Physician Reference Guide

Transcription

1 Cerner Physician Reference Guide June 4, 2012

2 Important Numbers Support Resources The IU Health Service Desk is available 24/7 to assist you with computer related issues, including password resets The Center for Physician Education provides computer application instruction and educational services The Center for Physician Education website, located on the Pulse page of the IU Health network, or via the link below: physician_education/ v2/index.php 2

3 Table of Contents Overview... 9 Introduction... 9 Cerner Password... 9 Security... 9 Log On and Off Introduction Remote Log On Procedure Downtime Procedures Log On Procedure Log Off Procedure Change Your Password Introduction Procedure Access Other Clinical Systems Introduction Available Systems View Surgical Schedules Procedure Utilize Message Center Introduction Sign Single Telephone and Verbal Orders Sign a Group of Telephone and Verbal Orders17 Forward Orders for Signature Refuse Orders for Signature Cosign a Note

4 Create and Maintain Patient Lists Introduction Lists Used Create a Relationship List Add Patient to Relationship List Remove Patient from Relationship List Create a Query List (Report) Modify a Query List Safeguard Printed Patient Information Search for a Patient Introduction Procedure Multiple Encounters Locate the Correct Patient Encounter Document Chart Access Introduction Procedure View and Add Allergies View Allergies Add Allergies Navigate to Sections of the Chart Introduction Manage Search Criteria on the Results Review Band 36 Move Forward or Back by One Day Navigate to Results View Result Details Set View Format for Current Session View Clinical Documentation

5 Four Bands Procedure Navigate Scanned Documents Create a Free-Text Clinical Note Write Notes Set Up Personal Document Types as Defaults 41 Suggested Content Procedure Create New PowerNote PowerNote Views Modify PowerNotes Advanced PowerNote Functions Computerized Provider Order Entry (CPOE) Customize Views The Orders Window Order Entry Basics Specialty Clinical Folders Set Your Clinical Specialty Folder as Your Home Folder Basic Order Search Search for Orders Enter Single Orders Modify Orders Favorites Folders Medication Order Frequencies Standard Schedules for IU Health Order Entry Tools Order Sets

6 PowerPlans Medication Order Entry IV: Titratable Drip IV Heparin Nomogram and Thrombostabilizer Infusions IV TPN Adult IV TPN Pediatric and Neonatal Medications: Dose Range Orders Medications: Hold a Single Dose Medications: Irrigation Orders Medications: Multiple PRN Reasons Medications: Multiple Route Orders Medications: Non-Formulary/ Substitution Alerts Medications: One-time STAT Doses Medications: STAT Doses with Ongoing Orders Medications: Patches Medications: Taper Doses Medications: Taper Dose, No Existing Taper Order Medications: Prescriptions Dosage Calculator Introduction Where to Find the Dosage Calculator Calculation Options by Weight Calculate Standard Doses

7 Pediatric Antimicrobial Stewardship Introduction Orders Program Goals PowerPlans Organization of Antimicrobial Agents Place Orders from a Subphase Locate an Antimicrobial Agent PowerPlan Restricted Agents Medical Student Orders Overview: Medical Student Orders Medical Students: Order Processes Other Order Entry Processes DNR Orders Medication Special Alerts/ Communication Transfer Order Review Note Discharge Instructions (edi) Glossary Frequently Used Phone Numbers IU Health Ball Memorial IU Health Methodist Riley Hospital for Children at IU Health IU Health University Richard L. Roudebush VA Hospital Wishard Memorial Hospital

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9 Overview Introduction Cerner is the vendor name of the EMR system used at IU Health. Cerner is a fully integrated EMR that is being introduced throughout IU Health. Cerner Password Your Cerner password: Must be 6-8 alpha-numeric characters May contain special characters (#, &...) Must be changed every 90 days May not be the same as your previous three passwords Security There are strict regulations that govern the use and protection of patient information. Certain measures have been put into place at IU Health that protects patient data in the EMR. Cerner automatically logs out after 15 minutes of no activity; however depending on the location, certain areas may have a different automatic logout time Do not share passwords Do not allow another person access under your ID and password Log out of the EMR when walking away from the computer 9

10 Log On and Off Introduction SSL is a browser-based connectivity solution that allows credentialed physicians to access Cerner remotely. SSL works on Windows Vista, XP, and Windows 7 operating systems as well as on Mac operating systems. Remote Log On Procedure 1. Open your web browser. 2. In the address locator bar, enter 3. Click Yes to install Juniper on your system. 4. Enter your IU Health Network ID and password. 5. Click Enter or Sign In. Available roles in the secure gateway display. 6. Click the Tier0 link. The Secure Access SSL Home page displays. 7. In the Web Bookmarks section, click the Cerner link. The CernerWorks applications portal displays. 8. Click to launch Cerner PowerChart. 10

11 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 11

12 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. 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 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 and report the computer name, location, and the name of the printer where the report printed. Place the report in the shred box. 12

13 Log On and Off, continued Log On Procedure 1. Double-click on your computer desktop. 2. Click displayed in the Applications window. 3. Enter your user ID (usually your dictation number) and password into the respective fields. 4. Click OK. Log Off Procedure 1. Close all open patient charts. 2. Click to immediately disconnect from the server. The Exit Application window displays. 3. Select Exit and shut down the application. Note: To suppress this message in the future, place a checkmark in the box. 13

14 Change Your Password Introduction You can change your password at any time using the following procedure. Procedure 1. When logged onto Cerner, click Task on the toolbar. 2. Select Change Password from the drop-down menu. 3. Enter your old password in the Old Password field. 4. Enter a new password in the New Password field. 5. Re-type your new password in the Retype Password field. 6. Click OK. 14

15 Access Other Clinical Systems Introduction Within Cerner, you can access other clinical systems used at IU Health. Available Systems System Description INPC Data repository that includes: Labs and documentation created prior to the Cerner implementation Current information from other health care sites around the state of Indiana ClinDoc Electronic nursing flowsheet contains data entered by nursing Data flows into Cerner It can be viewed from either ClinDoc or Cerner ClinSuite Tool used to facilitate the patient handoff process between physicians UpToDate IU Health s source for evidence-based clinical information 15

16 View Surgical Schedules Procedure 1. Click in the links within Cerner. 2. Click the appropriate surgical area. 3. Click to begin the print process. 4. Place a checkmark in the Preview box. 5. Click Print. 6. In the next box, click Print. The surgical schedule displays. 16

17 Utilize Message Center Introduction Cerner always initially opens to the Message Center where you can: Sign single or a group of telephone and verbal orders Forward orders for co-signature Refuse to sign orders Cosign notes Sign Single Telephone and Verbal Orders 1. Click the Orders, Cosign Orders or Med Student Orders folder. 2. Review order details for accuracy. 3. Right-click the order. 4. Select Approve from the menu. Sign a Group of Telephone and Verbal Orders 1. Click the Orders, Cosign Orders or Med Student Orders folder. 2. Review order details for accuracy. 3. Hold the Control key down while clicking on multiple orders. 4. Right-click anywhere WITHIN the highlighted orders. 5. Select Approve from the menu. 17

18 Utilize Message Center, continued Forward Orders for Signature 1. Select the order(s). 2. Click Forward Only. 3. Select Sign from the Additional Forward Action list. 4. Find the provider by: Typing the name of the intended recipient provider, or Click Search and look for the provider 5. Enter comments (up to 120 characters, including spaces) if necessary. Note: Comments become part of the permanent patient medical record. 6. Click OK. 18

19 Utilize Message Center, continued Refuse Orders for Signature 1. Click the Message Center Orders, Cosign Orders or Med Student Orders folder. 2. Double-click the order you wish to refuse. 3. Click Refuse. 4. Select a reason. 5. Type a comment (up to 120 characters) if needed. 6. Click OK or click OK and Next if you need to refuse additional orders. The order is routed to the refusal admin. Cosign a Note 1. Click the Documents folder. 2. Double-click the note requiring cosignature. 3. Review the note for accuracy. 4. Click OK to sign the note. 19

20 Create and Maintain Patient Lists Introduction Patient lists use defined criteria to organize patient charts. Each patient list displays on a separate tab. Lists Used Lists commonly used at IU Health include: Type Description Provider 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 Relationship Relationship lists display those patients you already have a relationship with, such as attending or resident. Query Query lists display the patients of another physician. Create a Relationship List Relationship lists are encounter or visit-based. An outpatient relationship does not carry over into a new inpatient encounter. 1. Click (List Maintenance) in the Patient List window. 2. Click New. 3. Select Relationship. 20

21 Create and Maintain Patient Lists, continued Create a Relationship List, cont. 4. Click Next. 5. Click + to the left of Visit Relationships. 6. Click Next. 7. Place a checkmark in the box to the left of the appropriate type of physician relationship(s). 8. Enter a name for your new list. 9. Place a checkmark in the box to the left of Encounter Types. 10. Place a checkmark in the boxes to the left of: Emergency Inpatient Observation Outpatient in a Bed 11. Click + to the left of Location, then click + to the left of each appropriate location. 21

22 Create and Maintain Patient Lists, continued Create a Relationship List, cont. 12. Place a checkmark in the box to the left of each location. 13. Click to the left of Discharged Criteria. 14. Select discharged criteria. 15. Click Finish. 16. Highlight the new list in the Available lists pane. 17. Click to move the list to the Active lists pane. 18. Click to move your Relationship list to the first position in the Active lists pane. Your list is moved to the first tab in the patient list window. 19. Click OK. 22

23 Create and Maintain Patient Lists, continued Add Patient to Relationship List 1. Click the patient list tab where you need to add the patient. 2. Click (Add Patient). 3. Enter the patient s last name or MRN (medical record number). 4. Click Search. 5. Select your patient from the search results list. 6. Select the appropriate encounter from the lower pane. 7. Click OK. 8. Click to refresh. Remove Patient from Relationship List 1. Click the specific patient list tab where you need to remove the patient. 2. Click the patient s name. 3. Click (Remove Patient). 4. Click Yes to confirm. If you have only one relationship with the patient, the patient drops off your list. But if you have more than one relationship with the patient, the patient does not drop off. 5. Select the appropriate relationship. 6. Click OK. 7. Click to refresh. 23

24 Create and Maintain Patient Lists, continued Create a Query List (Report) 1. Click.. 2. Click (List Maintenance). 3. Click New. 4. Select Query. 5. Click Next. 6. Select Physician List Query. 7. Change the name of the query to reflect the physician names and locations. 8. Click Next. 9. Type the first few letters of the physician s name to move quickly to that area of the physician list. 10. Place a checkmark in the box to the left of the desired physician s name. 11. Click Next to select locations from within the Organizations window. 12. Place a checkmark in the box to the left of each location. 13. Click Next. 14. Click Finish. 24

25 Create and Maintain Patient Lists, continued Create a Query List (Report), cont. 15. Highlight the new list in the Available lists pane. 16. Click to move your new list to Active Lists. 17. Click OK. 18. Click (Execute Query) to activate the list. Note: Each time you use the Query list, you must click the Execute Query icon to refresh the report results. Modify a Query List 1. Click. 2. Click (Modify Parameters). 3. Modify the parameters for a query list (add or remove a physician or location). 4. Click OK. 5. Click (Execute Query) to implement your changes. 25

26 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. 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 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 and report the computer name, location, and the name of the printer where the list printed. Place the list in the shred box. 26

27 Search for a Patient Introduction You can search for a patient by name or by medical record number (MRN). Procedure 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. 27

28 Search for a Patient, continued Locate the Correct Patient Encounter Step Action 1. Carefully view the patient encounters in the lower pane of the Patient Search window. 2. Search for an encounter near or on today s date. 3. Confirm that the encounter displays the correct facility and nursing unit. 4. Confirm that the encounter is Active. 5. After you have located the correct patient encounter, highlight the encounter in the lower pane. 6. Click OK. 28

29 Search for a Patient, continued Locate the Correct Patient Encounter, cont. 7. Review the patient header to ensure that you have accessed the correct encounter. 8. If you selected the wrong encounter, click the location in the patient header. 9. In the pop-up window, double-click the correct encounter. 29

30 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 1. Open a patient chart. 2. If a relationship window displays, select a relationship. 3. Click Chart on the toolbar at the top of the screen. 4. Scroll to the bottom and select Chart Accessed By. 5. Select Most Recent from the sub-menu. 6. Double-click in the Comment Column to the right of your name to enable a cursor. 7. Enter the reason you have accessed the patient chart. 8. Click Save. 9. Click Close. 30

31 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 1. Click (Allergy link) in the patient header to access allergy details. Note: Alternatively, you can click (Allergies band) to enter allergies. 2. Click + Add. 3. Click the + to the left of the appropriate allergy category folder. 31

32 View and Add Allergies, continued Add Allergies, cont. 4. Double-click the correct allergy name. 5. If the appropriate allergy does not display in the folder: a. Click the search tab. b. Enter your search terms. c. Click Search. d. Double-click the correct allergy name. 6. Click the + to the left of (Common Reactions folder). 7. Double-click the appropriate common reaction. 8. Click OK to add the allergy to the allergy list. 9. Click OK to close the allergy list. 10. Click to refresh the screen and display the new allergy in the patient header. 32

33 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. 33

34 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.) 34

35 Navigate to Sections of the Chart, continued Band Function 2 Year Displays notes by physicians and mid-level providers and is Physician a sub-set of clinical notes Notes PowerNote Allows for the use of templates to create structured notes. Use the PowerNote band to document your online notes. Problems and Diagnoses Displays problems and diagnoses entered into the system, also allows for adding or editing information. Patient Info Contains demographic and case-related information organized under sub-tabs, including list of procedures, problems, immunizations, and visits, as well as growth chart information, and a provider list through which you can manage physician relationships. Dictation View Chart Summary Discharge Instructions Chart Search 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 Problems Procedures Allergies Lab panels (currently must search for individual components) 35

36 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.). 36

37 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

38 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 1. Depending on the timeframe you need to view, click either the 2 Year Clinical Notes band or the 72 Hr Clinical Notes band. 2. Click one of the radio buttons to sort the index by one of the following options: Type Status Date Performed By Encounter 3. Double-click the needed folder to open. 4. If there are sub-folders, click the + to see more folders or documents. 5. Double-click to open a document. 6. Use the large blue arrows to move quickly from one document to the next or to move between note types. 38

39 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. Check to determine if multiple pages have been scanned into a single entry Click the right arrow to move to the next page if there is more than 1 page indicated Use the 4th arrow to jump to the last page Use magnifying glasses to zoom in (+) or out (-) For easier viewing, click the Fit to Page tool Use the rotate tools to rotate the document 39

40 Create a Free-Text Clinical Note Procedure 1. Click either the 2 Year Clinical Notes band or the 72 Hr Clinical Notes band. 2. Click (New Note). 3. Select the correct note Type. 4. Change date and time if necessary. Note: Clinical documentation always reflects the date and time that the note was created. If the documentation pertains to the prior day, you must change the date and time of the note prior to signing the note. 5. Enter the Subject of the note. 6. Type your note. 7. Click Sign, Save, Save & Close or Cancel. Option Function Sign Enters your note into the patient s permanent record Changes to the note must be made by addending the note Save Saves your note before signing Changes can be made to the note Save & Saves your 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 40

41 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 Description IP Inpatient OP Outpatient Admission/H&P Note Generic Initial Consult Note By specialty Progress Note By specialty Procedure Note Generic Orders Reconciliation Procedure 1. Open the patient chart. 2. Select PowerNote +Add from the menu. Note: You must click + Add and ensure that you have opened a PowerNote to proceed. 41

42 Write Notes, continued Procedure, cont. 3. Select View from the uppermost task bar. 4. Select Customize from the drop-down menu. 5. Select the Document Types tab. 6. Click to uncheck it. 7. Select Personal Note Type List from the Default List Type. 8. Click the appropriate Document Type in the All Available Document Types column on the left. 9. Click > to move it to the Personal Document Type List column on the right. Note: You can only select one document type at a time. However, this is a one-time set up that will make charting commonly used notes more efficient. 10. Click Apply. 11. Click OK. 42

43 Write Notes, continued Add Templates to Favorites 1. Click the Catalog drop-down arrow. 2. Select IUH Inpatient. 3. Click + next to Specialty (i.e., Adult). 4. Highlight the appropriate templates (e.g., Admission H&P, Progress Note, Consult Note, Transfer Order Review) 5. Click Add to Favorites. 6. Scroll down and click + next to Procedures. 7. Highlight the needed procedure templates. 8. Click Add to Favorites. Your selected templates display under your Favorites tab. Create New PowerNote PowerNotes utilize templates to prompt for relevant information and can import existing data into your note. 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). 43

44 Write Notes, continued Create New PowerNote, cont. Step Action 4. Proceed as follows: If you have created favorites, click your Favorites tab and select a template. Skip to Step 7. If you have not created favorites, click the Catalog tab and select IU Health from the drop-down menu. Continue to Step Click the + next to each folder to view its contents. 6. Click the template that indicates the type of note you are writing (i.e., Progress Note). Note: Note Type and Template chosen from the Catalog need to correspond. 7. Click OK. The Auto Populate screen displays. 8. Check the boxes for those items that you need included in your note. 9. Click OK. 44

45 Write Notes, continued Create New PowerNote, cont. 10. Click to expand and display the structure of the note. 11. Click terms in each sentence that you need to add to your note as follows: Single-click a term to select it by displaying a circle around it Double-click a term to negate it A third click on a term deletes the term from documentation 12. To enter free-text for a particular term, click or right-click and select Comment. 13. To enter free-text at the paragraph level, click. 14. Click Sign, Save, Save & Close or Cancel. Option Function Sign Enters your note into the patient s permanent record Changes to the note must be made by addending the note Save Saves your note before signing Changes can be made to the note Save & Close Saves the note before signing Closes it so that you may complete it at a later time Cancel Deletes your note with no saved record of the note 45

46 Write Notes, continued PowerNote Views Contributor View You can view a PowerNote in report format while you are creating the note. 1. Click the contributor icon to view the note in report format. 2. Click the contributor icon again to return to the PowerNote working format. Full Screen View You can enlarge a PowerNote to full screen format in order to more easily view the note as it is being created. 1. Click in the upper left corner of the note to expand the note view to full screen. 2. Click in the upper right corner to reduce the screen size. 46

47 Write Notes, continued Modify PowerNotes Addend a Note You can add information to your clinical documentation by using the addend function. 1. Click the Clinical Notes band. 2. Double-click to open the note that you need to addend. 3. Click (Modify) or right-click in the body of the note and select Modify. 4. Enter the additional text below *Insert Addendum Here:. 5. Sign the note when completed. Modify a Note You may occasionally need to strike out incorrect information within your note and enter the correct information. 1. Click the Clinical Notes band. 2. Double-click the appropriate note to open it. 3. Click or right-click the body of the note and select Modify. 47

48 Write Notes, continued Modify PowerNotes, cont. Modify a Note, cont. 4. Drag your cursor to highlight the incorrect text. 5. Click (Strikethrough). 6. Enter the corrected text below *Insert Addendum Here:. 7. Sign the note. In Error Note You may find that you have entered incorrect information on a patient or written a note on the wrong patient. Use the following In Error process to strike the in error note from view in the EMR. Note: Notes entered through PowerNotes or Clinical Notes must be made In Error through the Clinical Notes band. 48

49 Write Notes, continued Modify PowerNotes, cont. Strike the In Error Note from View 1. Click either the 2 Year or 72 Hr Clinical Notes band. 2. Double-click the note that was entered in error to display the note. 3. Right-click the note and select In Error to in error the existing note. 4. Type the In Error reason. 5. Click OK. 6. Either return to the PowerNotes or Physician Notes band to write your replacement note or select the correct patient to begin entering your documentation. 49

50 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. 1. Make sure that the note you need to copy into is open. 2. Click to minimize the new note. 3. Double-click to open the note that you need to copy from. 4. Highlight the appropriate text that you need to copy from the existing note. 5. Press ctrl>c on the keyboard to place the text on the electronic clipboard. 6. Click to maximize the new note. 7. Click the area of the note where you need to paste the new text. 8. Press ctrl>v on the keyboard to paste the text. 50

51 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. 1. Click + Add in PowerNote band. 2. Click the Existing tab. 3. Click to highlight the appropriate note to copy forward in the bottom pane. 4. Place a checkmark in the Copy to New Note box. 5. Select the appropriate Document Type.. 6. Type an appropriate Title. 7. Click OK. 8. Select paragraphs to copy. 9. Check and uncheck the appropriate items in the Auto Populate window. 10. Complete the note by modifying data to accurately reflect documentation for the date of entry. 11. Click Sign. 51

52 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. 1. In the selected structured note, select terms as positive or negative as needed for your macro. 2. Right-click the appropriate paragraph or sentence header at the level in which you need to save your macro. Note: You can save a macro at either the paragraph or sentence level (e.g., Review of Symptoms or Constitutional). 3. Select Save Macro As from the pop-up menu. 52

53 Write Notes, continued Advanced PowerNote Functions, cont. Create a Macro, cont. Step 4. Enter a Title. Action Note: You may want to use the initial paragraph/header name followed by a descriptor to ease future retrieval (e.g., Review of Systems negative). 5. Click Create New. Insert a Macro 1. Click the M in the section of the document where you have created the macro. 2. Select the appropriate macro from the list that displays. The note populates with the preselected terms from your macro. 3. Modify the macro as needed for your particular patient. 53

54 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. 1. Click the white space of the note until you see your cursor. The free-text mode becomes activated and displays the appropriate toolbar above your note. The toolbar contains the Auto Text icon. 2. Click (Manage Auto Text). 3. Click (New Phrase). 4. Enter an abbreviation. Note: Start all your abbreviations with a leading period. This is important to ensure that you are not interrupted with a display of your auto-text when you are typing your note (e.g.,.pyelo ). 5. Enter a description. Note: Be sure to enter a term that will help you know what is in your auto-text (e.g., pyelonephritis ). 6. Click (Add Text). The Formatted Text Entry window displays. 54

55 Write Notes, continued Advanced PowerNote Functions, cont. Create Auto Text, cont. 7. Type the relevant text (e.g., Ciprofloxacin 500mg po bid x 10 days. Push fluids. If ongoing fevers, chills or back pain, patient to notify. ). 8. Click OK to close the Formatted Text Entry window. 9. Click Save and then Close. You can also save any free-text that you have typed as an Auto-Text as follows: 1. Type the free-text. 2. Highlight the appropriate text and right-click it. 3. Select Save as Auto Text. 4. Enter an abbreviation. Note: Start all your abbreviations with a leading period. This is important to ensure that you are not interrupted with a display of your auto-text when you are typing your note (e.g.,.pyelo ). 5. Enter a description. Note: Be sure to enter a term that will help you know what is in your auto-text (e.g., pyelonephritis ). 6. Click Save and then Close. 55

56 Write Notes, continued Advanced PowerNote Functions, cont. Insert Auto-Text 1. Click the white space of your note where you need to type free-text. 2. Enter the first few characters of your auto-text abbreviation beginning with the period (. ). Note: If you hover over the abbreviation, the entire description displays for you. A drop-down menu displays. 3. Double-click the auto-text you need to insert into your note. Drawings You can draw on body images, annotate the images, and insert the drawings into your PowerNote. 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. 56

57 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. 1. Create a PowerNote but do not sign. 2. Click Documentation in the toolbar and select Save as Precompleted Note. 3. Enter a title for the note. 4. Click Save as New. The note is filed in the Precompleted tab in the PowerNotes window. 5. To use a Precompleted note, select the appropriate note in the Precompleted tab. 6. Click OK. 57

58 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

59 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 1. Open the patient chart. 2. Click the Orders band. 3. Click the Options menu at the top of the screen. 4. Click Enable Pop-up Windows for Selecting Orderables to remove the checkmark. Orders Band: Customize Filters, Columns, and Groups Each order filter selection displays different data based on the view criteria that the filter was designed to produce. Note: The last filter setting that you used will be displayed the next time you log in. If you change your filter view, remember to change it back to your default setting so that you do not accidentally overlook critical information. 59

60 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Orders Band: Customize Filters, Columns, and Groups, cont. 1. From the Orders band, click the Displayed: hyperlink to access the Advanced Filters window. 2. In the Display drop-down list, click one of the options that begins with * (asterisk) and contains Med Student to set the filter to display inpatient orders only. See related note and warning on the next page. 60

61 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Orders Band: Customize Filters, Columns, and Groups, cont. 2. In the Display drop-down list, click one of the options that begins with *(asterisk) and contains Med Student to set the filter to display inpatient orders only. (continued) Note: Home medications MUST be removed from the inpatient medication list. The filters in the Display list marked with an asterisk were designed to remove home medications from the Orders view. Warning: DO NOT modify the radio buttons or checkboxes in the Advanced Filter window. This is only used to modify the Display option. Changing these buttons may result in missed orders. 3. From the Current menu, select Customize View. 61

62 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Orders Band: Customize Filters, Columns, and Groups, cont. Step Action 4. Move the following columns from the Available columns pane to the *Selected columns pane by selecting them and clicking Add: a. Quick Discontinue b. Notifications c. Type d. Order Name e. Status f. Details g. Ordering Physician h. Last Updated By 5. Select a category in the *Selected columns pane and click to move the item up or down and change the display so that the order matches the shown in Step 4. 62

63 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Orders Band: Customize Filters, Columns, and Groups, cont. 6. Customize the grouping of orders to create Clinical Folders for locating and viewing existing orders as follows: a. In the drop-down list for Group orders by:, select Clinical Category. b. For Then by:, select Active/Inactive. c. For Sort orders by:, select Order Name or Chronological. 7. Confirm that upon completion, your Orders view pane appears in the following order: 63

64 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Medications List Band: Customize Filters, Columns and Groups After you have customized your Orders band, you must also customize your Medication List band. 1. Open the patient chart and click the Medication List band. 2. Click the Displayed: hyperlink to access the Advanced Filters window. 3. In the Display drop-down list, select All Medications (All Statuses). 64

65 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Medications List Band: Customize Filters, Columns and Groups, cont. 4. From the Current menu, click the Customize View link. 5. Move the following columns from the Available columns pane to the *Selected columns pane by selecting them and clicking Add: a. Quick Discontinue b. Notifications c. Type d. Order Name e. Status f. Details g. Ordering Physician h. Last Updated By 6. Select a category in the *Selected column pane and click to move the item up or down and change the display so that the order matches the sequence in Step 5. 65

66 Computerized Provider Order Entry (CPOE), continued Customize Views, cont. Medications List Band: Customize Filters, Columns and Groups, cont. 7. Customize the grouping of orders to create Clinical Folders for locating and viewing existing orders as follows: a. In the drop-down list for Group orders by:, select Venue. b. For Then by:, select Active/Inactive. c. For Sort orders by:, select Order Name or Chronological. 8. After you have created your filters, customized your columns, and defined the group and sort order for your Medications List pane, review the screen to familiarize yourself with the structure of the window and the location of orders. Note: You can click and drag column borders to adjust your view of data in any column. If your data displays ellipses ( ) at the end, this indicates more information is available. Hover over the data column to display the additional information. 66

67 Computerized Provider Order Entry (CPOE), continued The Orders Window Resize the Order Details Pane You can enlarge the Order details pane to view more detail information or minimize the pane to view orders in the Orders for Signature Pane. To enlarge the Order details pane 1. Hover your mouse over the upper border of the order details pane until a symbol appears. 2. Hold down the left mouse button and drag the window up or down to resize. To minimize the Order details pane 1. Click the down arrow in the upper left corner of the pane. 2. To open the Order details pane, click the up facing arrow in the lower left corner of the Orders for Signature window. Note: The Order details pane is only present when there is an unsigned order in the Orders for Signature pane. 67

68 Computerized Provider Order Entry (CPOE), continued Common CPOE Icons Cerner uses images to denote order type, status, and other important information. Order Type Icons Order Detail Icons Order Review Status Order Icons PowerPlan Icons Inpatient Orders Documented Meds by History (home meds) Prescriptions Ambulatory Orders Additional Reference Information Order Order Details Not Complete Dose Calculator Physician Order with Pending Cosign Medical Student Order Cosign Pending Pharmacy Review Pending Nurse Review Order Order Comment Order Set PowerPlan Initiate Plan or Phase View Excluded in PowerPlan Discontinue PowerPlan or Phase 68

69 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. 1. Open the patient chart. 2. Click the Orders band. 3. Click + Add. 4. Click the Root Folder to view subfolders. 5. Click the appropriate subfolder to view additional folders. 6. Right-click your specialty folder and click Set as Home Folder. 7. Click to ensure that your specialty folder is now set as your Home Folder. 8. To return to the Root Folder, click. Note: If you are a resident changing specialties, you can reselect the correct Home Folder with each rotation. 69

70 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 1. From the Orders band, click + Add. 2. Click the drop-down arrow to change the Order Search criteria to Starts with, if not already selected. 3. Enter your search word in the Search field. A list of search results displays. Search results may include synonyms for the same order. 4. Click the appropriate order once to select it. Note: If you double-click, the order will be duplicated. To remove a duplicate, right-click and select Remove prior to signing the orders. 70

71 Order Entry Basics, continued Search for Orders, cont. By Contains 1. From the Orders band, click + Add. 2. Click the drop-down arrow to change the Order Search criteria to Contains, if not already selected. 3. Enter your search word in the Search field.. 4. Click the appropriate order once to select it. Enter Single Orders 1. Search for the order. 2. Click the correct order in the search result list. Note: For peds, it is preferable to select a pediatric order set if available. CareSets provide the best information for dosing and ordering the medication in pediatrics. 3. If entering a medication order, select the order sentence that best matches the intended order. The Order Details pane opens. Note: Order details may need to be resized. 71

72 Order Entry Basics, continued Enter Single Orders, cont. 4. If displays, there are missing order details. Click to move from one missing detail to the next. 5. Highlight the Order detail, then complete or change the corresponding Detail value. 6. Review all new order details in the Orders for Signature pane. 7. Click Sign. 8. Click to refresh the screen. Signed orders file into the corresponding clinical category. 72

73 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 73

74 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 1. Click the Orders band. 2. Click + Add. 3. Click the arrow by the Favorites icon. 4. Select Organize Favorites. 5. Add folders by clicking Create Folder. Your first folder is a subfolder of the Favorites folder. 6. To create a subfolder, highlight the parent folder prior to clicking Create Folder. Move Favorites Folders 1. To move a folder to a different parent folder, highlight the folder you need to move. 2. Click Move to Folder. 3. Select the appropriate parent folder. 4. Click OK. 74

75 Order Entry Basics, continued Favorites Folders, cont. Rename Favorites Folders 1. To rename a folder, highlight the appropriate folder. 2. Click Rename. 3. Type the new folder name in the text field. Change Folder Order 1. Highlight the appropriate folder. 2. Click to move the folder up or down. Delete a Favorites Folder 1. Highlight the folder. 2. Click Delete. 3. Confirm Deletion and click Yes. 4. 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. 75

76 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. 1. Click the Orders band. 2. Search for the appropriate order. 3. Complete the order details. 4. Right-click the correct order. 5. Select Add to Favorites. 6. 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. 76

77 Order Entry Basics, continued Medication Order Frequencies Frequency Standard Administration Times Daily 0900 QAM/ 0900/2100 QPM At 2100 Bedtime BID 0900, 2100 TID 0900, 1500, 2100 Four times 0900, 1300, 1700, 2100 daily Q2 02, 04, 06, 08, 10, 12, 14, 16, 18, 20, 22, 24 Q4 0200, 0600, 1000, 1400, 1800, 2200 Q6 0600, 1200, 1800, 2400 Q8 0600, 1400, 2200 Q , 2100 Q_H 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. 77

78 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 Q_H Collection at the next even hour. Once is the default frequency for ALL lab orders. 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

79 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. 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 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. 79

80 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 1. Click a PowerPlan to open it. 2. 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. 3. 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. 80

81 Order Entry Tools, continued PowerPlans, cont. PowerPlans: Place Orders, cont. 4. 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. 5. 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. 6. 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. 81

82 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. 82

83 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 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. View and enter orders within that Subphase. 5. 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. 83

84 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 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 1. To initiate a PowerPlan later, highlight the PowerPlan in the view pane. 2. Click. 3. Click Orders for Signature. 4. Click Sign. 5. Click to refresh. 84

85 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 1. 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. 3. Place a checkmark by those orders you need to add to the PowerPlan. 85

86 Order Entry Tools, continued PowerPlans, cont. PowerPlans: Add Orders to an Initiated Plan, cont. 4. 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. 6. Search for the order(s) and click Done when all orders have been added. Note: Clicking more than once on an order will duplicate it in the PowerPlan. 7. Review your orders and sign as usual. 86

87 Medication Order Entry Order an Immunization /PPD 1. Select the order sentence with a frequency of ONCE. 2. Change the Requested Start Date/Time to tomorrow s date at 0900, unless you have reason to schedule otherwise. IV Fixed Rate 1. Click + Add in the Orders band. 2. 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. 3. Select the correct order from list. 4. Select the correct order sentence. 5. Verify the correct diluent (e.g., Dextrose 5%) and additive (Potassium Chloride). 6. Enter or change any missing order details. Note: When you select the rate, the Infuse Over detail calculates automatically. 7. Add comments, if needed. 8. Verify all information is correct and click Sign. 87

88 Medication Order Entry, continued IV Fluid Bolus 1. Click + Add in the Orders band. 2. Begin typing the name of the fluid to be bolused. 3. Select the order for the fluid that includes bolus in the name. 4. Select the correct order sentence. The fluid and free-text rate of bolus default in the Continuous Details tab. 5. Add the volume of fluid to be infused, if less than the size of the bag ordered. Note: This is required for Pediatrics. IV: Titratable Drip 1. Click + Add in the Orders band. 2. Search for the medication name. 3. Select the correct order from the list (drug name + adult-titrate or peds-titrate). 4. Enter Order Comments in the continuous details pane. 5. Complete the information for the drip order. 6. Add information for any PRN bolus orders. Note: Pharmacy will complete the order entry. 7. Verify all information and click Sign. 88

89 Medication Order Entry, continued IV Heparin Nomogram and Thrombostabilizer Infusions 1. Click the Orders band. 2. Click + Add. 3. Type "Hep". 4. Select the appropriate Heparin Nomogram /Thrombostabilizer PowerPlan. 5. Check or uncheck orders as you would any other PowerPlan. 6. Review the Heparin drip order. Note: The rate defaults as Per Nomogram. 7. Click Initiate and then Orders for Signature. 8. Click Sign and Refresh. IV TPN Adult 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 1. Click + Add in the Orders band. 2. Enter TPN in the Search window. 89

90 Medication Order Entry, continued IV TPN Adult, cont. Adult Day 1/Initial Order, cont. 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. 6. 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. 90

91 Medication Order Entry, continued IV TPN Adult, cont. Adult Day 1/Initial Order, cont. 7. 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. 91

92 Medication Order Entry, continued IV TPN Adult, cont. Adult Day 1/Initial Order, cont. 9. Click the green check mark in the upper left corner to sign the PowerForm. 10. 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. 11. 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. 92

93 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. 1. When entering ongoing daily TPN orders, search for TPN. 2. Select the appropriate single TPN order and NOT the PowerPlan or Order Set. 3. The PowerForm with the data from the previous order displays. Modify the PowerForm as needed. 4. 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. 93

94 Medication Order Entry, continued IV TPN Pediatric and Neonatal After completing the initial TPN PowerForm using the TPN- Neonatal or TPN-Peds order, subsequent TPN PowerForms prepopulate with the previously selected values for the additive fields. 1. When entering a TPN order, search for TPN. 2. Select the appropriate single TPN order, TPN- Neonatal or TPN-Peds, and NOT a PowerPlan or Order Set. 3. Select the correct order sentence and click OK. 94

95 Medication Order Entry, continued IV TPN Pediatric and Neonatal, cont. 4. 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. 6. Click the green checkmark in the upper left corner to sign the PowerForm. After signing the PowerForm, the order is signed as usual. 95

96 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 1. Click + Add in the Orders band. 2. Search for the medication name. 3. Select the medication order. 4. Enter the highest dose. 5. Enter the shortest frequency. 6. Open the Order Comments Tab. 7. Enter the dose range (e.g., DOSE RANGE 1-2mg q2-4 hours). 8. Click Sign. 96

97 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. 1. Click + Add in the Orders band. 2. Search for Hold Medication Dose. The Order details window opens with the instruction: Must Complete Order Comments. 3. 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 97

98 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. 98

99 Medication Order Entry, continued Medications: Non- Formulary/ Substitution 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. Alerts 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: 99

100 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. 100

101 Medication Order Entry, continued Medications: One-time STAT Doses 1. Click + Add in the Orders band. 2. Search for a medication to be ordered STAT. 3. On the Order Details tab, click Pharmacy Order Priority (on the left) and select STAT from the Detail values list (on the right). 4. In the Frequency detail, select ONCE. 5. Review the Requested Start Date and Time. 6. If start date and time are correct, click Sign. Medications: STAT Doses with Ongoing Orders 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 101

102 Medication Order Entry, continued Medications: Patches 1. Click + Add in the Orders band. 2. Search for the medication name. 3. 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. 4. 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. Medications: Taper Doses 1. Click + Add in the Orders band. 2. 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. 102

103 Medication Order Entry, continued Medications: Taper Doses, cont. 3. 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.). 4. Click Sign. Medications: Taper Dose, No Existing Taper Order If the medication you are ordering does not have a taper order in the system when you search for the drug name: 1. Enter "Pharmacy taper. Order Details opens with instructions: Must Complete Order Comments. 2. In the Order Comments tab, in addition to the tapering regimen, you MUST also enter the name of the medication. 3. Click Sign. 103

104 Medication Order Entry, continued Medications: Prescriptions Enter a Prescription Order 1. Prior to your order search, change the catalog Type to Prescriptions. 2. Search for the medication. 3. Select the prescription order sentence that contains the correct details. 4. If you need to change a selected order sentence, click the drop-down next to the order name in the Details pane. 5. 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 104

105 Medication Order Entry, continued Medications: Prescriptions, cont. Enter a Prescription Order, cont. 6. Select the type of therapy for the prescription. Note: A stop date and time automatically calculates for Acute types of therapy. 7. For maintenance prescriptions, select the dispense quantity (30 or 90 day supply). 8. If you need the dose calculator, click (Open Dose Calculator). 105

106 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 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 and report the computer name, location, and the name of the printer where the report printed. Place the report in the shred box. 106

107 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. 1. Click + Add and select prescriptions from the Type drop-down. 2. Search for the medication. 3. Select the prescription order sentence that contains the correct details. 4. Click the ellipses next to the Send To field in the Details pane. The Prescription Routing window displays. 107

108 Medication Order Entry, continued Medications: Prescriptions, cont. Add a Prescription Printer to Favorites, cont. 5. 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. 6. 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. 7. Click the + to the left of the facility. Click again on the + to the left of the facility. The Unit Locations display. 8. 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. 108

109 Medication Order Entry, continued Medications: Prescriptions, cont. Add a Prescription Printer, cont. 9. 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. 11. When you have added all of your needed printers, click OK. 12. Prior to signing the prescription, ensure that the proper prescription printer is displayed in the Send To box. 109

110 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. 1. Click the ellipses to the right of the Send To box. 2. 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. 3. Ensure that the correct printer name displays in the Send To box. 4. Complete and sign the prescription orders. 110

111 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. 1. 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. 2. Once the prescriptions are highlighted, rightclick the highlighted area and select Resend. 3. Select the correct printer from the Output Devices window. 4. Click OK to reprint the prescriptions. 111

112 Dosage Calculator Introduction The Dosage Calculator is available when you place inpatient medication and outpatient prescription orders. The Dosage Calculator is used to order weight-based medications. Where to Find the Dosage Calculator The dose calculator opens automatically when you place an order that contains mg/kg, mcg/kg or other weightbased dose calculations. 112

113 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 1. 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. 113

114 Dosage Calculator, continued Calculate Standard Doses, cont. 2. Using the drop-down menu, evaluate the Rounding Rule for this medication and patient weight. 3. Select a rounding parameter based on your clinical judgment. Note: In most instances, the nearest whole number or nearest tenth is appropriate. 114

115 Dosage Calculator, continued Calculate Standard Doses (continued) 4. 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. 5. Click Apply Dose. 115

116 Pediatric Antimicrobial Stewardship Introduction 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 Orders 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. Program Goals 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 116

117 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. 117

118 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. 1. 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. 118

119 Pediatric Antimicrobial Stewardship, continued Place Orders from a Subphase, cont. 2. 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. 119

120 Pediatric Antimicrobial Stewardship, continued Place Orders from a Subphase, cont. 4. 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. 5. Once you have selected the ordering option that applies to your patient, use the available dosing information to make order selections. 6. At this point, you could navigate back to your main PowerPlan and continue selecting and deselecting orders as necessary. 120

121 Pediatric Antimicrobial Stewardship, continued Place Orders from a Subphase, cont. 7. 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. 8. After you complete your documentation, click the green checkmark to save the form and continue ordering. 121

122 Pediatric Antimicrobial Stewardship, continued Place Orders from a Subphase, cont. 9. 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. 122

123 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 1. 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. 123

124 Pediatric Antimicrobial Stewardship, continued Restricted Agents, cont. Order a Restricted Agent, cont. 2. 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. 3. 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 124

125 Pediatric Antimicrobial Stewardship, continued Restricted Agents, cont. Order a Restricted Agent, cont. 3. From within the Override Reason Form, select from the following options: (cont.) Written Recommendation from ID service o If a consultation has been completed by ID Service and orders are being entered based on consultation recommendations 4. Once you have completed your documentation, click OK to close the Override Reason Form. 5. Click OK again to close the alert window. 125

126 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 orders. is associated with Medical Student 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. 126

127 Medical Student Orders, continued Medical Students: Order Processes, cont. Medical Student: Order Entry, cont. 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. 127

128 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. 1. Select the PowerPlan from the Orders search window. 2. Enter the Ordering Physician (as with single order entry). 3. Select the orders and ensure order details are appropriate. 4. 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. 128

129 Medical Student Orders, continued Medical Students: Order Processes, cont. Medical Student: Discontinue Orders 1. 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. 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) 3. Click Sign. The Alert below displays reminding you to follow up with your Supervising Physician to take the action of actually discontinuing this order. 129

130 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. 1. 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. 130

131 Medical Student Orders, continued Providers: Medical Student Order Processes, cont. Provider: Co-Sign Med Student Orders, cont. 3. Click the patient name and open the patient chart. 4. 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. 131

132 Medical Student Orders, continued Providers: Medical Student Order Processes, cont. Provider: Co-Sign Med Student Orders, cont. 6. Review all orders requiring co-signature. 7. Deselect any incorrect orders that will NOT be co-signed. 8. Click Cosign to close the Actions Requiring Co-Signature window and return to Message Center. 9. Click to refresh. The co-signed orders have been removed. Provider: D/C Medical Student Orders 1. While in Message Center, select Med Student Orders from the Inbox Summary. 2. 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. 132

133 Medical Student Orders, continued Providers: Medical Student Order Processes, cont. Provider: D/C Medical Student Orders, cont. 3. Click the patient name and open the patient chart. 4. Locate the Discontinue Order under the Other Departments section. 5. 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. 6. Sign the order as usual. 7. Click Orders For Cosignature. 8. Click Cosign to approve the original DC Medical Student order on which you have taken action; then close the Actions Requiring Cosignature window. 9. Click to refresh. 133

134 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. 1. While in Message Center, select Med Student Orders from the Inbox Summary. 2. 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. Click the patient name and open the patient chart. 4. Click the Orders band. 5. Right-click the order that you do not want to approve. 6. Select Void. 134

135 Medical Student Orders, continued Providers: Medical Student Order Processes, cont. Provider: Refuse Med Student Order Co-Signature, cont. 7. Enter a void reason. 8. Click Orders for Signature and complete the signature process as you normally would. 9. 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

136 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 1. Select the DNR order in the order entry field. The Code Status Order Form (DNR) PowerForm launches. 2. Complete the details within the PowerForm. 136

137 Other Order Entry Processes, continued DNR Orders, cont. DNR Order Process, cont. 3. Sign the PowerForm by clicking the green checkmark at the top left. An alert presents when the PowerForm is signed. 4. Click OK to close the Alert window. You are returned to the Orders for Signature window. 5. Sign the DNR Order. Note: The Code Status Order From must be manually forwarded to the designated attending physician to be cosigned. 137

138 Other Order Entry Processes, continued DNR Orders, cont. DNR Order: Resident Forward 1. Open the 2 Year Clinical Notes folder and locate the Code Status Order Form you just completed. 2. Click the Code Status Order Form so that the note is displayed in the view pane. 3. Right-click within the note and select the Forward option. 4. Change the Additional Forward Action option to sign. 5. Insert the name of the attending physician into the To: section of the window. 6. Click OK to send the request. 138

139 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. 1. Within the Documents folder located in the Message Center, identify any documents requiring cosignature. 2. Highlight the correct document for cosignature and double-click to open the note. 139

140 Other Order Entry Processes, continued DNR Orders, cont. DNR: Attending Staff, cont. 3. Review the document and click OK to cosign the note. 4. If you need to modify the note, right-click and select Modify to make changes. 5. When the modification is complete, sign the note. Medication Special Alerts/ Communication 1. To enter exception orders (i.e., No Heparin, No IM Injections, No ACE Inhibitors, No Aspirin, etc.), search for the MEDICATION SPECIAL ALERTS Order Set in the catalog. 2. Select the appropriate exception order(s) from the list displayed. 3. Verify start date and time in the Details tab. 4. Click OK. Note: By entering the exception order in the Order Set noted above, you enable the correct Alerts to display that effectively alert clinicians to avoid the exception medication. 140

141 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 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 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. 141

142 Other Order Entry Processes, continued Transfer Order Review Note, cont. Sign Transfer Order Review Note 1. Click Sign/Submit. 2. If all information is correct, click Sign. 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. There are three tabs in the discharge instructions form: Discharge Instructions Medication List Sign & Print 142

143 Other Order Entry Processes, continued Discharge Instructions (edi), cont. 1. Click the band to access the edi form. 2. Scroll down to complete the following sections or click each link to move to the desired section of the form. Patient Data Physicians to contact for Discharge Instructions Distribution Follow Up Visits Follow Up Tests Activity Limitations or Restrictions Treatment/Procedure/ Equipment Dietary Requirements Additional instructions Vaccinations & TB Testing Allergies & Sensitivities Final Release Info 3. Click + Add or + Edit to initially enter or edit information. A window pops up to allow you to enter data. 143

144 Other Order Entry Processes, continued Discharge Instructions (edi), cont. 4. After you have entered or edited data, click Save prior to moving to the next screen. 5. If a change must be made to an existing section, click to make changes to the information. 6. If you place orders for tests or labs, you must click esign to electronically sign the orders. 7. If you need to add more than one test order, click Save and Add for efficiency. Caution: If orders for future tests or services are placed in edi, they will NOT result in the scheduling of the tests or studies. A requisition prints for each lab order when the Final Sign & Print is completed. Medication List The medication list tab is used to evaluate and reconcile current home and inpatient medications in order to create a complete list of home medications for the patient after discharge. When completed and printed, medications listed on the patient instructions will be grouped into the following categories: Take these medicines at home STOP taking these medicines DO NOT TAKE these medicines until instructed by your Doctor 144

145 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Medication List, cont. 1. Verify that: The home medication list in Cerner PowerChart is updated and accurate All new prescriptions that the patient will be discharged with have been entered in the orders or medication list tab (CPOE facilities) 2. Click the Discharge Instructions band. 3. Click Medication List. 4. Move through the Home Meds list on the left side of the screen first, marking each medication according to the following guide: Home Medication List Options Action Result Continue Places medication into the Take these medicines at home section of the instructions Choose this option if the patient was NOT taking this medication as an inpatient Modify Click Modify if medication details must be modified Changes made here DO NOT change the medication details in PowerChart Changes made here file into the Take these medicines at home section of the instructions 145

146 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Home Medication List Options, cont. Action Result D/C This option places the medication into the STOP taking these medicines section of the patient instructions DO NOT D/C and then reenter an order for the same medication; use modify and then enter any additional comments or instructions. Hold Selecting Hold requires that additional instructions be entered in a pop-up window Medications that have a Hold status display in the DO NOT TAKE these medications until instructed by your Doctor section of the patient instructions Reviewed Click for those home medications that you do not want to display on the home medication list If this medication is being given as an inpatient medication and will be continued as a home medication, click Continue on the inpatient medication list in order to pull in the date and time of the last medication dose, and click Reviewed on the home medication list. 146

147 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Medication List, cont. 5. Move through the Inpatient Meds list next, marking each medication according to the following guide: Inpatient Medication List Options Action Result Continue Places the medication in the Take these medicines at home portion of the medication instructions The date and time of the last medication dose will be pulled into the discharge instructions Medications can be modified in the lower portion of the window using the Edit icon Hold Holding a medication places it in the DO NOT TAKE these medications until instructed by your Doctor section of patient instructions Additional details must be entered Reviewed Use this for inpatient medications that will not be taken at home Medications will not display in the patient instructions 6. Add any additional medications in the Add Medication link under the appropriate section (non-cpoe facilities only). 147

148 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Medication List, cont. 7. Enter comments to clarify any med orders. Note: Comments in the existing medication list displayed in blue font will not populate the discharge instructions and must be added in the comments area. Note: The Add Medication link under Continue these meds should be used to enter a home medication for which the patient will be given a handwritten prescription (non- CPOE facilities). 8. When all medications have been addressed, click Patient Version to view the patient copy of the discharge instructions and ensure that the medication list is accurate and uses patient-friendly language. Note: Medication orders may change frequently and changes made earlier in an admission may change prior to discharge and must be reviewed. 148

149 Other Order Entry Processes, continued Discharge Instructions (edi), cont. 9. You can click X to reset a medication and remove it from the lower portion of the screen to the home medication or inpatient medication list in the original state. Note: Modifications and new medication orders entered in the edi form do not flow to PowerChart; therefore, it is best to enter modifications on the medications list tab prior to reconciling on discharge instructions. At non- CPOE facilities new prescriptions must be entered in both places. Sign & Print The Sign & Print section is used to electronically sign the patient discharge instructions when the patient is ready to be released. 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. 149

150 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Sign & Print, cont. 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. 150

151 Other Order Entry Processes, continued Discharge Instructions (edi), cont. Sign & Print, cont. 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 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 and report the computer name, location, and the name of the printer where the material printed. Place the material in the shred box. 151

152 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 1. Click. 2. Enter the appropriate information in the form. Note: The descriptive title is for your use and does not display on the patient copy of the instructions. 3. Click Save when completed. 152