orders and documentation will not follow the appropriate workflow and will need to be corrected.

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Search for a Patient, continued

Correct Patient Encounter

Step Action

1. Carefully view the patient encounters in the

lower pane of the Patient Search window.

2. Search for an encounter near or on today’s

date.

3. Confirm that the encounter displays the

correct facility and nursing unit.

4. Confirm that the encounter is Active.

5. After you have located the correct patient

encounter, highlight the encounter in the lower pane.

6. Click OK.

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Search for a Patient, continued

7. Review the patient header to ensure that you

have accessed the correct encounter.

8. If you selected the wrong encounter, click the

location in the patient header.

9. In the pop-up window, double-click the correct

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Document Chart Access

Introduction If you access a patient chart for any reason other than direct patient care (e.g., research, administrative, or accidental access) you must document why you accessed the patient chart.

Procedure

Step Action

1. Open a patient chart.

2. If a relationship window displays, select a

relationship.

3. Click Chart on the toolbar at the top of the

screen.

4. Scroll to the bottom and select Chart

Accessed By.

5. Select Most Recent from the sub-menu.

6. Double-click in the Comment Column to the

right of your name to enable a cursor.

7. Enter the reason you have accessed the patient chart.

8. Click Save. 9. Click Close.

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View and Add Allergies

Allergies

If allergies have been entered into the patient chart, the name of each allergy displays in the patient demographic bar. The list may be truncated.

To view allergy details, click the Allergy link in the patient header.

Alternatively, you can click (Allergies band) to

view allergies.

Allergy details display as follows:

Add

Allergies _{Step Action}

1. Click (Allergy link) in

the patient header to access allergy details. Note: Alternatively, you can click

(Allergies band) to enter allergies.

2. Click + Add.

3. Click the + to the left of the appropriate allergy

category folder.

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View and Add Allergies, continued

Allergies,

cont. Step Action

4. Double-click the correct allergy name.

5. If the appropriate allergy does not display in

the folder:

a. Click the search tab.

b. Enter your search terms.

c. Click Search.

d. Double-click the correct allergy name.

6. Click the + to the left of

(Common Reactions folder).

7. Double-click the appropriate common

reaction.

8. Click OK to add the allergy to the allergy list.

9. Click OK to close the allergy list.

10. _{Click to refresh the screen and}

display the new allergy in the patient header.

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Navigate to Sections of the Chart

Introduction Cerner uses a menu to navigate to

different sections of the patient chart.

• Each section within the menu

is called a band

• Clicking a band moves you to

the corresponding section of the patient chart

• In addition, the menu band can

be minimized to provide a larger screen view

The EMR bands you may use most frequently are described in the following section.

Band Function

Results Review

Displays lab results, vital signs, significant events, and other pertinent information for your patient In Patient

Summary

Allows access to most of the patient data displayed in the patient chart. You can take action directly from this band, such as adding problems, diagnoses, and orders, and viewing physician notes and test results.

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Navigate to Sections of the Chart, continued

Band Function

Rounds Displays an online view of data similar to the printed

rounds report I/O / I

Flowsheet

• Provides advanced graphing functionality

• Is useful for viewing data trends over a period of time

• Displays volumes in split-screen format (flowsheet

and graph); optional split-screen display

• Default setting displays previous 24-hour totals

Allergies • Displays all allergies entered into the system

• Allows for additional allergies and reactions to be

documented MAR

Summary

Summarized medication administration over 24 hour timeframes during current encounter

Medication List

A record of all meds ordered for a patient, either by history, through online prescription ordering, or by PowerChart order entry. Also allows for new medication orders to be added.

Orders Provides the Order Profile for a patient—existing orders

as well as order statuses and detail information. Allows for new orders to be entered.

2 Year Clinical Notes

Contains notes from today to 2 years prior 72 Hr

Clinical Notes

Defaults to display only notes for the past 72 hours. Types of online documents include:

• Interfaced notes dictated from other systems

• Scanned documents (display under admission date)

• Direct-entered notes (PowerNotes, intra-operative

documentation, etc.)

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Navigate to Sections of the Chart, continued

Band Function

2 Year Physician Notes

Displays notes by physicians and mid-level providers and is a sub-set of clinical notes

PowerNote Allows for the use of templates to create structured notes.

Use the PowerNote band to document your online notes. Problems

and Diagnoses

Displays problems and diagnoses entered into the system, also allows for adding or editing information.

Patient Info Contains demographic and case-related information

organized under sub-tabs, including list of procedures, problems, immunizations, and visits, as well as growth chart information, and a provider list through which you can manage physician relationships.

Dictation View

Displays a combined view of Documentation and Lab & Diagnostic Results to assist physicians with the pertinent data they need to complete a Dictation (for example, to help facilitate the dictation of a Discharge Summary). Chart

Summary

Displays summarized information in window-frame layout. Includes information regarding special alerts, providers, patient data (e.g. reason for visit, surgical cases, etc.), medications and IVs, and patient care and ancillary orders. Discharge

Instructions

Secure electronic form used for documenting custom patient discharge instructions.

Chart Search

Is a search engine that allows users to search for patient data within the patient’s medical record. It will search for words, phrases, and clinical concepts. It can match and rank documents so that the most important documents move to the top of the results list. Chart Search does NOT include:

• Orders

• Problems

• Procedures

• Allergies

• Lab panels (currently must search

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Manage Search Criteria on the Results Review

Band

Move Forward or Back by One Day

To move forward or back by one day at a time on the Result Details screen, click the arrows to the right or left of the blue Search Criteria bar.

Navigate to Results

The Navigator, located to the left of the results panel, allows you to quickly navigate to results on the screen.

Click the Navigator bars to display the selected results at the top of the screen.

View Result Details

Double-click any result to see more detail (reports, result history, specimen information, etc.).

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Manage Search Criteria on the Results Review

Band, continued

Set View Format for Current Session

You can select a Display Format option to temporarily change how the flowsheet data displays by Table, Group or List.

Table

Table is the default format. It arranges results by category along the left of the screen and by time across the top.

Group

Group format arranges results by:

• Test descriptions across the top of the screen

• Category (e.g., Vital Signs) and dates/times within the

category on the left side of the screen

List

List format arranges results in a linear list format by event date and time.

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View Clinical Documentation

Four Bands There are four clinical documentation bands:

• 2 Year Clinical Notes

• 72 Hr Clinical Notes

• 2 Year Physician Notes

• PowerNote

Procedure

Step Action

1. Depending on the timeframe you need to view,

click either the 2 Year Clinical Notes band or the 72 Hr Clinical Notes band.

2. Click one of the radio buttons to sort the index

by one of the following options:

• Type

• Status

• Date

• Performed By

• Encounter

3. Double-click the needed folder to open.

4. If there are sub-folders, click the + to see more

folders or documents.

5. Double-click to open a document.

6. _{Use the large blue arrows to move}

quickly from one document to the next or to move between note types.

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View Clinical Documentation, continued

Scanned Documents

Scanned documents display with an additional toolbar at the bottom of the top view pane. The following tips will help you navigate scanned documents quickly and easily:

• Documents are scanned against admission or

appointment date, not by actual date/time of documentation

• Documents display in reverse chronological order by

patient visit date

Note: It may be helpful to sort by Encounter Type.

• Check to determine if multiple pages have

been scanned into a single entry

• Click the right arrow to move to the next page if

there is more than 1 page indicated

• Use the 4th arrow to jump to the last page

• Use magnifying glasses to zoom in (+) or out (-)

• For easier viewing, click the Fit to Page tool

40

Create a Free-Text Clinical Note

Step Action

1. Click either the 2 Year Clinical Notes band or the

72 Hr Clinical Notes band.

2. _{Click (New Note).}

3. Select the correct note Type.

4. Change date and time if necessary.

Note: Clinical documentation always reflects the date and time that the note was created. If the documentation pertains to the prior day, you must change the date and time of the note prior to signing the note.

5. Enter the Subject of the note.

6. Type your note.

7. Click Sign, Save, Save & Close or Cancel.

Option Function

Sign • Enters your note into the

patient’s permanent record

• Changes to the note must be

made by addending the note

Save • Saves your note before signing

• Changes can be made to the

note Save &

Close

• Saves your note before signing

• Closes it so that you may

complete it at a later time

Cancel Deletes your note with no saved

41

Write Notes

Before you enter your first PowerNote, you must set up your personal document types as defaults for your specialty and author status: Staff, Resident, Fellow, or Medical Student. All note types listed represent both Adult and Pediatric specialties.

Note: Medical students will not have document types by specialty.

Suggested Content

Suggested content for your document type list is:

Type Description

IP Inpatient

OP Outpatient

Admission/H&P Note Generic

Initial Consult Note By specialty

Progress Note By specialty

Procedure Note Generic

Orders Reconciliation

Procedure

Step Action

1. Open the patient chart.

2. Select PowerNote +Add from the menu.

Note: You must click + Add and ensure that you have opened a PowerNote to proceed.

42

Write Notes, continued

cont. _{Step Action}

3. Select View from the uppermost task bar.

4. Select Customize from the drop-down menu.

5. Select the Document Types tab.

6. Click to uncheck

it.

7. Select Personal Note Type List from the

Default List Type.

8. Click the appropriate Document Type in the All

Available Document Types column on the left.

9. Click > to move it to the Personal Document

Type List column on the right.

Note: You can only select one document type at a time. However, this is a one-time set up that will make charting commonly used notes more efficient.

10. Click Apply.

11. Click OK.

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Write Notes, continued

Templates to Favorites

Step Action

1. Click the Catalog drop-down arrow.

2. Select IUH Inpatient.

3. Click + next to Specialty (i.e., Adult).

4. Highlight the appropriate templates (e.g.,

Admission H&P, Progress Note, Consult Note, Transfer Order Review)

5. Click Add to Favorites.

6. Scroll down and click + next to Procedures.

7. Highlight the needed procedure templates.

8. Click Add to Favorites.

Your selected templates display under your Favorites tab.

Create New PowerNote

PowerNotes utilize templates to prompt for relevant information and can import existing data into your note.

Step Action

1. Select PowerNote +Add from the menu.

2. Select the Document Type in the *Type: field.

3. Type a clinically relevant title into the Title:

field (i.e., clinical diagnosis or symptom such as Gastroenteritis).

Note: If no title is entered, the title will default to the name of the template chosen (i.e., progress note).

44

Write Notes, continued

PowerNote, cont.

Step Action

4. Proceed as follows:

• If you have created favorites, click your

Favorites tab and select a template. Skip to Step 7.

• If you have not created favorites, click the

Catalog tab and select IU Health from the drop-down menu. Continue to Step 5.

5. Click the + next to each folder to view its

contents.

6. Click the template that indicates the type of note

you are writing (i.e., Progress Note).

Note: Note Type and Template chosen from the Catalog need to correspond.

7. Click OK.

The Auto Populate screen displays.

8. Check the boxes for those items that you need

included in your note.

9. Click OK.

45

Write Notes, continued

PowerNote, cont.

Step Action

10. Click to expand and display the

structure of the note.

11. Click terms in each sentence that you need to

add to your note as follows:

• Single-click a term to select it by displaying

a circle around it

• Double-click a term to negate it

• A third click on a term deletes the term

from documentation

12. To enter free-text for a particular term, click

or right-click and select Comment.

13. To enter free-text at the paragraph level, click

.

14. Click Sign, Save, Save & Close or Cancel.

Option Function

Sign • Enters your note into the

patient’s permanent record

• Changes to the note must be

made by addending the note

Save • Saves your note before

signing

• Changes can be made to the

note Save &

Close

• Saves the note before signing

• Closes it so that you may

complete it at a later time

Cancel Deletes your note with no saved

record of the note

46

Write Notes, continued

Views

Contributor View

You can view a PowerNote in report format while you are creating the note.

Step Action

1. Click the contributor icon to view the note in

report format.

2. Click the contributor icon again to return to

the PowerNote working format.

Full Screen View

You can enlarge a PowerNote to full screen format in order to more easily view the note as it is being created.

Step Action

1. _{Click in the upper left corner of}

the note to expand the note view to full screen.

2. _{Click in the upper right corner to}

reduce the screen size.

47

Write Notes, continued

PowerNotes

Addend a Note

You can add information to your clinical documentation by using the addend function.

Step Action

1. Click the Clinical Notes band.

2. Double-click to open the note that you need

to addend.

3. _{Click (Modify) or right-click in the body}

of the note and select Modify.

4. Enter the additional text below *Insert

Addendum Here:.

5. Sign the note when completed.

Modify a Note

You may occasionally need to strike out incorrect information within your note and enter the correct information.

Step Action

1. Click the Clinical Notes band.

2. Double-click the appropriate note to open it.

3. _{Click or right-click the body of the note}

and select Modify.

48

Write Notes, continued

PowerNotes, cont.

Modify a Note, cont.

Step Action

4. Drag your cursor to highlight the incorrect

text.

5. _{Click (Strikethrough).}

6. Enter the corrected text below *Insert

Addendum Here:.

7. Sign the note.

In Error Note

You may find that you have entered incorrect

information on a patient or written a note on the wrong patient. Use the following In Error process to strike the in error note from view in the EMR.

Note: Notes entered through PowerNotes or Clinical Notes must be made In Error through the Clinical Notes band.

49

Write Notes, continued

PowerNotes, cont.

Strike the In Error Note from View

Step Action

1. Click either the 2 Year or 72 Hr Clinical Notes

band.

2. Double-click the note that was entered in

error to display the note.

3. Right-click the note and select In Error to “in

error” the existing note.

4. Type the In Error reason.

5. Click OK.

6. Either return to the PowerNotes or Physician

Notes band to write your replacement note or select the correct patient to begin entering your documentation.

50

Write Notes, continued

PowerNote Functions

Copy Paragraph or Selected Text to a New Note

You can copy a single paragraph or selected text from one note to another.

Step Action

1. Make sure that the note you need to copy into

is open.

2. _{Click to minimize the new note.}

3. Double-click to open the note that you need to

copy from.

4. Highlight the appropriate text that you need to

copy from the existing note.

5. Press ctrl>C on the keyboard to place the text

on the electronic clipboard.

6. _{Click to maximize the new note.}

7. Click the area of the note where you need to

paste the new text.

8. Press ctrl>V on the keyboard to paste the text.

51

Write Notes, continued

PowerNote Functions, cont.

Copy to a New Note

You can copy forward a PowerNote that you or someone else has previously completed on a patient. The lab, medications, and vital signs data will automatically be updated for that date.

Note: It’s your responsibility to modify the rest of the note to accurately reflect documentation for the date of entry.

Step Action

1. Click + Add in PowerNote band.

2. Click the Existing tab.

3. Click to highlight the appropriate note to copy

forward in the bottom pane.

4. Place a checkmark in the Copy to New Note

box.

5. Select the appropriate Document Type.

.

6. Type an appropriate Title.

7. Click OK.

8. Select paragraphs to copy.

9. Check and uncheck the appropriate items in

the Auto Populate window.

10. Complete the note by modifying data to

accurately reflect documentation for the date of entry.

11. Click Sign.

52

Write Notes, continued

PowerNote Functions, cont.

Create a Macro

A macro allows for quick, repeated use of a selection of structured content where the terms have been preselected by you and can later be retrieved and modified as needed.

Pre-selecting the negatives in your note can improve efficiency of documentation, allowing for you to retrieve this macro and modify as necessary for a given patient without having to reselect all the negatives each time but rather allowing you to modify the necessary components.

Step Action

1. In the selected structured note, select terms

as positive or negative as needed for your macro.

2. Right-click the appropriate paragraph or

sentence header at the level in which you need to save your macro.

Note: You can save a macro at either the paragraph or sentence level (e.g., Review of Symptoms or Constitutional).

3. Select Save Macro As from the pop-up menu.

53

Write Notes, continued

PowerNote Functions, cont.

Create a Macro, cont.

Step Action

4. Enter a Title.

Note: You may want to use the initial paragraph/header name followed by a descriptor to ease future retrieval (e.g., Review of Systems – negative).

5. Click Create New.

Insert a Macro

Step Action

1. Click the M in the section of the document

where you have created the macro.

2. Select the appropriate macro from the list that

displays.

The note populates with the preselected terms from your macro.

3. Modify the macro as needed for your particular

patient.

54

Write Notes, continued

PowerNote Functions, cont.

Create Auto Text

Auto text is text developed by the user to auto-populate sections of a note with content that is repeatedly used.

Step Action

1. Click the white space of the note until you see

your cursor.

The free-text mode becomes activated and displays the appropriate toolbar above your note. The toolbar contains the Auto Text icon.

2. Click (Manage Auto Text).

3. Click (New Phrase).

4. Enter an abbreviation.

Note: Start all your abbreviations with a leading period. This is important to ensure that you are not interrupted with a display of your auto-text when you are typing your note (e.g., “.pyelo”).

5. Enter a description.

Note: Be sure to enter a term that will help you know what is in your auto-text (e.g.,

“pyelonephritis”).

6. Click (Add Text).

The Formatted Text Entry window displays.

55

Write Notes, continued

PowerNote Functions, cont.

Create Auto Text, cont.

Step Action

7. Type the relevant text (e.g., “Ciprofloxacin

500mg po bid x 10 days. Push fluids. If ongoing fevers, chills or back pain, patient to notify.”).

8. Click OK to close the Formatted Text Entry

window.

9. Click Save and then Close.

You can also save any free-text that you have typed as an Auto-Text as follows:

Step Action

1. Type the free-text.

2. Highlight the appropriate text and right-click it.

3. Select Save as Auto Text.

4. Enter an abbreviation.

Note: Start all your abbreviations with a leading period. This is important to ensure that you are not interrupted with a display of your auto-text when you are typing your note (e.g., “.pyelo”).

5. Enter a description.

Note: Be sure to enter a term that will help you know what is in your auto-text (e.g.,

“pyelonephritis”).

56

Write Notes, continued

1. Click the white space of your note where you

need to type free-text.

2. Enter the first few characters of your auto-text

abbreviation beginning with the period (“.”).

Note: If you hover over the abbreviation, the entire description displays for you.

A drop-down menu displays.

3. Double-click the auto-text you need to insert

into your note.

Drawings

You can draw on body images, annotate the images, and insert the drawings into your PowerNote.

Step Action

1. _{Click next to the appropriate section.}

2. Click the appropriate drawing location.

3. Click an icon in the toolbar to draw on the

image.

Note: Hover over an icon to see its function.

4. When your image has been completed, click

OK to save to the PowerNote.

57

Write Notes, continued

PowerNote Functions, cont.

Precompleted Notes

Precompleted notes allow you to save a note with any combination of terms, macros, auto-text and/or free-text, and then retrieve it for repeated use on any patient. Note: It is your responsibility to ensure that a

Precompleted note accurately reflects the condition and status of the current patient.

Step Action

1. Create a PowerNote but do not sign.

2. Click Documentation in the toolbar and select

Save as Precompleted Note.

3. Enter a title for the note.

4. Click Save as New.

The note is filed in the Precompleted tab in the PowerNotes window.

5. To use a Precompleted note, select the

appropriate note in the Precompleted tab.

6. Click OK.

58

Write Notes, continued

PowerNote Functions, cont.

Symbols

Understanding the symbols that are available in PowerNotes can help you document in more detail.

Symbol Function

(= = =) Allows you to enter numeric values such as

BP or pulse

* • Automatically repeats the affiliated

terms to allow for documentation of differences between two sides, etc.

• If no * is present, you can manually

repeat selection of terms where there may be a discrepancy between two sides or two locations by right-clicking on a term header (i.e., Capillary Refill) and selecting Repeat

(…) • Provides additional descriptive choices

for a term in a separate display window

• Items selected from an ellipses (…) do

not immediately display but will be included in your final note Note: You can see your added descriptions in the Contributor View.

+ • Signifies that additional information for

that term exists

• Additional terms can be accessed by

59

Computerized Provider Order Entry (CPOE)

Views BEFORE placing your first order, you MUST set up display filters and custom views on both the Orders and Medication List bands within PowerChart. Setting up display filters and custom views prior to placing your first order is extremely important to ensure you accurately interpret orders entered into Cerner. Note: This is a one-time process. If not completed, medication order errors may result.

Disable the Order Window Pop-Up

Step Action

1. Open the patient chart.

2. Click the Orders band.

3. Click the Options menu at the top of the

screen.

4. Click Enable Pop-up Windows for Selecting

Orderables to remove the checkmark.

Orders Band: Customize Filters, Columns, and Groups Each order filter selection displays different data based on the view criteria that the filter was designed to produce. Note: The last filter setting that you used will be displayed the next time you log in. If you change your filter view, remember to change it back to your default setting so that you do not accidentally overlook critical information.

60

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Orders Band: Customize Filters, Columns, and Groups, cont.

Step Action

1. From the Orders band, click the Displayed:

hyperlink to access the Advanced Filters window.

2. In the Display drop-down list, click one of the

options that begins with * (asterisk) and contains Med Student to set the filter to display inpatient orders only.

See related note and warning on the next page.

61

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Orders Band: Customize Filters, Columns, and Groups, cont.

Step Action

2. In the Display drop-down list, click one of the

options that begins with * (asterisk) and contains Med Student to set the filter to display inpatient orders only. (continued) Note: Home medications MUST be removed from the inpatient medication list. The filters in the Display list marked with an asterisk were designed to remove home medications from the Orders view.

Warning: DO NOT modify the radio buttons or checkboxes in the Advanced Filter window. This is only used to modify the Display option. Changing these buttons may result in missed orders.

3. From the Current menu, select Customize

View.

62

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Orders Band: Customize Filters, Columns, and Groups, cont.

Step Action

4. Move the following columns from the

Available columns pane to the *Selected columns pane by selecting them and clicking Add: a. Quick Discontinue b. Notifications c. Type d. Order Name e. Status f. Details g. Ordering Physician h. Last Updated By

5. Select a category in the *Selected columns

pane and click to move the item up or down and change the display so that the order matches the shown in Step 4.

63

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Orders Band: Customize Filters, Columns, and Groups, cont.

Step Action

6. Customize the grouping of orders to create

Clinical Folders for locating and viewing existing orders as follows:

a. In the drop-down list for Group orders by:,

select Clinical Category.

b. For Then by:, select Active/Inactive.

c. For Sort orders by:, select Order Name or

Chronological.

7. Confirm that upon completion, your Orders view

pane appears in the following order:

64

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Medications List Band: Customize Filters, Columns and Groups

After you have customized your Orders band, you must also customize your Medication List band.

Step Action

1. Open the patient chart and click the Medication

List band.

2. Click the Displayed: hyperlink to access the

Advanced Filters window.

3. In the Display drop-down list, select All

Medications (All Statuses).

65

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Medications List Band: Customize Filters, Columns and Groups, cont.

Step Action

4. From the Current menu, click the Customize

View link.

5. Move the following columns from the Available

columns pane to the *Selected columns pane by selecting them and clicking Add:

a. Quick Discontinue b. Notifications c. Type d. Order Name e. Status f. Details g. Ordering Physician h. Last Updated By

6. Select a category in the *Selected column pane

and click to move the item up or down and change the display so that the order matches the sequence in Step 5.

66

Computerized Provider Order Entry (CPOE),

continued

Customize Views, cont.

Medications List Band: Customize Filters, Columns and Groups, cont.

Step Action

7. Customize the grouping of orders to create

Clinical Folders for locating and viewing existing orders as follows:

a. In the drop-down list for Group orders

by:, select Venue.

b. For Then by:, select Active/Inactive.

c. For Sort orders by:, select Order Name or

Chronological.

8. After you have created your filters, customized

your columns, and defined the group and sort order for your Medications List pane, review the screen to familiarize yourself with the structure of the window and the location of orders.

Note: You can click and drag column borders to adjust your view of data in any column. If your data displays ellipses (…) at the end, this indicates more information is available. Hover over the data column to display the additional information.

67

Computerized Provider Order Entry (CPOE),

continued

The Orders Window

Resize the Order Details Pane

You can enlarge the Order details pane to view more detail information or minimize the pane to view orders in the Orders for Signature Pane.

Step Action

To enlarge the Order details pane…

1. Hover your mouse over the upper border of

the order details pane until a symbol

appears.

2. Hold down the left mouse button and drag

the window up or down to resize. To minimize the Order details pane…

1. Click the down arrow in the upper left

corner of the pane.

2. To open the Order details pane, click the up

facing arrow in the lower left corner of the Orders for Signature window.

Note: The Order details pane is only present when there is an unsigned order in the Orders for Signature pane.

68

Computerized Provider Order Entry (CPOE),

continued

Common CPOE Icons

Cerner uses images to denote order type, status, and other important information.

Inpatient Orders

Documented Meds by History (home meds) Prescriptions

Order Type Icons

Ambulatory Orders

Additional Reference Information Order Order Details Not Complete

Order Detail Icons

Dose Calculator

Physician Order with Pending Cosign Medical Student Order Cosign Pending Pharmacy Review Order

Review Status

Pending Nurse Review Order

Order Comment Order Set Order Icons

PowerPlan

Initiate Plan or Phase View Excluded in PowerPlan PowerPlan

Icons

69

Order Entry Basics

Clinical Folders

Clinical specialty folders are available in the Orders and Medication List bands. These folders have been populated with orders that are specific to your medical specialty.

Set Your Clinical Specialty Folder as Your Home Folder

To increase your ordering efficiency, set your clinical specialty folder as your Home Folder so that you can access it with one click.

Step Action

1. Open the patient chart.

2. Click the Orders band.

3. Click + Add.

4. Click the Root Folder to view subfolders.

5. Click the appropriate subfolder to view

additional folders.

6. Right-click your specialty folder and click Set as

Home Folder.

7. _{Click to ensure that your specialty}

folder is now set as your Home Folder.

8. To return to the Root Folder, click .

Note: If you are a resident changing specialties, you can reselect the correct Home Folder with each rotation.

70

Order Entry Basics, continued

Search

You can search for a single order, PowerPlan, or Orders Set by the first word of the order name or by a specific word contained in the order name. PowerPlans and Order Sets are covered in further detail starting on page 79. Note: You must enter at least 3 letters of the order name to perform a Contains search. Entering too many letters may increase the chances of misspelling your search word; it is best to enter between 3 and 6 letters.

Search for Orders

By Order Name

Step Action

1. From the Orders band, click + Add.

2. Click the drop-down arrow to change the

Order Search criteria to Starts with, if not already selected.

3. Enter your search word in the Search field.

A list of search results displays. Search results may include synonyms for the same order.

4. Click the appropriate order once to select it.

Note: If you double-click, the order will be duplicated. To remove a duplicate, right-click and select Remove prior to signing the orders.

71

Order Entry Basics, continued

Orders, cont.

By “Contains”

Step Action

1. From the Orders band, click + Add.

2. Click the drop-down arrow to change the

Order Search criteria to Contains, if not already selected.

3. Enter your search word in the Search field.

.

4. Click the appropriate order once to select it.

Enter Single Orders

Step Action

1. Search for the order.

2. Click the correct order in the search result list.

Note: For peds, it is preferable to select a pediatric order set if available. CareSets provide the best information for dosing and ordering the medication in pediatrics.

3. If entering a medication order, select the order

sentence that best matches the intended order.

The Order Details pane opens.

Note: Order details may need to be resized.

72

Order Entry Basics, continued

Orders,

cont. Step Action

4. _{If displays, there are missing order}

details. Click to move from

one missing detail to the next.

5. Highlight the Order detail, then complete or

change the corresponding Detail value.

6. Review all new order details in the Orders for

Signature pane.

7. Click Sign.

8. _{Click to refresh the screen.}

Signed orders file into the corresponding clinical category.

73

Order Entry Basics, continued

Orders

Use Modify to:

• Adjust the rate (IV fluids, cont. infusions)

• Input stop date and time

• Add comments

Changes to the Details of a Signed Medication Order Cancel/Reorder should NOT be used for Medication Orders. If you need to make changes to other details of a signed Medication Order, Cancel/DC the order and place a new order with the corrected information.

If an order has not been acted upon and was placed in error, you can Void it and place a new order.

Note: Always select Cancel/ DC to modify a Medication Order unless you are modifying the:

• Rate of an IV fluid (must use modify)

• Stop date and time

• Comments

74

Order Entry Basics, continued

Folders

You can create your own Favorites folders where you can store and access orders that you use frequently or orders that are difficult to locate.

Create Favorites Folders

Step Action

1. Click the Orders band.

2. Click + Add.

3. Click the arrow by the Favorites icon.

4. Select Organize Favorites.

5. Add folders by clicking Create Folder.

Your first folder is a subfolder of the Favorites folder.

6. To create a subfolder, highlight the parent

folder prior to clicking Create Folder.

Move Favorites Folders

Step Action

1. To move a folder to a different parent folder,

highlight the folder you need to move.

2. Click Move to Folder.

3. Select the appropriate parent folder.

4. Click OK.