Inpatient Cerner Navigation And Documentation For Nursing .

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Inpatient Cerner Navigation and DocumentationFor Nursing StudentsAudience Note:Cerner PowerChart training is for all students in the following inpatient areasMed/Surg, OSN, Oncology, ARU, Peds, FMC, GYN, PACU, PCU, and CCUPurpose:To provide an introduction to Cerner PowerChart navigation andfunctionality.Objectives:By the end of this training session, the participant(s) will be able to: Last Updated 8/17/2020Understand basic RN workflow in PowerChart.Recognize various tools within PowerChartThe PowerChart Organizer and Patient List.Locate a patient, open and exit the patient chart.Navigate through the patient chart to locate and document clinicalinformation.Adjust search criteria and modify documentationINTRODUCTIONLog in to the NETWORK.Log in to PowerChart (Cerner) using the training logins provided onseparate sheet.NOTE: Remember your HIPPA training and the Privacy Rule:o You may not view your own patient recordo You may not open any patient’s record unless required for yourjob/clinical assignment.1

Basic RN Workflow for Care Compass1. When Nurses or Unit Techs first log into PowerChart it will open to CareCompass.2. The Patient List on CareCompass will appear. This will be blank until you create locations.a. To build this list click onList Maintenance to the right of Patient Listas shown above.3.To add locations.a. Select List Maintenanceb. Select New.c. Select Location and Next.d. Click on the sign next to the Locations folder,then click on the sign for Evergreen HealthCare,click on the sign for Evergreen.e. Scroll down until you find 6 Silver-East and checkthe box. Select Finish.Repeat steps 4a-d for 6 Silver-West, 7 Silver-Eastand 7 Silver-West.***Due to HIPAA protocols, you should only accessthe side and floor your assigned patients are located.f.Highlight the location under Available lists andclick on the blue arrow to move it to Active lists.Repeat this until all availablelists are moved to the right under Active Lists.g. Highlight a list and click on the up or down arrowto arrange them by floor. Click OK when finished.Last Updated 8/18/20202

4. You are able to switch between units you’ve created byusing the drop down box next to Patient List.5. To chart on a patient or open a chart, a relationship must be established:a. Select Establish Relationship.b. Choose Nursing Student from drop down and refresh.6.Once a relationshp is established, you will bbeable to see more details on a patient:a. Hover over patient name to see general information,diet, and code status.Task List:7. Select the arrow at the end of the patient name. A task listwill appear, to the right, with additional information onyour patient. Three tabs will be displayed.The first tab is Schedule/Unscheduled.① Patient name, age, Sex, DOB, MRN,and FIN #②Tasks and medications that will be dueover the next 2, 4 or 12 hours③Overdue task are displayed in red1328. Completing Tasks: Select Scheduled/Unscheduled. Right click on the gray arrow next to the patientsname to open task list view to complete tasks.a. Select the task, right clicki. Select Document, to completethe taskii. Select Done, if alreadycompletediii. Select Not Done, thengive reasoningLast Updated 8/18/20203

9. Fill in your assessment. (All area with yellow backgrounds must be filled in). After reviewing, click on thegreen check mark in the upper left hand corner to sign the form.10. Completing Tasks from prior shift on the task list:a. For overdue tasks from previous shifts (Braden, Morse, PRN Pain Response, Medications)notify primary RN.11. Throughout your day check Care Compass for new orders, results, and/or tasks. Refresh OFTEN to seenew information for your patient.12. To review orders:a. Click on orange or red box around patient nameOrange Box around patient name with Orange Circle containing ‘!’ inside:‘New Results’ or ‘New Orders’. Click on the Orange Circle in the box toview/review these items.Red Box around patient name with Red Circle containing ‘!!’ inside:‘STAT Orders’ or ‘CRITICAL Results’. Click on the right end of the box toview/review these itemsb. If the user put the order in themselves, the orange or red box will not appear, the systemassumes you are aware of the order because you entered itc. PLEASE always try to document your tasks from the task list instead of using Ad Hocd. Remember to clean up your task list regularly throughout your shift and also prior to shiftchange report.*** Students: Do not click Marked as Reviewed when reviewingorders from CareCompass.Name Alerts – Patients with similar names will be italicized.Symbols – (Hover over these symbols to see further information):Biohazard symbol - Patient Isolation Status. Will appear if patient has any isolation status otherthan Standard PrecautionsRed Triangle - High Patient Risks i.e: Skin Risk, Fall Risk, Restraints, CIWAA score greater than 10NIK (No Information Known) – patients who do not want outside people to call in and getinformation. DO NOT acknowledge that the patient is in the hospitalLast Updated 8/18/20204

Activity Timeline – (at the bottom of CareCompass)Red bar, on left end - Overdue tasksClick to see what type of tasks are overdue, enter patient information window to documentHourly Green Bars - Visual cue of upcoming nursing tasks, (medications, patient care, charting)Click on green bar to see a breakdown of type of task for specified hour.Review across the top of the patient chart***open your assigneded PCTrain, Patient to review the followingTitle Bar –Shows PATIENT NAME, MRN and NAME of who opened the chart.Menu Bar –Task: Change User – use when you want your primary nurseor preceptor to cosign your documentation Exit - enables user to gracefully exit the PowerChart system.Patient: Search – Locate patient by FIN # or 3 patient identifiers Recent – shows recent patient charts you have viewedIcon Bar –CareCompass – Click you return to your CareCompassService Directory – Most up-to-date hospital wide directory with every department’s contactinformation (phone or pager)Patient List – Find your patient on the Patient List.(Used by clinical staff, other nurses and unit techs)Last Updated 8/18/20205

Links – provides access to online applications: i.e. DynaMed, Lexicomp, Lucidoc, & other resources. DynaMed – Tool for efficient and evidence-based patient care. Lexicomp – Medication resource tool to look up medications information such as IVcompatibility interactions, patient education and more. Lucidoc –EvergreenHealth’s policies and proceduresExit – closes all applications.Calculator – a tool that includes formulas that convert inches to centimeters, IV fluid rate, CCs perhour, etc.AdHoc Charting – Categorizedby disciplines (folders on left).Available forms are within aselected disciplines (on theright side).Medication Administration – displays patient medications after you have scanned the patient.Patient Education –Allows nurses to add Educational material to the patient’s chart. (Only an optionwhen in a patient’s chart)Documents – enables end users to print Patient information such as Face Sheets, arm bands, or ADTlabels.Collections Inquiry - view collections scheduled or collected through the current time, ability toreprint labels for specimens as needed.Refresh or ‘As Of’ – updates all information entered on your patient. Youmust remember to refresh after making any changes and refresh often tosee new orders or changes others have made.Last Updated 8/18/20206

Navigation Within the Patient’s ChartDemographic Bar – Displays information regarding the patient’s current visit1. Patient Name – (active link) double clicking on the patientname will show general patient information.2. MRN# (medical record number, patient’s hospital ID) &FIN # (unique financial number for a specific visit) – both aredisplayed.3. Other items found on the Banner Bar:a. Allergies, Code status, Patient Age, Date of Birth,Sex, Admission Dateb. Encounter type, and Patient location (active link shows General Information)c. Isolation Status – Standard, Contact, Contact Enteric, etc.Navigation down the Menu Bar in the Patient’s ChartThe menu bar is similar to the tabs in a hard chart.Select the pushpin to keep it open on the left side of the patient’s chart.Nursing ViewPoint –Nursing Handoff, Nursing WorkFlow, Discharge Summary,Depart Process and Impatient SummaryOrders – Lists all active orders.Plan of Care Summary – List of interdisciplinary plan(s) of care (IPOCs) for thepatient. These are your nursing goals or nursing plan of care.Medication List – List of the patient’s current medications. This will bealso covered with the Orders. There is also a list of the patient’s home medicationsunderMEWS-Sepsis – modified early warning system with a computer calculated scoreof patient’s possible sepsis status.IVEW – Patient assessments are documented here. All documentationdone by the Student RN in IVIEW will show as unauthenticated until theprimary RN signs it.Entering Information into IVIEW1. Click on the IVEW tab to open the flowsheet for documentation.It will first open to the Vitals.2. Double click on the time to open wholecolumn to chartLast Updated 8/18/20207

Or3. Double click in the blue header above the sectionto activate the section to enable data entry.Or3. Double Click in the cell you wish to document in.4. The documentation will be purple until it is signed.5. Sign your documentation by clicking on the green checkmark at the upper left of the IVEW window. Thedocumentation will now be black.6. Isolation Status – must be documented inIVIEW if the patient is under any type ofspecial isolation precautions. Patient Isolationis located in the Vitals band directly belowthe Vital Signs.7. Intake and Output –Enter the patient’sI&O. i.e oral, urine, stool ect).8. Interventions – Document on activities and interventionsLast Updated 8/18/20208

Documenting by Exception for the Routine Nursing AssessmentAssessment documentation in IVIEW is described as charting by exception. The following examples areunder Routine Assessment.1. If your assessment for a specific system is WithinNormal Limits (WNL), you can just select WNL. Areference is available for you to see what thenormal limits are for that system.2. If there are exceptions to the assessment the nurse would choose WNL Except and additionalassessment information will become available. Document only what is abnormal in that systemassessment.3. If the patient’s condition improves and the system assessment is now normal, at the time theassessment becomes normal the nurse will need to document to show how and when the patientassessment is normal by selecting WNL for that system.4. After the documentation shows what thenormal value is, WNL can now be documented.From then on, as long as the assessmentcontinues to be WNL, this may be documented.Last Updated 8/18/20209

Documenting dynamic groups1. In Tubes and Drains, select Drain Assessment.2. To add a drain, click on the grid toAdd a dynamic group .3. Fill in Drain type, Drain #, Drain location, and Draininsertion date/time. ***Make sure to fill inthe date even if you do not know the exacttime. In this case, leave the time blank.4. Add a drain volume Double click in the Drain Output field,then enter the amount 600. Sign data, by clicking the green check mark,then refresh the screen.5. Modify Patient Data Right click in the field where you just chartedand select Modify Enter the correct amount and sign.A delta sign will appear in the fieldindicating a change.6. The student nurse documentation inIView will be displayed as shownon the right.7. All documentation done in CareCompasswill then show as pending validationuntil the primary RN cosigns the charting in thestudent nursing sign-off band usingthis icon is at the top of IView in the RN’s view.Last Updated 8/18/202010

MARMedications should never be given by the RN studentwithout observation from an RN or the student’sinstructor. Immediately before the medication is givenit should be scanned, reviewed and documented in thepatient’s chart at bedside.Open the MAR to review the scheduled, prn and IVmedications.Medication administration should be done using thehand held scanner. Click on the Medication Administrationicon on the tool bar to open the scanner application. Scanboth the patient’s armband & the medication***Remember to look at your Medication Administration screen after each medication is scanned.Thisensures the medication actually scanned. The scanners on the floor BEEP even if the medication did not scanor if additional steps are needed before scanning the next medication.Medications will show Pending Validationuntil cosigned by the primary RN or student’sRN instructor.Any medications that are RED on the MAR pleasereview with the primary RN before the end of yourshift (why was the med not given at all or thetime it was given late and why).MAR SUMMARY- provides a summary of all medications scheduled for the patient in the 24 hour period —highlighted in yellow or the period of which the Search Criteria banner is set to.LAB – shows labs resultsAdjusting the Search Criteria - Several of the pages may require you change the date range to viewpreviously documented items.1. Right click on the gray bar, select Change Search Criteria, and fill out the dates you need to view.2. There will be multiple ways for you to lookup your results.DI – Diagnostic Imaging results will be displayed here.Last Updated 8/18/202011

Histories – Displays Social and Past Medical HistoryForms – all completed forms from the task list & Ad Hoc can be found here.Modifying Entries Made on FORMS – Go to forms tab and RIGHT CLICK the form that needs to bemodified or uncharted and enter the changed information.Documents – Consults, previous discharge instructions, history and physical, admission health historyreports and provider and nursing progress notes.Results Review – Shows trends in IVEW documentation on the vitalsPatient Information – lists patient information, such as demographics, allergies, visit lists and growth chart.Problems and Diagnosis – List of Problems and Diagnoses for the patientKARDEX – d Products Mpage – Shows thepatient’s blood type, all blood productsthat have been administered to the patient,blood product orders, and available anyblood products for the patient.Glycemicare – Blood glucose levels if applicable.RxStation – Location where medications can be queued to be pulled out of the medication room. Onlyqueue medications that you have reviewed with the primary RN or your instructor.Charting Quick Tips:T TodayRecent Patients – shows last 9 patientsN NowRight click for additional informationRefresh frequently so that you can see new orders and changes.Last Updated 8/18/202012

Inpatient Cerner Navigation and Documentation For Nursing Students Audience Note: Cerner PowerChart training is for all students in the following inpatient areas Med/Surg, OSN, Oncology, ARU, Peds, FMC, GYN, PACU, PCU, and CCU Purpose: To provide an introduction to Cerner PowerChart navigation and functionality.