Download Combined Cerner Guide_5x7_final060412

C e rn e r
Physician Reference
Guide
June 4, 2012
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
2
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
Cosign a Note .................................................. 19
3
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
View Clinical Documentation..................................... 38
4
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
Order Sets ....................................................... 79
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PowerPlans...................................................... 79
Medication Order Entry .............................................. 87
IV: Titratable Drip............................................ 88
IV – Heparin Nomogram and Thrombostabilizer 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
Calculate Standard Doses ............................. 113
6
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
Wishard Memorial Hospital .......................... 160
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8
Overview
Introduction
Cerner
Password
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.
Your Cerner password:
•
•
•
•
Security
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
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
computer
9
Log On and Off
Introduction
Remote Log
On
Procedure
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.
Step
1.
2.
3.
4.
5.
6.
7.
8.
Action
Open your web browser.
In the address locator bar, enter
https://sragate.clarian.org
Click Yes to install Juniper on your system.
Enter your IU Health Network ID and
password.
Click Enter or Sign In.
Available roles in the secure gateway display.
Click the Tier0 link.
The Secure Access SSL – Home page displays.
In the Web Bookmarks section, click the
Cerner link.
The CernerWorks applications portal displays.
Click
to launch Cerner PowerChart.
Continued on next page
10
Log On and Off, continued
Downtime
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
Continued on next page
11
Log On and Off, continued
Downtime
Procedures,
cont.
Safeguard Printed Patient Information
Follow these guidelines for printing reports:
You Are Printing a Report
Carefully select the correct printer
from the drop-down menu.
You Find a Printed Report
If you find a report containing
patient information on a printer,
contact the person who printed
the report.
If unable to contact the report
owner, place the report in the
shred box.
If the report prints a second time,
contact the Service Desk at 317962-2828 and report the computer
name, location, and the name of
the printer where the report
printed.
Place the report in the shred box.
Retrieve the printed report from
the printer immediately.
If the report did not print, reselect
the correct printer and attempt to
print the report again.
If the report does not print after a
second attempt, contact the
Service Desk at 962-2828.
Continued on next page
12
Log On and Off, continued
Log On
Procedure
Step
1.
2.
Log Off
Procedure
Action
Double-click
on your computer desktop.
3.
Click
displayed in the Applications
window.
Enter your user ID (usually your dictation
number) and password into the respective
fields.
4.
Click OK.
Step
1.
2.
3.
Action
Close all open patient charts.
Click
to immediately disconnect from
the server.
The Exit Application window displays.
Select Exit and shut down the application.
Note: To suppress this message in the future,
place a checkmark in the box.
13
Change Your Password
Introduction
You can change your password at any time using the
following procedure.
Procedure
Step
1.
2.
3.
4.
5.
6.
Action
When logged onto Cerner, click Task on the
toolbar.
Select Change Password from the drop-down
menu.
Enter your old password in the Old Password
field.
Enter a new password in the New Password
field.
Re-type your new password in the Retype
Password field.
Click OK.
14
Access Other Clinical Systems
Introduction
Available
Systems
Within Cerner, you can access other clinical systems used
at IU Health.
System
INPC
ClinDoc
ClinSuite
UpToDate
Description
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
• Electronic nursing flowsheet contains
data entered by nursing
• Data flows into Cerner
• It can be viewed from either ClinDoc
or Cerner
Tool used to facilitate the patient
handoff process between physicians
IU Health’s source for evidence-based
clinical information
15
View Surgical Schedules
Procedure
Step
1.
2.
3.
4.
5.
6.
Action
Click
in the links within Cerner.
Click the appropriate surgical area.
Click to begin the print process.
Place a checkmark in the Preview box.
Click Print.
In the next box, click Print.
The surgical schedule displays.
16
Utilize Message Center
Introduction
Sign Single
Telephone
and Verbal
Orders
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
Step
1.
2.
3.
4.
Sign a Group
of Telephone
and Verbal
Orders
Step
1.
2.
3.
4.
5.
Action
Click the Orders, Cosign Orders or Med
Student Orders folder.
Review order details for accuracy.
Right-click the order.
Select Approve from the menu.
Action
Click the Orders, Cosign Orders or Med
Student Orders folder.
Review order details for accuracy.
Hold the Control key down while clicking on
multiple orders.
Right-click anywhere WITHIN the highlighted
orders.
Select Approve from the menu.
Continued on next page
17
Utilize Message Center, continued
Forward
Orders for
Signature
Step
1.
2.
3.
4.
5.
6.
Action
Select the order(s).
Click Forward Only.
Select Sign from the Additional Forward Action
list.
Find the provider by:
• Typing the name of the intended recipient
provider, or
• Click Search and look for the provider
Enter comments (up to 120 characters,
including spaces) if necessary.
Note: Comments become part of the
permanent patient medical record.
Click OK.
Continued on next page
18
Utilize Message Center, continued
Refuse
Orders for
Signature
Step
1.
2.
3.
4.
5.
6.
Cosign a
Note
Step
1.
2.
3.
4.
Action
Click the Message Center Orders, Cosign
Orders or Med Student Orders folder.
Double-click the order you wish to refuse.
Click Refuse.
Select a reason.
Type a comment (up to 120 characters) if
needed.
Click OK or click OK and Next if you need to
refuse additional orders.
The order is routed to the refusal admin.
Action
Click the Documents folder.
Double-click the note requiring cosignature.
Review the note for accuracy.
Click OK to sign the note.
19
Create and Maintain Patient Lists
Introduction
Lists Used
Create a
Relationship
List
Patient lists use defined criteria to organize patient
charts. Each patient list displays on a separate tab.
Lists commonly used at IU Health include:
Type
Description
Provider
Provider Group lists are helpful if you
Group
and your colleagues share a list of
patients.
Provider Groups can be created by
contacting the Help Desk at 317-9622828.
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.
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.
Continued on next page
20
Create and Maintain Patient Lists, continued
Create a
Relationship
List, cont.
Step
4.
5.
Action
Click Next.
Click + to the left of Visit Relationships.
6.
7.
Click Next.
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
Click + to the left of Location, then click + to
the left of each appropriate location.
11.
Continued on next page
21
Create and Maintain Patient Lists, continued
Create a
Relationship
List, cont.
Step
12.
Action
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.
16.
Click Finish.
Highlight the new list in the Available lists
pane.
17.
Click
to move the list to the Active lists
pane.
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.
Click OK.
18.
19.
Continued on next page
22
Create and Maintain Patient Lists, continued
Add Patient
to
Relationship
List
Step
1.
2.
3.
4.
5.
6.
7.
8.
Remove
Patient from
Relationship
List
Step
1.
2.
3.
4.
5.
6.
7.
Action
Click the patient list tab where you need to
add the patient.
Click
(Add Patient).
Enter the patient’s last name or MRN (medical
record number).
Click Search.
Select your patient from the search results list.
Select the appropriate encounter from the
lower pane.
Click OK.
Click
to refresh.
Action
Click the specific patient list tab where you
need to remove the patient.
Click the patient’s name.
Click
(Remove Patient).
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.
Select the appropriate relationship.
Click OK.
Click
to refresh.
Continued on next page
23
Create and Maintain Patient Lists, continued
Create a
Query List
(Report)
Step
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Action
Click
..
Click
(List Maintenance).
Click New.
Select Query.
Click Next.
Select Physician List Query.
Change the name of the query to reflect the
physician names and locations.
Click Next.
Type the first few letters of the physician’s
name to move quickly to that area of the
physician list.
Place a checkmark in the box to the left of the
desired physician’s name.
Click Next to select locations from within the
Organizations window.
Place a checkmark in the box to the left of each
location.
Click Next.
Click Finish.
Continued on next page
24
Create and Maintain Patient Lists, continued
Create a
Query List
(Report),
cont.
Step
15.
16.
17.
18.
Action
Highlight the new list in the Available lists
pane.
Click
to move your new list to Active Lists.
Click OK.
Click
list.
(Execute Query) to activate the
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
1.
2.
3.
4.
5.
Action
Click
.
Click
(Modify Parameters).
Modify the parameters for a query list (add or
remove a physician or location).
Click OK.
Click
(Execute Query) to implement
your changes.
Continued on next page
25
Create and Maintain Patient Lists, continued
Safeguard
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
Carefully select the correct printer
from the drop-down menu.
You Find a Printed List
If you find a list containing patient
information on a printer, contact
the person who printed the list.
If unable to contact the list owner,
place the list in the shred box.
If the list prints a second time,
contact the Service Desk at 9622828 and report the computer
name, location, and the name of
the printer where the list printed.
Place the list in the shred box.
Retrieve the printed list from the
printer immediately.
If the list did not print, reselect the
correct printer and attempt to
print the list again.
If the list does not print after a
second attempt, contact the
Service Desk at 962-2828.
26
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.
Continued on next page
27
Search for a Patient, continued
Locate the
Correct
Patient
Encounter
Step
1.
2.
Action
Carefully view the patient encounters in the
lower pane of the Patient Search window.
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.
Click OK.
6.
Continued on next page
28
Search for a Patient, continued
Locate the
Correct
Patient
Encounter,
cont.
Step
7.
Action
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
encounter.
29
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
1.
2.
3.
4.
Action
Open a patient chart.
If a relationship window displays, select a
relationship.
Click Chart on the toolbar at the top of the
screen.
Scroll to the bottom and select Chart
Accessed By.
5.
6.
Select Most Recent from the sub-menu.
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.
Click Save.
Click Close.
8.
9.
30
View and Add Allergies
View
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
view allergies.
(Allergies band) to
Allergy details display as follows:
Add
Allergies
Step
1.
2.
3.
Action
Click
(Allergy link) in
the patient header to access allergy details.
Note: Alternatively, you can click
(Allergies band) to enter allergies.
Click + Add.
Click the + to the left of the appropriate allergy
category folder.
Continued on next page
31
View and Add Allergies, continued
Add
Allergies,
cont.
Step
4.
Action
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).
Double-click the appropriate common
reaction.
7.
8.
9.
10.
Click OK to add the allergy to the allergy list.
Click OK to close the allergy list.
Click
to refresh the screen and
display the new allergy in the patient header.
32
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
Results
Review
In Patient
Summary
Function
Displays lab results, vital signs, significant events, and
other pertinent information for your patient
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.
Continued on next page
33
Navigate to Sections of the Chart, continued
Band
Rounds
I/O / I
Flowsheet
Allergies
MAR
Summary
Medication
List
Orders
2 Year
Clinical
Notes
72 Hr
Clinical
Notes
Function
Displays an online view of data similar to the printed
rounds report
• 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
• Displays all allergies entered into the system
• Allows for additional allergies and reactions to be
documented
Summarized medication administration over 24 hour
timeframes during current encounter
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.
Provides the Order Profile for a patient—existing orders
as well as order statuses and detail information. Allows
for new orders to be entered.
Contains notes from today to 2 years prior
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.)
Continued on next page
34
Navigate to Sections of the Chart, continued
Band
2 Year
Physician
Notes
PowerNote
Problems
and
Diagnoses
Patient Info
Dictation
View
Chart
Summary
Discharge
Instructions
Chart
Search
Function
Displays notes by physicians and mid-level providers and is
a sub-set of clinical notes
Allows for the use of templates to create structured notes.
Use the PowerNote band to document your online notes.
Displays problems and diagnoses entered into the system,
also allows for adding or editing information.
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.
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).
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.
Secure electronic form used for documenting custom
patient discharge instructions.
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
• Allergies
• Problems
• Lab panels (currently must search
for individual components)
• Procedures
35
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.).
Continued on next page
36
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.
37
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
1.
2.
3.
4.
5.
6.
Action
Depending on the timeframe you need to view,
click either the 2 Year Clinical Notes band or
the 72 Hr Clinical Notes band.
Click one of the radio buttons to sort the index
by one of the following options:
• Type
• Status
• Date
• Performed By
• Encounter
Double-click the needed folder to open.
If there are sub-folders, click the + to see more
folders or documents.
Double-click to open a document.
Use the large blue arrows
to move
quickly from one document to the next or to
move between note types.
Continued on next page
38
View Clinical Documentation, continued
Navigate
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.
to determine if multiple pages have
• Check
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
• Use the rotate tools
39
to rotate the document
Create a Free-Text Clinical Note
Procedure
Step
1.
Action
Click either the 2 Year Clinical Notes band or the
72 Hr Clinical Notes band.
2.
Click
(New Note).
Select the correct note Type.
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.
Enter the Subject of the note.
Type your note.
Click Sign, Save, Save & Close or Cancel.
3.
4.
5.
6.
7.
Option
Sign
Save
Save &
Close
Cancel
Function
• Enters your note into the
patient’s permanent record
• Changes to the note must be
made by addending the note
• Saves your note before signing
• Changes can be made to the
note
• Saves your note before signing
• Closes it so that you may
complete it at a later time
Deletes your note with no saved
record of the note
40
Write Notes
Set Up
Personal
Document
Types as
Defaults
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
IP
OP
Admission/H&P Note
Initial Consult Note
Progress Note
Procedure Note
Orders Reconciliation
Description
Inpatient
Outpatient
Generic
By specialty
By specialty
Generic
Procedure
Step
1.
2.
Action
Open the patient chart.
Select PowerNote +Add from the menu.
Note: You must click + Add and ensure that
you have opened a PowerNote to proceed.
Continued on next page
41
Write Notes, continued
Procedure,
cont.
Step
3.
Action
Select View from the uppermost task bar.
4.
5.
Select Customize from the drop-down menu.
Select the Document Types tab.
6.
Click
to uncheck
it.
Select Personal Note Type List from the
Default List Type.
7.
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.
Click Apply.
Click OK.
10.
11.
Continued on next page
42
Write Notes, continued
Add
Templates
to Favorites
Step
1.
2.
3.
4.
5.
6.
7.
8.
Create New
PowerNote
Action
Click the Catalog drop-down arrow.
Select IUH Inpatient.
Click + next to Specialty (i.e., Adult).
Highlight the appropriate templates (e.g.,
Admission H&P, Progress Note, Consult Note,
Transfer Order Review)
Click Add to Favorites.
Scroll down and click + next to Procedures.
Highlight the needed procedure templates.
Click Add to Favorites.
Your selected templates display under your
Favorites tab.
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).
Continued on next page
43
Write Notes, continued
Create New
PowerNote,
cont.
Step
4.
5.
6.
7.
8.
9.
Action
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.
Click the + next to each folder to view its
contents.
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.
Click OK.
The Auto Populate screen displays.
Check the boxes for those items that you need
included in your note.
Click OK.
Continued on next page
44
Write Notes, continued
Create New
PowerNote,
cont.
Step
10.
11.
12.
13.
14.
Action
Click
to expand and display the
structure of the note.
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
To enter free-text for a particular term, click
or right-click and select Comment.
To enter free-text at the paragraph level, click
.
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 & • Saves the note before signing
Close
• Closes it so that you may
complete it at a later time
Cancel Deletes your note with no saved
record of the note
Continued on next page
45
Write Notes, continued
PowerNote
Views
Contributor View
You can view a PowerNote in report format while you are
creating the note.
Step
1.
Action
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
1.
2.
Action
Click
in the upper left corner of
the note to expand the note view to full
screen.
Click
in the upper right corner to
reduce the screen size.
Continued on next page
46
Write Notes, continued
Modify
PowerNotes
Addend a Note
You can add information to your clinical documentation
by using the addend function.
Step
1.
2.
Action
Click the Clinical Notes band.
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.
Enter the additional text below *Insert
Addendum Here:.
4.
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
1.
2.
3.
Action
Click the Clinical Notes band.
Double-click the appropriate note to open it.
Click
or right-click the body of the note
and select Modify.
Continued on next page
47
Write Notes, continued
Modify
PowerNotes,
cont.
Modify a Note, cont.
Step
4.
5.
Action
Drag your cursor to highlight the incorrect
text.
6.
Click
(Strikethrough).
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.
Continued on next page
48
Write Notes, continued
Modify
PowerNotes,
cont.
Strike the In Error Note from View
Step
1.
Action
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.
6.
Click OK.
Either return to the PowerNotes or Physician
Notes band to write your replacement note
or select the correct patient to begin entering
your documentation.
Continued on next page
49
Write Notes, continued
Advanced
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
1.
Action
Make sure that the note you need to copy into
is open.
2.
Click
to minimize the new note.
Double-click to open the note that you need to
copy from.
Highlight the appropriate text that you need to
copy from the existing note.
Press ctrl>C on the keyboard to place the text
on the electronic clipboard.
3.
4.
5.
6.
7.
8.
Click
to maximize the new note.
Click the area of the note where you need to
paste the new text.
Press ctrl>V on the keyboard to paste the text.
Continued on next page
50
Write Notes, continued
Advanced
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
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Action
Click + Add in PowerNote band.
Click the Existing tab.
Click to highlight the appropriate note to copy
forward in the bottom pane.
Place a checkmark in the Copy to New Note
box.
Select the appropriate Document Type.
.
Type an appropriate Title.
Click OK.
Select paragraphs to copy.
Check and uncheck the appropriate items in
the Auto Populate window.
Complete the note by modifying data to
accurately reflect documentation for the date
of entry.
Click Sign.
Continued on next page
51
Write Notes, continued
Advanced
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
1.
2.
3.
Action
In the selected structured note, select terms
as positive or negative as needed for your
macro.
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).
Select Save Macro As from the pop-up menu.
Continued on next page
52
Write Notes, continued
Advanced
PowerNote
Functions,
cont.
Create a Macro, cont.
Step
4.
5.
Action
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).
Click Create New.
Insert a Macro
Step
1.
2.
3.
Action
Click the M in the section of the document
where you have created the macro.
Select the appropriate macro from the list that
displays.
The note populates with the preselected terms
from your macro.
Modify the macro as needed for your particular
patient.
Continued on next page
53
Write Notes, continued
Advanced
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.
6.
Note: Be sure to enter a term that will help you
know what is in your auto-text (e.g.,
“pyelonephritis”).
Click (Add Text).
The Formatted Text Entry window displays.
Continued on next page
54
Write Notes, continued
Advanced
PowerNote
Functions,
cont.
Create Auto Text, cont.
Step
7.
8.
9.
Action
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.”).
Click OK to close the Formatted Text Entry
window.
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.
5.
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”).
Enter a description.
6.
Note: Be sure to enter a term that will help you
know what is in your auto-text (e.g.,
“pyelonephritis”).
Click Save and then Close.
55
Write Notes, continued
Advanced
PowerNote
Functions,
cont.
Insert Auto-Text
Step
Action
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.
3.
A drop-down menu displays.
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.
Continued on next page
56
Write Notes, continued
Advanced
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
1.
2.
Action
Create a PowerNote but do not sign.
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.
Click OK.
6.
Continued on next page
57
Write Notes, continued
Advanced
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
clicking on the symbol
58
Computerized Provider Order Entry (CPOE)
Customize
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
1.
2.
3.
4.
Action
Open the patient chart.
Click the Orders band.
Click the Options menu at the top of the
screen.
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.
Continued on next page
59
Computerized Provider Order Entry (CPOE),
continued
Customize
Views, cont.
Orders Band: Customize Filters, Columns, and Groups,
cont.
Step
1.
2.
Action
From the Orders band, click the Displayed:
hyperlink to access the Advanced Filters
window.
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.
Continued on next page
60
Computerized Provider Order Entry (CPOE),
continued
Customize
Views, cont.
Orders Band: Customize Filters, Columns, and Groups,
cont.
Step
2.
Action
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.
3.
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.
From the Current menu, select Customize
View.
61
Computerized Provider Order Entry (CPOE),
continued
Customize
Views,
cont.
Orders Band: Customize Filters, Columns, and Groups,
cont.
Step
4.
Action
Move the following columns from the
Available columns pane to the *Selected
columns pane by selecting them and clicking
Add:
e. Status
a. Quick Discontinue
b. Notifications
f. Details
c. Type
g. Ordering Physician
d. Order Name
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.
Continued on next page
62
Computerized Provider Order Entry (CPOE),
continued
Customize
Views,
cont.
Orders Band: Customize Filters, Columns, and Groups,
cont.
Step
6.
Action
Customize the grouping of orders to create
Clinical Folders for locating and viewing existing
orders as follows:
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.
Confirm that upon completion, your Orders view
pane appears in the following order:
a.
7.
Continued on next page
63
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
1.
2.
3.
Action
Open the patient chart and click the Medication
List band.
Click the Displayed: hyperlink to access the
Advanced Filters window.
In the Display drop-down list, select All
Medications (All Statuses).
Continued on next page
64
Computerized Provider Order Entry (CPOE),
continued
Customize
Views,
cont.
Medications List Band: Customize Filters, Columns and
Groups, cont.
Step
4.
5.
6.
Action
From the Current menu, click the Customize
View link.
Move the following columns from the Available
columns pane to the *Selected columns pane
by selecting them and clicking Add:
a. Quick Discontinue
e. Status
b. Notifications
f. Details
c. Type
g. Ordering Physician
d. Order Name
h. Last Updated By
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.
Continued on next page
65
Computerized Provider Order Entry (CPOE),
continued
Customize
Views,
cont.
Medications List Band: Customize Filters, Columns and
Groups, cont.
Step
7.
Action
Customize the grouping of orders to create
Clinical Folders for locating and viewing
existing orders as follows:
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.
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.
a.
8.
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.
Continued on next page
66
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…
Hover your mouse over the upper border of
1.
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.
Continued on next page
67
Computerized Provider Order Entry (CPOE),
continued
Common
CPOE Icons
Order Type
Icons
Cerner uses images to denote order type, status, and
other important information.
Inpatient Orders
Documented Meds by History (home meds)
Prescriptions
Ambulatory Orders
Order
Detail Icons
Additional Reference Information Order
Order Details Not Complete
Dose Calculator
Order
Review
Status
Physician Order with Pending Cosign
Medical Student Order Cosign
Pending Pharmacy Review
Pending Nurse Review
Order Icons
Order
Order Comment
Order Set
PowerPlan
PowerPlan
Icons
Initiate Plan or Phase
View Excluded in PowerPlan
Discontinue PowerPlan or Phase
68
Order Entry Basics
Specialty
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
1.
2.
3.
4.
Action
Open the patient chart.
Click the Orders band.
Click + Add.
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.
To return to the Root Folder, click
.
8.
Note: If you are a resident changing specialties, you can
reselect the correct Home Folder with each rotation.
Continued on next page
69
Order Entry Basics, continued
Basic Order
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
1.
2.
Action
From the Orders band, click + Add.
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.
Continued on next page
70
Order Entry Basics, continued
Search for
Orders,
cont.
Enter Single
Orders
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.
Step
1.
2.
3.
Action
Search for the order.
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.
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.
Continued on next page
71
Order Entry Basics, continued
Enter Single
Orders,
cont.
Step
4.
5.
Action
If
displays, there are missing order
details. Click
to move from
one missing detail to the next.
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.
8.
Click Sign.
Click
to refresh the screen.
Signed orders file into the corresponding clinical
category.
Continued on next page
72
Order Entry Basics, continued
Modify
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
Continued on next page
73
Order Entry Basics, continued
Favorites
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
1.
2.
3.
4.
5.
6.
Action
Click the Orders band.
Click + Add.
Click the arrow by the Favorites icon.
Select Organize Favorites.
Add folders by clicking Create Folder.
Your first folder is a subfolder of the Favorites
folder.
To create a subfolder, highlight the parent
folder prior to clicking Create Folder.
Move Favorites Folders
Step
1.
2.
3.
Action
To move a folder to a different parent folder,
highlight the folder you need to move.
Click Move to Folder.
Select the appropriate parent folder.
4.
Click OK.
Continued on next page
74
Order Entry Basics, continued
Favorites
Folders,
cont.
Rename Favorites Folders
Step
1.
2.
3.
Action
To rename a folder, highlight the appropriate
folder.
Click Rename.
Type the new folder name in the text field.
Change Folder Order
Step
1.
2.
Action
Highlight the appropriate folder.
Click
to move the folder up or down.
Delete a Favorites Folder
Step
1.
2.
3.
4.
Action
Highlight the folder.
Click Delete.
Confirm Deletion and click Yes.
When you are done managing folders, click
Close.
Note: Favorites Folders cannot be electronically shared with
others. One folder cannot be copied and placed into two
different parent folders. Each folder must be created
individually.
Continued on next page
75
Order Entry Basics, continued
Favorites
Folders,
cont.
Add Orders to Favorites Folders
You can add orders to your Favorites Folders as you write
orders. This allows you to save orders that have your
preferred order details already selected.
Step
1.
2.
3.
4.
5.
6.
Action
Click the Orders band.
Search for the appropriate order.
Complete the order details.
Right-click the correct order.
Select Add to Favorites.
Highlight the folder where you need to save
the order.
7.
Click OK.
Note: Signed orders cannot be added to a Favorites
Folder. If you have added order details, such as STAT
times, these order details will remain with the order in
your Favorites Folder.
Continued on next page
76
Order Entry Basics, continued
Medication
Order
Frequencies
Frequency
Daily
QAM/
QPM
At
Bedtime
BID
TID
Four times
daily
Q2
Q4
Q6
Q8
Q12
Q_H
Standard Administration Times
0900
0900/2100
2100
0900, 2100
0900, 1500, 2100
0900, 1300, 1700, 2100
02, 04, 06, 08, 10, 12, 14, 16, 18, 20, 22,
24
0200, 0600, 1000, 1400, 1800, 2200
0600, 1200, 1800, 2400
0600, 1400, 2200
0900, 2100
The next hour after the order is written
and at the specified interval thereafter.
Note: Some medications (i.e., Warfarin) have
administration times that are non-standard.
Continued on next page
77
Order Entry Basics, continued
Standard
Schedules for
IU Health
Laboratory Order Collection Times
Frequency
Collection Time
Daily &
Every
Default is 0600 unless there is a unitspecific standard collection time (Orders
placed after 0600 will default to 0600
the Next Day)
Once
Collection at the next even hour. Once is
the default frequency for ALL lab orders.
Q_H
First Collection rounds to the next even
hour and the subsequent intervals are
based on the frequency chosen
Labs: Collection Priority and Results
Collection
Results
Definition
Priority
Needed
Routine
Routine Collection time = next even
hour unless there is a unitspecific standard collection
time.
Results = routine turnaround.
Routine
Stat
Collection time = next even
hour.
Results = stat turn-around.
Stat
Routine Collection time = stat.
Results = routine turnaround.
Stat
Stat
Collection time = stat.
Results = stat turn-around.
78
Order Entry Tools
Order Sets
Order Sets are orders that are grouped together by
common use, disease, or process for ease of use.
An order set is denoted by
.
Step
Action
1.
Select the appropriate orders within the order
set by placing a checkmark next to the order(s).
2.
When all orders have been selected, click OK.
3.
Sign the orders.
4.
Click
to refresh the screen.
PowerPlans
A PowerPlan is an Order Set with added features to
optimize order entry.
• PowerPlans allow for faster planning
• All orders within a PowerPlan can be discontinued as a
group
• PowerPlans have been developed by Medical Specialty
and promote standardized order content
• A PowerPlan is indicated by
Locate a PowerPlan
Step
Action
1.
Click + Add on the Orders band.
2.
In the Search window, search for the
appropriate Plan.
Note: If you click a PowerPlan to view the contents, the
PowerPlan remains in your Plans section. You must
remove the plan if you do not intend to use it by rightclicking the title in the view pane and selecting Remove.
Continued on next page
79
Order Entry Tools, continued
PowerPlans,
cont.
Using the Specialty and Favorites folders increases your
order entry efficiency. PowerPlans and other common
orders pertinent to a given Medical Specialty have been
included in the Specialty folders.
• As you change services, set the appropriate Specialty
folder (e.g., Infectious Disease) as your Home Folder
• You can also use your Favorites folder to save any
additional orders that you may use recurrently.
PowerPlans: Place Orders
Step
1.
2.
3.
Action
Click a PowerPlan to open it.
Select/deselect orders from the Plan by
placing/removing a checkmark in the box next
to the order name.
Note: Order details can be completed in
several ways. To proceed with this, ensure
that the box next to the appropriate order is
checked.
When an order has alternate order options, a
down arrow displays. Proceed as follows:
a. Click the arrow to select alternate order
details such as dose, frequency or rates
for your orders.
b. Click the appropriate details from the
drop-down list that displays.
Continued on next page
80
Order Entry Tools, continued
PowerPlans,
cont.
PowerPlans: Place Orders, cont.
Step
4.
5.
6.
Action
When an order does not have an arrow
option, proceed as follows:
a. Right-click and select Modify Planned
Order.
b. Complete the required details.
c. If the screen is obscured by the Order
Details, use
to resize the Order
Details screen.
As you select/deselect orders in the
PowerPlan, review and modify the order
details as you select each order.
Note: Do not click Sign until you have
completed all your orders and their
associated details.
If an order is not included in a PowerPlan and
needs to be added, proceed as follows:
a. Click + Add to Phase.
b. Click Add Order.
c. Search for the order.
d. Complete the order details.
The new order is then grouped within the
selected PowerPlan.
Continued on next page
81
Order Entry Tools, continued
PowerPlans,
cont.
PowerPlans: Place Orders, cont.
Orders that are added outside of a PowerPlan (
)
behave differently than those orders added within a
PowerPlan (
).
Orders are not grouped
with the PowerPlan
Orders only display in
the Orders section of the
view pane and not in the
PowerPlan section
Orders cannot be placed
in Planned status
Orders need to be
discontinued individually
Orders are grouped with
the PowerPlan
Orders display with
other PowerPlan orders
Orders can be placed in
Planned status
Orders can be
discontinued together
when you discontinue
the PowerPlan
Note: Follow these guidelines:
• Only single orders can be added to PowerPlans using
Add to Phase
• PowerPlans and Order Sets cannot be added to a
PowerPlan and can ONLY be ordered using + Add
• + Add must be used to place an order outside of the
PowerPlan.
Continued on next page
82
Order Entry Tools, continued
PowerPlans,
cont.
PowerPlans: Add Subphases
• Subphases are subsets of orders in a PowerPlan
• DVT and PUD prophylaxis and other diagnosis-based
orders such as Pneumonia orders are built in as
Subphases of the PowerPlans
• A Subphase is indicated by
Step
Action
1.
Locate the appropriate Subphase.
2.
Place a checkmark in the box next to the
Subphase.
3.
Select the Subphase in the view pane.
4.
5.
View and enter orders within that Subphase.
To review ALL of your orders, you MUST
return to your main PowerPlan in the view
pane.
Note: You can also use Subphases as stand-alone orders.
For example: if your patient develops pneumonia during
a hospital stay, just search for the Pneumonia Subphase
(denoted as “mini” as opposed to “admission”), and
then use this as a stand-alone PowerPlan without having
to use a full Admission Profile.
Continued on next page
83
Order Entry Tools, continued
PowerPlans,
cont.
PowerPlans: Planned or Initiated
You have the option to leave your orders in a Planned
state or to Initiate the orders.
Planned= Orders NOT Active
Initiate= Orders ARE Active
Place a PowerPlan in Planned State
Step
Action
1.
After selecting the appropriate orders, click
Orders for Signature.
2.
Click Sign.
3.
Click
to refresh.
A pending PowerPlan displays in the Plans
section of the view pane as follows:
Initiate a PowerPlan Later
Step
Action
1.
To initiate a PowerPlan later, highlight the
PowerPlan in the view pane.
2.
3.
4.
5.
Click
.
Click Orders for Signature.
Click Sign.
Click
to refresh.
Continued on next page
84
Order Entry Tools, continued
PowerPlans,
cont.
Initiate a PowerPlan Immediately
A PowerPlan can be initiated immediately using
at the time that the orders are entered.
PowerPlans: Add Orders to an Initiated Plan
You can add orders to a PowerPlan after it has been
initiated in one of two ways.
a. You can select orders that reside in the PowerPlan
but were not initially selected, or
b. You can add outside orders to the PowerPlan
Step
1.
Action
Select the PowerPlan by clicking the initiated
PowerPlan name in the view pane.
2.
Click
(View Excluded) to check for orders
in the Plan that were not initially selected.
Note: Orders already selected display with a
checkmark.
Place a checkmark by those orders you need
to add to the PowerPlan.
3.
Continued on next page
85
Order Entry Tools, continued
PowerPlans,
cont.
PowerPlans: Add Orders to an Initiated Plan, cont.
Step
4.
Action
Conversely, you can remove orders from the
PowerPlan by removing an existing
checkmark.
5.
If the needed order does not exist in the
PowerPlan, click + Add to Phase.
Search for the order(s) and click Done when
all orders have been added.
6.
Note: Clicking more than once on an order
will duplicate it in the PowerPlan.
7.
Review your orders and sign as usual.
86
Medication Order Entry
Order an
Immunization
/PPD
Step
1.
2.
IV – Fixed
Rate
Step
1.
2.
3.
4.
5.
6.
7.
8.
Action
Select the order sentence with a frequency of
ONCE.
Change the Requested Start Date/Time to
tomorrow’s date at 0900, unless you have
reason to schedule otherwise.
Action
Click + Add in the Orders band.
Type the first few letters of the fluid to be
ordered. (i.e., "Sod" for Sodium Chloride,
"Dext" for Dextrose, "Lacta" for Lactated
Ringers).
Note: You may also search using the
synonyms: D5, LR, D10, NS, ½ NS.
Select the correct order from list.
Select the correct order sentence.
Verify the correct diluent (e.g., Dextrose 5%)
and additive (Potassium Chloride).
Enter or change any missing order details.
Note: When you select the rate, the Infuse
Over detail calculates automatically.
Add comments, if needed.
Verify all information is correct and click Sign.
Continued on next page
87
Medication Order Entry, continued
IV – Fluid
Bolus
Step
1.
2.
Action
Click + Add in the Orders band.
Begin typing the name of the fluid to be bolused.
3.
Select the order for the fluid that includes bolus
in the name.
Select the correct order sentence.
The fluid and free-text rate of “bolus” default in
the Continuous Details tab.
4.
5.
IV:
Titratable
Drip
Step
1.
2.
3.
4.
5.
6.
7.
Add the volume of fluid to be infused, if less
than the size of the bag ordered.
Note: This is required for Pediatrics.
Action
Click + Add in the Orders band.
Search for the medication name.
Select the correct order from the list (drug
name + adult-titrate or peds-titrate).
Enter Order Comments in the continuous
details pane.
Complete the information for the drip order.
Add information for any PRN bolus orders.
Note: Pharmacy will complete the order entry.
Verify all information and click Sign.
Continued on next page
88
Medication Order Entry, continued
IV –
Heparin
Nomogram
and
Thrombostabilizer
Infusions
Step
1.
2.
3.
4.
5.
6.
7.
8.
IV – TPN
Adult
Action
Click the Orders band.
Click + Add.
Type "Hep".
Select the appropriate Heparin Nomogram
/Thrombostabilizer PowerPlan.
Check or uncheck orders as you would any
other PowerPlan.
Review the Heparin drip order.
Note: The rate defaults as Per Nomogram.
Click Initiate and then Orders for Signature.
Click Sign and Refresh.
Ordering TPN at IU Health Ball Memorial Hospital: At Ball
Memorial to order TPN, enter an order for ‘Write/Manage
TPN’ and a pharmacist and dietitian will evaluate the
patient for the most appropriate formula.
Ordering TPN at all other IU Health CPOE Facilities:
Adult Day 1/Initial Order
Step
1.
2.
Action
Click + Add in the Orders band.
Enter “TPN” in the Search window.
Continued on next page
89
Medication Order Entry, continued
IV – TPN
Adult, cont.
Adult Day 1/Initial Order, cont.
Step
Action
3.
Select the appropriate PowerPlan: TPN
Parenteral Nutrition.
Note: Failure to select the correct order may
result in delays or incorrect formulation.
4.
Select the appropriate formulation.
5.
Review the orders that have been included
with the PowerPlan by scrolling down.
Make additional selections or changes. When
finished selecting orders, click Initiate.
Only when you click Initiate in the TPN
PowerPlan does the PowerForm appear for you
to complete.
6.
Continued on next page
90
Medication Order Entry, continued
IV – TPN
Adult, cont.
Adult Day 1/Initial Order, cont.
Step
7.
Action
A PowerForm opens to complete the details for
the TPN order. All highlighted fields must be
completed before you will be able to sign the
PowerForm.
8.
Complete all necessary details.
• Indicate the amount of any additives to be
included in the TPN
• All required fields call for a value. If you do
not want an additive, enter zero
Note: The Comments section is for Pharmacy
Use Only. Any comments to Nursing (i.e.,
tapering rates) must be entered on the Order
Comments Tab of the TPN Order and not on
the comments section of the TPN PowerForm.
Continued on next page
91
Medication Order Entry, continued
IV – TPN
Adult, cont.
Adult Day 1/Initial Order, cont.
Step
9.
10.
11.
Action
Click the green check mark
in the
upper left corner to sign the PowerForm.
Volume is calculated based upon additives,
patient’s weight, etc. and is determined by
Pharmacy.
Start date and time for the order default to the
standard hang time for the facility.
Click Orders for Signature, Sign, then Refresh.
Note: You can review the information entered on a TPN
order at any time from the Forms band or the TPN
Therapy Analysis tab in the Results Review band.
Continued on next page
92
Medication Order Entry, continued
IV – TPN
Adult, cont.
Adult Day 2 and Onward
After completing the initial TPN PowerForm using the TPN
PowerPlan, subsequent TPN PowerForms prepopulate
with the previously selected values for the additive fields.
Step
1.
2.
3.
4.
Action
When entering ongoing daily TPN orders,
search for “TPN”.
Select the appropriate single TPN order and
NOT the PowerPlan or Order Set.
The PowerForm with the data from the
previous order displays. Modify the
PowerForm as needed.
Click the green checkmark
in the upper
left corner to sign the PowerForm.
After signing the PowerForm, the order is
signed as usual.
Note: The TPN orders from the prior day automatically
expire at 24 hours after the standard hang time for the
facility.
Continued on next page
93
Medication Order Entry, continued
IV – TPN
Pediatric
and
Neonatal
After completing the initial TPN PowerForm using the TPNNeonatal or TPN-Peds order, subsequent TPN PowerForms
prepopulate with the previously selected values for the
additive fields.
Step
1.
2.
Action
When entering a TPN order, search for “TPN”.
Select the appropriate single TPN order, TPNNeonatal or TPN-Peds, and NOT a PowerPlan or
Order Set.
3.
Select the correct order sentence and click OK.
Continued on next page
94
Medication Order Entry, continued
IV – TPN
Pediatric
and
Neonatal,
cont.
Step
4.
Action
A PowerForm opens to complete the details for
the TPN order. All highlighted fields must be
completed before you will be able to sign the
PowerForm.
5.
On subsequent days after the initial order, the
PowerForm with the data from the previous
order displays. Modify the PowerForm as
needed.
Click the green checkmark
in the upper
left corner to sign the PowerForm.
After signing the PowerForm, the order is
signed as usual.
6.
Continued on next page
95
Medication Order Entry, continued
IV – TPN
Pediatric
and
Neonatal,
cont.
These guidelines apply to IV – TPN Pediatric and TPN
Neonatal:
• Enter any associated lab orders from your Home
folder
• The TPN orders from the prior day automatically
expire at 24 hours after the standard hang time for
the facility
• You can review the information entered on a TPN
order at any time from the Forms band or the TPN
Therapy Analysis tab in the Results Review band
Medications:
Dose Range
Orders
Step
1.
2.
3.
4.
5.
6.
7.
8.
Action
Click + Add in the Orders band.
Search for the medication name.
Select the medication order.
Enter the highest dose.
Enter the shortest frequency.
Open the Order Comments Tab.
Enter the dose range (e.g., DOSE RANGE 12mg q2-4 hours).
Click Sign.
Continued on next page
96
Medication Order Entry, continued
Medications:
Hold a
Single Dose
In most instances, if you need to hold a single dose of a
medication (i.e., for a procedure, you will enter a Hold
Medication Dose(s) order). Pharmacy will use this
information to communicate that the dose is to be held.
Note: Do not forget to also communicate directly with the
nurse.
Step
1.
2.
3.
Action
Click + Add in the Orders band.
Search for Hold Medication Dose.
The Order details window opens with the
instruction: Must Complete Order Comments.
On the Order Comments tab, type the name of
the medication and dose(s) to be held.
Note: Each medication must have its own hold
order.
Note: If you need to hold a medication for an
undetermined amount of time, discontinue and enter a
new order when you need to restart
Continued on next page
97
Medication Order Entry, continued
Medications:
Irrigation
Orders
Irrigation orders can be entered either for intermittent
or continuous Medication irrigation solutions.
• Select the order sentence with the route of
IRRIGATION when ordering to communicate that
these orders are to be used for irrigation.
• If Continuous, the Continuous Details screen will
open for entry of Rate or Infuse Over field.
Medications:
Multiple PRN
Reasons
A PRN medication order must include each indication
that is associated with the order.
Medications:
Multiple
Route Orders
If you are entering orders for a medication and would
like to indicate administration by more than one route
(e.g., Tylenol orally or suppository), you need to
enter 2 separate orders: one order for the medication to
be given orally and the other for the medication to be
given rectally.
Continued on next page
98
Medication Order Entry, continued
Medications:
NonFormulary/
Substitution
Alerts
If you enter a non-formulary medication substitution,
you are presented with either:
a. The Physician Request for Non-formulary Drug
form. Complete this form as indicated.
OR
b. Therapeutic Interchange Order Set with formulary
compliant medication. Select the appropriate order
from the information provided. Complete Order
details and sign.
You are presented with an alert if you order a nonstandard dose. Standard medication doses have been
approved by the System P & T Committee. If a nonstandard dose is ordered, the following alert will display:
Continued on next page
99
Medication Order Entry, continued
Alerts,
cont.
To avoid receiving this alert, make sure that you:
a.
Select Apply Standard Dose in the dose calculator
window when it appears.
b.
Select a pre-built order sentence.
Continued on next page
100
Medication Order Entry, continued
Medications:
One-time
STAT Doses
Medications:
STAT Doses
with Ongoing
Orders
Step
1.
2.
3.
Action
Click + Add in the Orders band.
Search for a medication to be ordered STAT.
On the Order Details tab, click Pharmacy
Order Priority (on the left) and select STAT
from the Detail values list (on the right).
4.
5.
6.
In the Frequency detail, select ONCE.
Review the Requested Start Date and Time.
If start date and time are correct, click Sign.
To enter a STAT and an ongoing dose of a medication,
enter two separate orders. One entry is for the STAT
order and the second entry is for the ongoing order.
Note: It is very important to ensure that the start date
and time of the ongoing order is appropriately spaced,
based on the ordered frequency in relation to the stat
dose.
• STAT = Medication must be administered within 15
minutes
• Now = Medication must be administered within 1
hour
Continued on next page
101
Medication Order Entry, continued
Medications:
Patches
Step
1.
2.
3.
4.
Medications:
Taper Doses
Step
1.
2.
Action
Click + Add in the Orders band.
Search for the medication name.
Select the appropriate medication patch
order set.
Note: Medication patches are built into the
system as order sets because the patch
order needs to be paired with a patch
removal order. The patch removal order is
automatically checked, so it will always be
ordered.
Select the appropriate patch strength and
complete the order details.
Note: The patch removal order serves as a
reminder to the nurse to remove the
previous patch before placing a new one.
Action
Click + Add in the Orders band.
Search for the medication name and select
the orderable with the term "taper" after
the order (e.g., Prednisone taper).
Order Details opens with the instructions:
Must Complete Order Comments.
Continued on next page
102
Medication Order Entry, continued
Medications:
Taper Doses,
cont.
Step
3.
4.
Medications:
Taper Dose,
No Existing
Taper Order
Action
In the Order Comments tab, enter your
tapering regimen (e.g., Prednisone 60mg po
daily x 6 doses, 40mg po daily x 6 doses,
etc.).
Click Sign.
If the medication you are ordering does not have a taper
order in the system when you search for the drug name:
Step
1.
2.
3.
Action
Enter "Pharmacy taper”.
Order Details opens with instructions: Must
Complete Order Comments.
In the Order Comments tab, in addition to
the tapering regimen, you MUST also enter
the name of the medication.
Click Sign.
Continued on next page
103
Medication Order Entry, continued
Medications:
Prescriptions
Enter a Prescription Order
Step
1.
2.
3.
4.
5.
Action
Prior to your order search, change the
catalog Type to Prescriptions.
Search for the medication.
Select the prescription order sentence that
contains the correct details.
If you need to change a selected order
sentence, click the drop-down next to the
order name in the Details pane.
In the Details pane, move from one missing
detail field to the next using the Next
Missing Required Detail button or the
yellow arrow.
Note: The following symbols are used in
prescription order details:
Symbo
Meaning
l
Most common
Common
Uncommon
Generic Value
Continued on next page
104
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Enter a Prescription Order, cont.
Step
6.
7.
8.
Action
Select the type of therapy for the
prescription.
Note: A stop date and time automatically
calculates for Acute types of therapy.
For maintenance prescriptions, select the
dispense quantity (30 or 90 day supply).
If you need the dose calculator, click
(Open Dose Calculator).
Continued on next page
105
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Safeguard Printed Patient Information
Follow these guidelines for printing reports:
You Are Printing a Report
Carefully select the correct printer
from the drop-down menu.
Retrieve the printed report from
the printer immediately.
If the report did not print, reselect
the correct printer and attempt to
print the report again.
If the report does not print after a
second attempt, contact the
Service Desk at 962-2828.
You Find a Printed Report
If you find a report containing
patient information on a printer,
contact the person who printed
the report.
If unable to contact the report
owner, place the report in the
shred box.
If the report prints a second time,
contact the Service Desk at 317962-2828 and report the computer
name, location, and the name of
the printer where the report
printed.
Place the report in the shred box.
Continued on next page
106
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Add a Prescription Printer to Favorites
When you place Prescription orders within Cerner, you
need to choose the appropriate prescription printer. If
you regularly print prescriptions in multiple areas, you
need to set up prescription printers in your Favorites.
Step
1.
2.
3.
4.
Action
Click + Add and select prescriptions from
the Type drop-down.
Search for the medication.
Select the prescription order sentence that
contains the correct details.
Click the ellipses next to the Send To field in
the Details pane.
The Prescription Routing window displays.
Continued on next page
107
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Add a Prescription Printer to Favorites, cont.
Step
5.
6.
7.
8.
Action
In the Prescription Routing window:
a. Select Printer in *Send to.
b. Select All Pending Non-Tamperproof
Prescriptions in Apply to.
c. Select Always use the default output
destination associated with the
computer that I am using.
If the printer you need to use in your current
location is not already listed in the Favorites
tab, click the Other Output Devices tab and
scroll to the appropriate facility printer
location.
Click the + to the left of the facility. Click
again on the + to the left of the facility.
The Unit Locations display.
Click the Unit Location to highlight it.
Caution: Do NOT click the + next to the unit
name.
The prescription printers for that unit display
with “Rx” in the name.
Continued on next page
108
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Add a Prescription Printer, cont.
Step
9.
Action
Right-click the appropriate printer and select
Add to Favorites.
The printer displays in your Favorites tab.
10.
If you need to add additional printers:
a. Click the Other Output Devices tab
again.
b. Locate additional printers.
c. Right-click and select Add to Favorites.
When you have added all of your needed
printers, click OK.
Prior to signing the prescription, ensure that
the proper prescription printer is displayed
in the Send To box.
11.
12.
109
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Change a Prescription Printer
The last prescription printer that you used automatically
displays in the Send To box. If you are placing
prescription orders in a different location, the correct
printer must be selected.
Step
1.
2.
3.
4.
Action
Click the ellipses to the right of the Send To
box.
In the Favorites tab, highlight the desired
printer and click OK.
Note: If the correct printer does not display
in the Favorites tab, follow the Add a
Prescription Printer instructions.
Ensure that the correct printer name
displays in the Send To box.
Complete and sign the prescription orders.
Continued on next page
110
Medication Order Entry, continued
Medications:
Prescriptions,
cont.
Prescriptions Sent to Wrong Printer
If you routed a prescription to the wrong printer, you
are responsible for making sure that the prescription is
disposed of and not left unattended or unretrieved on
the prescription printer.
Step
1.
2.
3.
4.
Action
Highlight the electronic prescription orders
that were sent to the incorrect printer.
Note: You can re-route multiple
prescriptions at one time by highlighting all
of the incorrectly printed prescription
orders.
Once the prescriptions are highlighted, rightclick the highlighted area and select Resend.
Select the correct printer from the Output
Devices window.
Click OK to reprint the prescriptions.
111
Dosage Calculator
Introduction
Where to
Find the
Dosage
Calculator
The Dosage Calculator is available when you place
inpatient medication and outpatient prescription orders.
The Dosage Calculator is used to order weight-based
medications.
The dose calculator opens automatically when you place
an order that contains mg/kg, mcg/kg or other weightbased dose calculations.
Continued on next page
112
Dosage Calculator, continued
Calculation
Options by
Weight
The Dosage Calculator provides several options for
calculating correct dosing for a patient’s weight:
• Apply a Standard Dose
• Select a Rounding Rule for normalized doses
• Manually enter a Final Dose
Calculate
Standard
Doses
Step
1.
Action
Complete the following:
a. Review Dose Values for accuracy based on
patient weight.
b. Select the appropriate Rounding Rule for
this dose.
Note: Click Apply Standard Dose, when
available.
Continued on next page
113
Dosage Calculator, continued
Calculate
Standard
Doses,
cont.
Step
2.
3.
Action
Using the drop-down menu, evaluate the
Rounding Rule for this medication and patient
weight.
Select a rounding parameter based on your
clinical judgment.
Note: In most instances, the nearest whole
number or nearest tenth is appropriate.
Continued on next page
114
Dosage Calculator, continued
Calculate
Standard
Doses
(continued)
Step
4.
5.
Action
If the available dosing options are not
appropriate, then type the appropriate dose in
the Final Dose field.
The mg/kg automatically calculates and the
Rounding Rule updates to Manually Entered.
Click Apply Dose.
115
Pediatric Antimicrobial Stewardship
Introduction
Orders
Program
Goals
Antimicrobial overuse contributes to the growing problem
of drug resistance in healthcare facilities and in the
community. Improving antibiotic use through stewardship
interventions and programs:
• Improves patient outcomes
• Reduces antimicrobial resistance
• Saves money
In an effort to focus on improving antimicrobial use in
inpatient healthcare settings, orders have been developed
that incorporate antimicrobial stewardship. These
antimicrobial stewardship orders are interventions
designed to ensure that hospitalized patients receive the
right medication at the right dose, at the right time, and
for the right duration.
The IU Health Pediatric Antimicrobial Stewardship program,
or PAS, was developed with the following goals:
• Provide optimal, evidence-based pediatric dosing for all
IV antimicrobials in order to prevent underdosing and
emergence of resistance as well as overdosing and
associated toxicities
• Reduce and or prevent the emergence of resistance
through appropriate utilization
• Manage the use of expensive antimicrobials in a fiscally
responsible manner
• Impact practice by educating providers on the
appropriate use of antimicrobials for specific indications
Continued on next page
116
Pediatric Antimicrobial Stewardship, continued
PowerPlans
To facilitate the appropriate use of IV antimicrobial
agents, individual PowerPlans have been developed for
each agent. The PowerPlans assist the clinician in
determining a custom antimicrobial dose for their patient.
Antimicrobial subphases have also been inserted into
PowerPlans under the Medications header within the
PowerPlan.
Organization of
Antimicrobial
Agents
The antimicrobial agents are divided into subcategories
based on diagnosis. Each antimicrobial is identified by its
drug name and whether it is intended for pediatrics or
neonates.
Continued on next page
117
Pediatric Antimicrobial Stewardship, continued
Place
Orders
from a
Subphase
Antibiotic PowerPlans have distinct sections to aid ordering.
• You can generate orders based on diagnosis
• There is also an option for one time dose ordering
• There is an option for peri-op prophylaxis ordering built
into individual plans where applicable
• Plans for certain agents may also include Restart of
Previous Established Dose and Dose Change Ordering
options
Note: With both of these options, the doses and
frequencies are left blank for the physician to fill
in the established dose or put a distinct dose in
that field if they are increasing or decreasing from
a previous dose.
Step
1.
Action
Select the appropriate subphase by placing a
checkmark in the box next to it.
Caution: Be careful when selecting an
antimicrobial subphase. For each agent, there
may be separate subphases for pediatric and
neonate.
Continued on next page
118
Pediatric Antimicrobial Stewardship, continued
Place Orders
from a
Subphase,
cont.
Step
2.
Action
Click the selected subphase in the View pane
to navigate to the orders.
Note: Once inside the plan, notice the robust
dosing information provided to assist with
antimicrobial ordering.
3.
If the pharmacokinetic calculations of a
patient already on an antimicrobial necessitate
a change in dosage, select the Dose Change
Ordering option and enter the new dosage
and frequency.
Caution: Be sure to adjust the start time of the
new dose and frequency. The Cerner default
start time for a “Q__H, (or interval)”
medication would be the next hour.
Continued on next page
119
Pediatric Antimicrobial Stewardship, continued
Place
Orders
from a
Subphase,
cont.
Step
4.
5.
6.
Action
If your patient was recently discharged and had
previously received a calculated dose/frequency
of an antimicrobial or the patient’s antibiotic was
discontinued, use the Previously Established
Dose option.
Note: In this situation, you could use the Restart
of Previously Established Dose option. Rather
than using a normalized dose, this allows you to
simply enter the order details as the dose and
frequency.
Once you have selected the ordering option that
applies to your patient, use the available dosing
information to make order selections.
At this point, you could navigate back to your
main PowerPlan and continue selecting and
deselecting orders as necessary.
Continued on next page
120
Pediatric Antimicrobial Stewardship, continued
Place
Orders from
a Subphase,
cont.
Step
7.
8.
Action
If a new IV antimicrobial order is being entered
within 24 hours of the patient’s admission, this
PowerForm displays. In order to complete the
antimicrobial order, provide documentation of
the prior administered doses including doses
administered at a prior hospital, en route, in
the ED, etc.
Note: In order to prevent medication variances
caused by the administration of antimicrobial
doses too close together, select groups of
medications have Prior Dose documentation
built into their plans.
After you complete your documentation, click
the green checkmark
to save the form
and continue ordering.
Continued on next page
121
Pediatric Antimicrobial Stewardship, continued
Place
Orders
from a
Subphase,
cont.
Step
9.
Action
Enter a Separate PowerPlan for a Missing
Antimicrobial
If, while in the process of ordering a PowerPlan,
a desired antimicrobial is not included as a
subphase, you need to enter a separate
PowerPlan for this agent. Most plans can be
located by searching your specialty folder.
• There is not a subphase for every
antimicrobial agent in every PowerPlan
Note: The decision to include a
specific agent within a specific plan
was evidence-based.
• PowerPlan and Order Sets cannot be added
to other PowerPlans via the Add to Phase
button
Note: Only individual orders can be
added using Add to Phase.
Locate an
Antimicrobial
Agent
PowerPlan
Each antimicrobial agent has its own stand-alone
PowerPlan. To locate an antimicrobial agent PowerPlan,
search the catalog by the agent's name.
Note: Remember to select the pediatric option.
Continued on next page
122
Pediatric Antimicrobial Stewardship, continued
Restricted
Agents
An agent may be identified as a Restricted Agent.
Restricted Antimicrobial Agents must meet utilization
criteria prior to initiation.
Note: When ordering a restricted agent at Riley Hospital,
prior authorization from the PAS team is required.
Order a Restricted Agent
Step
1.
Action
Once inside the Antimicrobial PowerPlan, select
and deselect orders as you normally would.
An alert fires once you attempt to initiate the
order.
Note: The restricted antimicrobial agent alert is
only in place at Riley Hospital. The remaining IU
Health facilities conducted respective review of
restricted antimicrobial orders.
Continued on next page
123
Pediatric Antimicrobial Stewardship, continued
Restricted
Agents,
cont.
Order a Restricted Agent, cont.
Step
2.
3.
Action
When you receive the alert, either:
• Select Cancel the Order to obtain approval,
or
• Select Override the Alert if approval has
already been obtained or you are on the ID
Service
Note: If the clinician who approved the
antimicrobial is not documented, pharmacy
will page you for the information. The PAS
pager is also automatically paged when a
restricted agent is entered.
From within the Override Reason Form, select
from the following options:
• Prescriber is PAS Team Member
o If you are a member of the PAS Team
• Received PAS on call approval
o If you have received approval from
the PAS Team. After selecting this
option, document the PAS team
member’s name in the Additional
Freetext Override Reason field
Continued on next page
124
Pediatric Antimicrobial Stewardship, continued
Restricted
Agents,
cont.
Order a Restricted Agent, cont.
Step
3.
Action
From within the Override Reason Form, select
from the following options: (cont.)
• Written Recommendation from ID service
If a consultation has been completed
by ID Service and orders are being
entered based on consultation
recommendations
Once you have completed your
documentation, click OK to close the Override
Reason Form.
Click OK again to close the alert window.
o
4.
5.
125
Medical Student Orders
Overview:
Medical
Student
Orders
Orders entered by Medical Students are placed in an On
Hold, Med Student status and are NOT active until the
supervising physician (resident or attending) cosigns the
order in Cerner.
The symbol
is associated with Medical Student
orders.
Medical Student Filter View
To ensure you are able to view orders properly, you
must select an appropriate display filter on the Orders
Band. Select one of the following filters labeled:
• All Active + 1 Day Inactive + Med Student – No Home
Meds, or
• All Active + 5 Day Inactive + Med Student – No Home
Meds
Medical
Students:
Order
Processes
Medical Student: Order Entry
Orders entered by Medical Students are not active until
they have been cosigned by the Supervising Physician.
Orders must be routed to the Supervising Physician for
approval.
Continued on next page
126
Medical Student Orders, continued
Medical
Students:
Order
Processes,
cont.
Medical Student: Order Entry, cont.
Step
Action
1.
Search for and select the first order.
2.
In the Ordering Physician pop-up window,
enter the following:
•
Enter the Physician Name to whom the
order will be routed for co-signature.
The order is routed to the physician's
Inbox in Message Center.
•
Leave the default as Written for
Communication Type.
Note: The Ordering Physician window will
pop-up only once per ordering session.
3.
Click OK.
4.
Complete the details for the order.
5.
Search for and select any additional orders.
6.
Click Sign.
Note: Notice that the order displays with the
status of On Hold,
Med Student.
Continued on next page
127
Medical Student Orders, continued
Medical
Students:
Order
Processes,
cont.
Medical Student: PowerPlan Orders
Medical students can enter PowerPlan orders; however,
in order for the orders to be reviewed and approved by
the Supervising Physician, the PowerPlan orders entered
by a Medical Student must always be initiated.
Step
Action
1.
Select the PowerPlan from the Orders search
window.
2.
Enter the Ordering Physician (as with single
order entry).
3.
4.
Select the orders and ensure order details
are appropriate.
When all order selection is completed, you
must BOTH SIGN & INITIATE the PowerPlan.
Note: A PowerPlan must be initiated and
cannot be left in a planned status. If a
PowerPlan is left in a planned status, an alert
displays. Return to the patient chart to
initiate or void the PowerPlan.
Continued on next page
128
Medical Student Orders, continued
Medical
Students:
Order
Processes,
cont.
Medical Student: Discontinue Orders
Step
1.
Action
Search for and select the DC Existing Order
(Medical Student Order Entry) order.
Note: For ordering efficiency, right-click the
DC Existing Order (Medical Student Order
Entry) and save to your Favorites.
2.
3.
Complete the order detail specifying the
order to be discontinued with as much
details as possible including:
• Dose
• Route
• Frequency of the order(s)
(e.g., Please discontinue the 2mg Ativan q6
order)
Click Sign.
The Alert below displays reminding you to
follow up with your Supervising Physician to
take the action of actually discontinuing this
order.
Continued on next page
129
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes
Provider: Co-Sign Med Student Orders
Follow the steps in the table below to co-sign an order
entered by a Medical Student.
Note: Use Message Center only to initially preview the
order sent by the Medical Student and to open the
appropriate Patient Chart. All actions taken on the
student's Order MUST be taken from the Orders section
of the patient chart and NOT from Message Center.
Step
1.
Action
While in Message Center, select Med
Student Orders from the Inbox Summary.
2.
In the view pane, double-click the
appropriate order and review the details.
Note: DO NOT take any action on the order
from this screen; manage order approval
from within the patient chart.
Continued on next page
130
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes,
cont.
Provider: Co-Sign Med Student Orders, cont.
Step
3.
4.
Action
Click the patient name and open the patient
chart.
Go to the Orders band and review all
existing orders on this patient.
Note: Notice that Medical Student orders
have an On Hold status and are denoted
with an icon .
5.
Click Orders for Cosignature.
Note: You will be presented with both On
Hold Medical Student orders (On Hold
Orders Pending Co-Signature) and also
Verbal Orders from your colleagues (Order
Actions Pending Co-Signature) for review
prior to co-sign.
Continued on next page
131
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes,
cont.
Provider: Co-Sign Med Student Orders, cont.
Step
6.
7.
8.
9.
Action
Review all orders requiring co-signature.
Deselect any incorrect orders that will NOT
be co-signed.
Click Cosign to close the Actions Requiring
Co-Signature window and return to Message
Center.
Click
to refresh.
The co-signed orders have been removed.
Provider: D/C Medical Student Orders
Step
1.
2.
Action
While in Message Center, select Med
Student Orders from the Inbox Summary.
Double-click the appropriate order and
review the details.
Note: DO NOT take any action on the order
from this screen; manage order approval
from within the patient chart.
Continued on next page
132
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes,
cont.
Provider: D/C Medical Student Orders, cont.
Step
3.
4.
5.
6.
7.
8.
9.
Action
Click the patient name and open the patient
chart.
Locate the Discontinue Order under the
Other Departments section.
If the discontinue request is appropriate,
select the order to be discontinued and
uncheck
(Quick Discontinue box)
in front of the order.
The order now has a strikethrough.
Sign the order as usual.
Click Orders For Cosignature.
Click Cosign to approve the original DC
Medical Student order on which you have
taken action; then close the Actions
Requiring Cosignature window.
Click
to refresh.
Continued on next page
133
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes,
cont.
Provider: Refuse Med Student Order Co-Signature
Follow the steps in the table below to manage Medical
Student orders that you do not want to approve.
Step
1.
2.
Action
While in Message Center, select Med
Student Orders from the Inbox Summary.
Double-click the appropriate order and
review the details.
Note: DO NOT REFUSE an order in the
Message Center that you do not approve of;
manage Refusal from within the patient
chart.
3.
4.
5.
6.
Click the patient name and open the patient
chart.
Click the Orders band.
Right-click the order that you do not want to
approve.
Select Void.
Continued on next page
134
Medical Student Orders, continued
Providers:
Medical
Student
Order
Processes,
cont.
Provider: Refuse Med Student Order Co-Signature,
cont.
Step
7.
8.
9.
Action
Enter a void reason.
Click Orders for Signature and complete the
signature process as you normally would.
Click
to refresh.
The voided order has been removed.
Note: DO NOT USE Refuse for an order in Message
Center that you do not approve. You must go to the
original order, right-click and VOID this order to remove
it from the patient chart.
135
Other Order Entry Processes
DNR Orders
Code Status orders can be placed by residents and
faculty/attending staff. However, all Code Status orders
that are less than Full Code orders must be cosigned by
the designated attending physician if placed by
residents. The Code Status Order Form (DNR/ Limited
Code) must be manually forwarded to the attending for
cosignature.
DNR Order Process
Step
1.
Action
Select the DNR order in the order entry field.
The Code Status Order Form (DNR)
PowerForm launches.
2.
Complete the details within the PowerForm.
Continued on next page
136
Other Order Entry Processes, continued
DNR Orders,
cont.
DNR Order Process, cont.
Step
3.
4.
5.
Action
Sign the PowerForm by clicking the green
checkmark
at the top left.
An alert presents when the PowerForm is
signed.
Click OK to close the Alert window.
You are returned to the Orders for Signature
window.
Sign the DNR Order.
Note: The Code Status Order From must be manually
forwarded to the designated attending physician to be
cosigned.
Continued on next page
137
Other Order Entry Processes, continued
DNR Orders,
cont.
DNR Order: Resident Forward
Step
1.
Action
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.
Change the Additional Forward Action
option to sign.
4.
5.
6.
Insert the name of the attending physician
into the To: section of the window.
Click OK to send the request.
Continued on next page
138
Other Order Entry Processes, continued
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
1.
2.
Action
Within the Documents folder located in the
Message Center, identify any documents
requiring cosignature.
Highlight the correct document for
cosignature and double-click to open the
note.
Continued on next page
139
Other Order Entry Processes, continued
DNR Orders,
cont.
DNR: Attending Staff, cont.
Step
3.
4.
5.
Medication
Special Alerts/
Communication
Step
1.
2.
3.
4.
Action
Review the document and click OK to cosign
the note.
If you need to modify the note, right-click
and select Modify to make changes.
When the modification is complete, sign the
note.
Action
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.
Select the appropriate exception order(s)
from the list displayed.
Verify start date and time in the Details
tab.
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.
Continued on next page
140
Other Order Entry Processes, continued
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.
Continued on next page
141
Other Order Entry Processes, continued
Transfer
Order
Review
Note, cont.
Sign Transfer Order Review Note
Discharge
Instructions
(eDI)
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.
Step
1.
2.
Action
Click Sign/Submit.
If all information is correct, click Sign.
There are three tabs in the discharge instructions form:
• Discharge Instructions
• Medication List
• Sign & Print
Continued on next page
142
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Step
1.
2.
3.
Action
Click the
band to access
the eDI form.
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
Click + Add or + Edit to initially enter or edit
information.
A window pops up to allow you to enter data.
Continued on next page
143
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Step
4.
5.
6.
7.
Action
After you have entered or edited data, click
Save prior to moving to the next screen.
If a change must be made to an existing
section, click
to make changes to the
information.
If you place orders for tests or labs, you must
click eSign
to electronically
sign the orders.
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
Continued on next page
144
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Medication List, cont.
Step
1.
2.
3.
4.
Action
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)
Click the Discharge Instructions band.
Click Medication List.
Move through the Home Meds list on the left
side of the screen first, marking each
medication according to the following guide:
Action
Continue
Modify
Home Medication List Options
Result
• 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
• 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
Continued on next page
145
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Home Medication List Options, cont.
Result
• 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.
Action
D/C
Continued on next page
146
Other Order Entry Processes, continued
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
Result
• 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
Action
Continue
6.
Add any additional medications in the Add
Medication link under the appropriate section
(non-CPOE facilities only).
Continued on next page
147
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Medication List, cont.
Step
7.
8.
Action
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 (nonCPOE facilities).
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.
Continued on next page
148
Other Order Entry Processes, continued
Discharge
Instructions
(eDI), cont.
Step
9.
Action
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 nonCPOE 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.
Continued on next page
149
Other Order Entry Processes, continued
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.
Continued on next page
150
Other Order Entry Processes, continued
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
Carefully select the correct
printer from the drop-down
menu.
Retrieve the printed material
from the printer immediately.
If the discharge instructions did
not print, reselect the correct
printer and attempt to print the
material again.
If the material does not print
after a second attempt, contact
the Service Desk at 962-2828.
You Find Printed Discharge
Instructions
If you find discharge instructions
containing patient information
on a printer, contact the person
who printed the material.
If unable to contact the
discharge instruction owner,
place the material in the shred
box.
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.
Place the material in the shred
box.
Continued on next page
151
Other Order Entry Processes, continued
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
1.
2.
3.
Action
Click
.
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.
Click Save when completed.
Continued on next page
152
Other Order Entry Processes, continued
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.
153
Glossary
Clinical
Notes Band
ClinDoc
CPOE
Encounter
Filter
Flowsheet
General
View Bands
MAR
Summary
Band
Message
Center
A viewer for scanned, dictated, or other documents
sent to or generated within the Cerner system. (e.g.
operative or progress notes).
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.
An acronym for Computerized Provider Order Entry.
A single patient interaction, such as an inpatient
admission or an outpatient visit.
A filter allows the user to manipulate data views so
that only the desired groups of data display, based on
the user’s preference.
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.
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.
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.
The Physician default view when opening
PowerChart, allowing for management and
processing of orders and documents.
154
Order
Sentence
Order Set
Patient List
PowerChart
PowerNote
PowerPlan
Relationship
Results
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.
Contains groups of orders that are related by process
or function so as to increase ordering efficiency and
support ordering best practices.
Allows the tracking of patients and can be filtered by
several criteria, including inpatient/outpatient status,
unit/location, provider relationship, and discharge
status.
Cerner view that supports inpatient and outpatient
workflow.
Structured clinical note created from a pre-defined
template. Allows for auto-populating, select data
within the note to expedite documentation.
Groups of condition-based or admission-specific
orders that allow for standardized orders based on
specialty, ordering efficiency and ease of
discontinuing orders.
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.
Clinical data entered via PowerChart directly or from
an ancillary or departmental system.
155
Frequently Used Phone Numbers
IU Health
Ball
Memorial
Site
General
OR
Description
Main
Patient Access
Central Dictation
Dictation Help
Main OR
SAU/PACU
Rad
Telemetry
IU Health
Methodist
Site
General
Description
Main #
Bed Control
Central Dictation
Dictation Help
ED
IMACS OneCall
IUH 24/7 Transfer Center-Adult
IUH 24/7 Transfer Center- Neo/Peds
Lab- (Main)
Pharmacy (Inpt)
OR
Main OR
PACU
PreOp
Rad
Reading-Plain Film
Reading- Body/bone
Reading- Neuro
Techs
Telemetry
156
Number
765-747-3111
765-741-1073
765-757-3153
317-962-8501
765-747-3389
765-747-4451
765-747-3236
765-751-2789
Number
317-962-2000
317-962-9800
317-962-8401
317-962-8501
317-962-8355
317-944-5000
877-247-1177
877-447-4539
317-491-6000
317-962-5487
317-963-6300
317-962-6500
317-963-6260
317-963-9342
317-963-9300
317-962-2637
317-962-8306
317-962-3211
Riley
Hospital
for
Children
at IU
Health
Site
General
Description
Main #
Bed Control
Central Dictation
Dictation Help
ED
IMACS OneCall
IUH 24/7 Transfer Center- Adult
IUH 24/7 Transfer Center-Neo/Peds
Lab (Main)
Pharmacy (Inpt)
OR
Main OR
PACU
PreOp
Rad
IR
Reading Rooms
Reading- Plain Film
Reading- CT
Reading -MRI
Reading- US
Techs
Telemetry
157
Number
317-944-5000
317-944-3903
317-962-8401
317-962-8501
317-944-3936
317-944-5000
877-247-1177
877-447-4539
317-491-6000
317-948-8762
317-944-8222
317-944-9943
317-944-8634
317-948-6328
317-948-6343
317-948-6315
317-948-6300
317-948-6331
317-948-6300
317-948-6336
317-962-3211
IU Health
University
Site
General
Description
Main #
Bed Control
Central Dictation
Dictation Help
ED
IMACS OneCall
IUH 24/7 Transfer Center- Adult
IUH 24/7 Transfer Center- Neo/Peds
Lab (Main)
Pharmacy (Inpt)
OR
Main OR desk
Pre-Op
PACU
Simon OR desk
Simon Pre-Op
Simon PACU
Rad
IR
Reading- Chest
Reading- Abdomen
Reading- MRI
Reading- Neuro
Reading- US
Techs
Telemetry
158
Number
317-944-5000
317-944-3903
317-962-8401
317-962-8501
317-944-4705
317-944-5000
877-247-1177
877-447-4539
317-491-6000
317-944-0362
317-944-4001
317-948-5400
317-944-4088
317-948-7493
317-948-7100
317-948-7522
317-944-1828
317-948-8483
317-944-1831
317-944-3692
317-944-3692
317-948-8219
317-944-3351
317-944-0362
Richard L.
Roudebush
VA
Hospital
Site
General
Lab
OR
Pharmacy
Radiology
Description
Main #
Bed Control
ED
Dictate
Main Lab
Main OR
Pre-Op
PACU
Inpatient
Techs
Reading Rooms
Abdomen
Chest
GI
IR
Msk
Neuro
Nuclear
Diagnostic
Telemetry
159
Number
317-554-0000
317-988-2536
317-988-3059
317-988-2047
317-988-2545
317-988-2350
317-988-3190
317-988-2237
317-988-2583
317-988-3173
317-988-2806
317-988-2806 x1
317-988-2806 x2
317-988-2806 x3
317-988-2806 x4
317-988-2806 x5
317-988-2806 x6
317-988-2806 x7
317-988-2806 x8
317-988-3659
Wishard
Memorial
Hospital
Site
General
Labs
OR
Radiology
Description
Main #
Bed Control
ED
Dictation
Main Lab
Main OR
Pre-Op
PACU
Xray Techs
Chest
Abdomen
Neuro
160
Number
317-639-6671
317-630-2233
317-630-6243
800-454-9106
317-630-7442 x1
317-630-7205
317-630-8179
317-630-7030
317-630-6570
317-630-6231
317-630-7911
317-630-6998