Academic EHR
POWERED BY CERNER
USER GUIDE
2014
Procedures – The Academic EHR System
PowerChart
INTRODUCTION
The Academic EHR Subscription System was developed at the College of St. Scholastica in
Duluth, MN as the ATHENS Project with funding by a grant from the U.S. Department of
Education, Title III Program (2002-2007).
In October 2004, the ATHENS Project received national recognition when Dr. David Brailer, at
that time the National Coordinator of Health Information Technology, described it to an audience
in Washington, DC as a groundbreaking effort to bring computer-based information systems to
classes for healthcare students. In the fall of 2008, Health Data Magazine awarded The College
of St. Scholastica an Innovations award for the creation of the Academic Electronic Health
Record through the ATHENS project.
Health professions’ students and faculty access the Academic EHR Subscription System via a
secured Internet connection to a remote-hosted environment located in Kansas City, MO at
Cerner Managed Services. The Academic EHR Subscription System involves several
applications from Cerner’s HNA Millennium suite: PowerChart, Knowledge and Content, Open
Management Foundations, PowerVision and ProFile. In combination, these applications provide
health professional students with a very robust, integrated electronic medical record and health
information system that supports their professional education and ensures their readiness for
practice in a healthcare industry that is rapidly being transformed by health information
technology.
The Academic EHR Subscription was initiated in spring, 2006 by the Center for Healthcare
Innovation at The College of St. Scholastica to provide schools across the nation with an
economical way to share in the system and benefit from the educational advantages it provides.
“As the transition to an electronic health record gains momentum, healthcare delivery will need
to dramatically reinvent the way it collects, processes and uses health information. A workforce
capable of innovating, implanting and using health communications and information technology
will be critical to healthcare’s success.” (Building the Workforce for Health Information
Transformation, 2006, Chicago, IL: American Health Information Management Association).
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Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
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Table of Contents
How to Use This Document……………………………………..………….
Chapter 1: Getting Started………………………………………………………
 Confidentiality agreement ………………………………………………..
 vWorkspace ……………………………………………………………….
 Change your password……………………………………………………
 Logging In…………………………………………………………………...
Chapter 2: Patient Search.………………………………………………...
 Practice exercise…………………………………………………………..
Chapter 3: Navigation Menu and Chart Tour………………………………...
 Practice exercise………………………………………………………….
4
5
7
13
15
16
17
Chapter 5. Patient Lists………………………………………………………….
 Practice exercise…………………………………………………………..
19
28
30
33
33
34
35
39
Chapter 6: Procedures & Diagnosis/ Problems & Diagnosis……………..
 Adding a Diagnosis………………………………………………………...
 Entering a Procedure………………………………………………………
 Adding a Problem…………………………………………………………..
39
40
41
44
Chapter 7. Allergies………………………………………………………………
45
Chapter 8. Immunization Schedule…….……………………………………...
 Historic………………………………………………………………………
 Current (AdHoc Immunization Charting)…………………………………
 Childhood Immunization Schedule……………………………………….
 Practice Exercise………………………………………………….............
48
49
50
51
53
Chapter 9. Orders…………………………………………………………………
 Order Sets…………………………………………………………………..
 Practice Exercise………………………………………………………......
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57
Chapter 10. Medications Displays....………………………………………
58
Chapter 11. Reports/Notes……………….…………..…………………………
 PowerNote………………………………………………………………….
 Exercise………………………………………………………………..
59
63
66
Chapter 4. Registering or creating a new patient…………………………
 Modifying a registration……………………………………………………
 Adding a New Encounter………………………………………………….
 Practice Exercise…………………………………………………………...
54
Chapter 12. Charting Patient Care &
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Updated 09/09/2014 NS
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Assessments……..…………………………………………………………………
 AdHoc Charting…………………………………………………………….
 Interactive Charting………………………………………………………..
 Practice………………………………………………………………...
Chapter 13. Miscellaneous
 Exercises ………………………………………………………………….
Trouble Shooting ……………………………………………………………….
Computer Requirements……………………………………………………….
Help Resources ………………………………………………………………….
App A: School Web Addresses and Mnemonics……………………….....
App B: PowerChart Icons Explained…………………………………………
App C: PT and PTA Exercises…………………………………………………
App D: HIM Exercises ProFile and Registration………………………..
App E: HIM Exercises for 6501……………... . . . . . . ... . . . . . . . . . . . .
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How to Use This Document
Use this procedure manual as a reference. The quick link is
http://www.css.edu/aehruserguides.xml It includes the information you’ll need most often. It
doesn’t include a lot of details that you’ll rarely use. For more information, please use the Help
menu that’s built into the software.
At key steps, this procedure manual includes pictures of what is actually seen on the computer
screen. It will make it easier to find the information that you need.
Finding the Information Needed
First, check the Table of Contents on the previous page. Turn to that page for more details. Read
through the steps. Then try it on the computer.
Help Menu
For more information on the system functions, click on the Help drop down menu at the top of the
screen. There are explanations of the icons on the toolbar, definitions of the items on the dropdown menus, general topics listed in the table of contents, and specific topics in the alphabetical
index.
Figure 1. The Help menu available in PowerChart
If the Help menu doesn’t answer your questions, please contact the Center Staff at any time during
weekday hours:
Center for Healthcare Innovation Contact Information
Nancy Sivertson [email protected] ph 218-723-6180
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The College of St. Scholastica
Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
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Toni Pearson [email protected] ph 218-625-4933
Joe Janchar [email protected] ph 218-625-4974
Getting Started - The Academic EHR System Confidentiality Statement
Instructions
Each user of the Academic EHR is required to read and agree to a confidentiality agreement
protecting the patient information in the system and the screen/program content of the system.
You will receive your password to the system upon completion of the confidentiality agreement.
To complete your agreement to these terms, follow these steps:
 navigate to the following website: http://www.css.edu/aehruserguides.xml
 scroll down the screen, and click on Confidentiality Agreement
 review the agreement, then click on NEXT
 fill out all requested information
 click SUBMIT and exit from the website when finished with these steps.
This printed version is a courtesy copy of the agreement.
Access to and Use of Proprietary and Personal (Patient) Information As an
employee/contracted agent/student with access to technical and training information as well as
systems and software owned by Cerner Corporation and with access to personal (patient)
information within the electronic applications known as The Academic EHR System, you will have
access to what this agreement refers to as "Proprietary Confidential Information” and “Personal
(Patient) Confidential Information. The purpose of this agreement is to help you understand your
duty regarding this Proprietary and Personal (Patient) Confidential Information.
Proprietary Confidential Information: Proprietary Confidential Information includes application
access and information. You may learn of or have access to some or all of this Proprietary
Confidential Information through a computer system or through your academic activities.
Proprietary Confidential information is valuable and sensitive and is protected by law and by strict
Cerner Corporation policies, as reflected in the College’s contract with Cerner Corporation. The
intent of these laws and policies is to assure that Proprietary Confidential Information will remain
confidential - that is, that it will be used only as necessary for academic purposes. As an
employee/contracted agent/student, you are required to conduct yourself in strict conformance to
applicable laws and Cerner Corporation policies governing Proprietary Confidential Information.
Personal (Patient) Confidential Information: Personal (Patient) Confidential Information
includes patient identifiable demographic, historical and clinical information. You may learn of or
have access to some or all of this Personal (Patient) Confidential Information through a computer
system or through your academic activities. The intent of these rules and policies is to assure that
Personal (Patient) Confidential Information will remain confidential - that is, that it will be used only
as necessary for legitimate academic purposes. As an employee/contracted agent/student, you are
required to conduct yourself in strict conformance to applicable laws and Academic EHR System
policies governing Personal (Patient) Confidential Information.
___________________________________________________________________________________
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Updated 09/09/2014 NS
Copyright © 2014
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The Center for Healthcare Innovation.
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Your principal obligations in these two areas are explained below. You are required to read and to
abide by these duties. The violation of any of these duties will subject you to discipline, which
might include, but is not limited to, legal liability. Accordingly, as a condition of and in consideration
of your access to The Academic EHR System, you promise that: You will use Proprietary and
Personal (Patient) Confidential Information only as needed to perform your legitimate duties as an
employee/contracted agent/student receiving information from The Academic EHR System and
about Cerner Corporation. This means, among other things, that:
A. You will only access Proprietary and Personal (Patient) Confidential Information for which you
have a need to know in the context of your official role as an employee, contracted agent or
student; you will not access the Personal (Patient) Confidential Information unless it is specifically
assigned to you or created by you for a legitimate academic purpose.
B. You will not in any way disclose, use, copy, distribute, sell, license, publish, reproduce or
otherwise make available Proprietary Confidential Information except as properly authorized by
Cerner Corporation.
C. You will not misuse Proprietary or Personal (Patient) Confidential Information or carelessly
handle such information so as to risk its release to any unauthorized individual.
D. You will safeguard and will not disclose your access code or any other authorization you have
that allows you to access Proprietary and Personal (Patient) Confidential Information.
E. You accept responsibility for all activities undertaken using your access code and other
authorization.
F. You will report activities by any individual or entity that you suspect may compromise the
confidentiality of Proprietary or Personal (Patient) Confidential Information. Reports made in good
faith about suspect activities will be held in confidence to the extent permitted by law, including the
name of the individual reporting the activities.
G. You understand that your obligations under this Agreement will continue after you conclude
your coursework and your academic program. You understand that your privileges hereunder are
subject to periodic review.
H. You understand that you have no right or ownership interest in any Proprietary or Personal
(Patient) Confidential Information referred to in this Agreement except as it is yours to access for
your personal legitimate academic purposes. Your access code, other authorization, or access to
these applications may be revoked at any time. At all times, you will safeguard and retain the
confidentiality of all Proprietary and Personal (Patient) Confidential Information.
I. You will be responsible for your misuse or wrongful disclosure of Proprietary and/or Personal
(Patient) Confidential Information and for your failure to safeguard your access code or other
authorization access such information. You understand that your failure to comply with this
Agreement may also result in your loss of access privileges, disciplinary action, and/or other legal
liability.
__________________________________
Employee/Contracted Agent/Student Signature
__________________________
Date
___________________________________________________________________________________
The College of St. Scholastica
Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
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Procedures – The Academic EHR System
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_________________________________________________________________ Printed Name
Installing Dell vWorkspace on a Windows workstation or Windows Laptop
To install vWorkspace on a MAC or an Ipad or an Android tablet, go to this site for
instructions: http://www.css.edu/aehruserguides.xml
The Academic EHR is accessible via the internet. If you have not installed vWorkspace before on
your PC, you will need to install this software in order to access the EHR. . This will already be installed
on your school PCs. You will need to do this for your personal PC only. .
Navigate to https://cernaesq.cernerworks.com in either IE or FireFox.
The following screen will appear.
Click on the Downloads tab to see the different download links based on the type of device you have.
The next screen should look like this. Click on the vWorkspace Connector for Windows to begin installing
Quest. There are links listed for other types devices as well.
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The College of St. Scholastica
Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
The Center for Healthcare Innovation.
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If you are installing via Firefox see additional steps below. Skip to Step 1 if installing in
IE.
Save File to the downloads folder.
You will see the following file in your downloads. Click to install.
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Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
The Center for Healthcare Innovation.
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Follow the remaining steps to install.
1. Click Run when this screen displays.
2. The installation will begin.
3. Click Run on the next prompt to run the software.
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Updated 09/09/2014 NS
Copyright © 2014
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4. Click Next when this screen appears.
5. Accept the terms and click Next
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Updated 09/09/2014 NS
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6. Click Next when this screen displays – IGNORE the fields for User Name: and Organization:
7. Click Next when this screen appears.
8. Click Next when this screen displays -- don’t worry about the Credentials pass-through entry
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Updated 09/09/2014 NS
Copyright © 2014
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9. Click Next when this screen displays.. . don’t worry about the check boxes
10. Click Install to begin the install.
11. The installation should begin and a window showing status will display.
___________________________________________________________________________________
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Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
The Center for Healthcare Innovation.
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12. When the installation has successfully completed, the following screen will appear.
Click Finish.
13. You will be prompted to restart your computer after the installation. Close all open items before
entering Yes or select No to restart later. (Note: You will not be able to log in to the EHR until you have
restarted your PC.)
To change your password please, make sure you are not logged in. Log out if you are.
1. Navigate to the vWorkspace page, and click the link at the top right of the webpage where it says change password.
___________________________________________________________________________________
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Updated 09/09/2014 NS
Copyright © 2014
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The Center for Healthcare Innovation.
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https://cernaesq.cernerworks.com/Cernaes
If you don’t remember your password, click on Forgot Password for instructions.
2. The next screen is to Change your Password - as you fill out this screen, the CERNAES choice field should be grayed
out
3. In the username area fill in your school email address.
4. The Old Password should be: Q b pt z j2 9 ( O n l y f o r f ir s t tim e a c c e s s) or the last password used.
The new password must not include: your
Username or parts of the Username that exceed two consecutive
characters
The new password must include:
1. A minimum of 8 characters long
2. At least 3 of the 4 items below
a.
b.
c.
d.
One UPPERCASE letter
One lowercase letter
One number
One special character
RECORD YOUR PASSWORD so you do not forget it. We suggest
you record your password in your cell phone for easy access.
Saving it in your phone will keep it readily available. Do not
share your password.
Help for a forgotten password is only available M-F, 7:00 am to
7:00 Central Time.
Make sure you receive a ‘Successful’ messge for changing your password. If you do not, please try again.
___________________________________________________________________________________
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Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
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If you have forgotten you password, please use the email or phone number below for
support.
The Cerner Support Team is available from 7:00 AM to 7:00 PM Central Time, Monday through Friday.
a. [email protected]
b. 816-888-2362
Please provide your username, school, a screenshot of the error message and a way to contact you if
we do not speak to you directly. This will expedite support.
If you leave a message after hours or on the weekend, your request will be answered during the next
available service period. If contacted during service hours, your request will be addressed either
immediately if we speak to you on the phone or within 4 hours for email or voicemail.
Common reasons for not being able to log in:
1. Not getting a “Password Successfully Message” and thinking that you did. The password has
specific rules that need to be followed,
2. Not writing down your new password and forgetting it.
3. Not logging out before trying to change your password.
Logging in to the EHR.
*PLEASE NOTE* This application works best with a high-speed internet connection.
1. Navigate to https://cernaesq.cernerworks.com in IE, Firefox or Google Chrome
(Do NOT click on the vWorkspace icon)
2. Enter Either:
Your school email address
Or
Your Previous Personal Username
(previous users with existing logons)
for the username
Your instructor will have an accurate list of the usernames for each, contact them for details.
___________________________________________________________________________________
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Updated 09/09/2014 NS
Copyright © 2014
Center for Healthcare Innovation, The College of St. Scholastica.
The Center for Healthcare Innovation.
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And Qbptzj29 for the password for testing the installation (or other value as instructed) *
3. Click on the PowerChart icon to launch the EHR
4. Powerchart will start - - You are now logged in to the EHR.
*all users need to reset their password We don’t have access to passwords so we can’t set up the accounts
with existing users passwords. All new accounts will use Qbptzj29 for the default password.
Chapter 2: Patient Search
Search for a Patient and Open the Chart
1. At the top of the PowerChart screen, Click on the Spyglass icon on the right or the
drop down patient menu (use the search option), to open the Person Search window.
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Updated 09/09/2014 NS
Copyright © 2014
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2. Type “Demo” in the Last Name field, and click on Search to call up a list including
Demo, Fiftyone. You do not need to enter a full name, and a partial name entry will be
helpful when you are unsure of the spelling.
3. Select the entry named Demo, Fiftyone in the list of patients on the right. Click on it.
4. Select an episode of care on the lower half of the window. You may have more than
one choice if the patient was seen more than one time. Click OK.
5.
When opening a
patient’s chart for the
first time, you are
usually asked to select
a relationship with the
patient. Highlight the
option that fits your role,
click OK.
6. Patient chart home screen view: The default view is the Chart Summary View showing
a quick view of what is in the chart. The next chapter will go through the Navigation
menu at the left of this screen.
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Updated 09/09/2014 NS
Copyright © 2014
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Chapter 2 - Practice Exercise:
Objective: To become comfortable with opening a patient’s chart.
Close out all patients by selecting the “x” next to their name above the demographic bar.
Select the Patient option located at the top of the chart and select “search”
Input pristine in the name field and select “search.” Select Pristine, Twentysix.
Find three demographic details under the “patient Info” section ___________,
________________&_______________.
5. Find two diagnoses under “Procedures and Diagnoses” tab in the left menu.
_____________,_____________________.
1.
2.
3.
4.
Close out all patients by selecting the “x” next to their name above the demographic bar.
Select the “Patient” option located at the top of the chart and select “search”
Input Pristine in the name field and select “search.” Select Pristine, Fortysix.
List three belongings listed under the “form browser” section, then sort by ”form”
(Valuables/belongings) ___________, ________________&_______________.
5. Find two categories of intake and output under the “Results Review” tab in the left
menu. Select Intake and Output on the flow sheet toward the top of the page. You may
need to change the date bar to the clinical date range by right clicking in the date line and
changing the date rage to the admission date.__________, __________.
1
2
3
4
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Updated 09/09/2014 NS
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Chapter 3. The Navigation Menu and Chart Tour
Chart Summary
The Chart opens up to the Chart Summary. This screen combines several views to give the user a
quick summary of the patient’s chart. Multiple charts can be opened at once; the names will appear
next to one another on the name bar, each in a different color. To open an additional chart, click
the Spyglass icon again and search for another patient. The new chart will open as the first one did
when the search is completed. To switch from one chart to the other, simply click on the other
name.
The Menu bar stretches down the left hand side of the screen, and offers the user access to
various applications to view and enter data into the patient chart. Click on any entry to open a
different view of the patient’s data.
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Procedures & Diagnoses
A listing of procedures undergone, and diagnoses for this patient. Once opened the blue +
allows the user to add new entries. Right clicking on a selected procedure or diagnosis will
provide options of actions to take. Double clicking the blue i symbol to the left of a diagnosis or
procedure indicates that a Medline search is available.
Allergies
Click on Allergies. A healthcare provider can view and/or add in allergies while interviewing
the patient by clicking the blue +. The check marks next to the allergies indicate a drug
interaction has been checked using a data base. This screen allows you to store favorite or
frequent allergies, and search through common allergies. Reactions and allergy detail are also
put into the record on this screen. Allergy status can be reviewed and updated on each new
encounter by right clicking on an existing allergy.
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Updated 09/09/2014 NS
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Medication Administration Record (MAR)
The MAR is used to chart into the record directly after administration of the medication. Details
of the medication can also be viewed. By right clicking on a medication you are able to view
the possible actions you would like to perform.
Once the medication is administered, the dose admin window will disappear, and the
administration info will show in the light blue bar under the date.
You have the options to view categories of medications from this screen. Medications that are
Grayed are no longer active – they may have been stopped or discontinued.
Note: The default date range when the MAR opens is limited to Today. For historical case
studies, you will need to change the blue timeframe bar located in the middle of the screen.
Right click, select Change Search Criteria and type in the timeframe desired (usually from
admit to discharge date).
Medication List
This view lists the medications that the patient is on currently as well as those in the past, and
allows medication reconciliation upon admission, transfer or discharge.
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Result Review
This view has three sub-tabs with are displayed in a flow sheet format: Key Results, Vital View
and Lab; also a timeframe bar to limit the display to a specific period of time, such as the clinical
range. You can graph results to see trends by selecting specific result fields, see. You can
change the view of the results to group or list and see the results in a different format.
You can scroll horizontally across the timeframe of the visit, OR
You can scroll vertically through the list of resulted items.
You can graph numeric results by checking their rows and then clicking the graph icon.
Reports
This screen shows written or scanned documents that have been attached to or typed into the
patient’s record. Reports can be viewed, or modified. Folders of the forms will be shown and
clicking on them until a pink icon appears will allow you to access the form directly.
You can
rearrange the display by using the radio buttons below the folder list to help sort and find the form
by category.
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Power Note
The PowerNote screen provides an alternate view of all chart documents, and also is the place to
go to add a new PowerNote to the chart using the Blue + Add function.
+Add opens a new screen, where the user can select the type of note, the date, and enter a title;
Preformatted Notes can be selected by clicking the Catalog tab, then selecting a catalog below.
Then a specific Note from the list below the catalog name.
Once a note template is opened, the user clicks their choices and the formatted note is created
automatically. Use the Sign/Submit choice to complete the note and publish to the chart.
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Updated 09/09/2014 NS
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Using the ‘DISPLAY’ choices at the top of the document list will allow filtering of which documents
you see. This allows the viewer to eliminate documents that are “In Error” from the display.
Clicking on any document in the list will cause it to display in the right hand window.
Users can move through the documents one by one by clicking the Previous/Next buttons.
Orders
This screen opens to a listing of all patient orders for this encounter and allows addition of new
orders by using the blue +. Right clicking on any order will open a menu & allow you to select
the action you would like to take. Orders in the chart and those for signature are listed In bold to
the left of the screen. The orders will populate to the MAR and the Task list automatically.
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Form Browser
This view shows all the forms completed on the patient. Double click on a line to view the form. To
select another action you wish to perform, right click on the form. This screen allows you to filter
the forms into categories to help find the form you want to view. To add forms, go to the Adhoc
icon on the toolbar, or use the drop down list under Chart and select Adhoc charting. Ask the
Center for Healthcare Innovation staff for a list of the available forms in the AEHR.
Patient Info
This screen displays demographics, visit list, patient/provider relationship summary. You are able
to view all people who have worked or viewed the chart from the PPR tab. This view can be used
for a module on data privacy along with other similar topics In your curricula. Tabs include Patient
Demographics, Visit List and PPR Summary.
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Advanced Growth Chart
This view shows the growth chart of the patient and allows data to be directly input into the graph.
Various views can be selected from the menu running down the left side
Immunization Schedule
This tab displays the patient’s immunizations, and allows users to enter new immunizations into
the chart. Select the Adhoc button to input new immunizations. Click on Add to Selections to
begin an entry. Yellow fields will appear to show the required fields for input before you can sign
the form. Click the Chart button to save the data entered for a new immunization.
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Reference Text Browser
This screen is used to browse to reference text on drugs, orders education. Use the tabs to
determine which search to perform, Enter the item to be referenced into the search box under the
tabs,
then click the SEARCH button.
Problems & Diagnoses
This screen shows a listing of problems and diagnosis on the patient. A blue
new problems or diagnosis.
+ allows you to add
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Chapter 3 - Practice Exercise: AEHR Scavenger Hunt
Objective: This scavenger hunt is intended to assist participants in navigating the pristine cases in
the EHR, links and website.
Outcome: Participants will negotiate website and describe features to enhance learning in an
electronic medical record.
Since you are already logged in:
1. Find Pristine, Twentyfive and open the outpatient encounter. Find vital signs for
May 6, 2005 at 1:22 pm. Scroll over to the date to find the values. PPR______
RR________B/P___________________ (Right click on the abnormal values (red) to view
norms.)
Hint: When searching for pristine cases, >patient>search> type in pristine and click
search to get the list of pristine cases. Select the case, then the encounter from the
bottom half of the screen. There are over 40 cases in this system.
2. While still in Pristine Twentyfive’s chart, record the patient’s age________, date of
birth________, allergies_________ and visit type_______________________.
Please observe the various tabs under menu for the following:
3. Now find the patient’s religion by going to the patient info tab and clicking on
demographics.______________________________.
4. The patient has two medications listed on the MAR (meds are discontinued as this
is a historical case.) What are they? ___________________. Remember to right click on
the dateline and change the date to the admission date.
5. Now click on the Reference Browser tab and look up fentanyl in the drug
reference. What is the medication used for in this case? _____________. Find one
side effect_______________________________________.
6. What is the patient’s diagnosis? ________________________________. To find out more,
click on the Chart Summary tab under Menu > find the Navigation Menu >Scroll
down and select Pathology Reports and then double click on pathology reports.
(You will need to scroll through the dates to find the report dated 5/7/05 at 14:05
pm.) Can you find staging? ________________.
7. Now think about what would be your priority nursing care for this patient and
write it here______________________________________________________.
8. Under links on the task bar, go to the “Help Place” under Point of Care Reference
Resources. (Note the various links to medical information available to you) Click
on Consumer Health Information Resources. Do a MedlinePlus search for the
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patient’s diagnosis and list two risk factors for this condition.
________________________________________,&________________________________________
9. Close Pristine Twentyfive and search for Pristine Fiftythree. Under Results
Review, look up this patient’s lab values for 1/7/07 at 7:02 am. (You will have to
scroll over to the date and time.) Place your cursor over each value and right click
>view details and note the common ranges. How abnormal are these values?
_____________________.
10 Return to the “Help Place” and go to Lab Test Reference Information. Search for
WBC and pick an article from the list. Click on “what does the test result mean?”
Now explain what you think is the patient’s
diagnosis._________________________________________________________.
12. Go to the Reports tab and drill through History and Physical to get to the report
and view the patient’s H & P and see if you were right. Y______ N______
13. Now search for the other abnormal values (red color) under Results Review and
Key Results flowsheet and describe what you might teach the patient about them.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________.
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Chapter 4. Registering or Creating a New Patient
In Chapters 2 & 3 you learned how to find a patient and look up key pieces of information in his or
her chart. In the remaining chapters you will learn how to create patients and manipulate data
stored in the Academic Electronic Health Record (AEHR). The AEHR is a Cerner product and is
the same Electronic Health Record software used in many Hospitals and Clinics around the
country. This means HIPAA software standards such as audit tracking and the inability to
permanently delete entries or records are found in the AEHR. Please be respectful when making
entries and treat the patient information as you would a “real” patient in a Hospital or Clinical
setting. In addition please do not access or alter a patint that has not been assigned to you or that
you did not create.
Registering a New Patient
HIM Users see Appendix D for instructions on Creating/Registering a
Patient
When creating your first patient in the EHR we suggest that you register yourself as a
play patient or have students register themselves (use their own names) for an
assignment.
1.
To Register a new patient, make sure all other patients’ charts are closed and that
you are on the Organizer View of the application. You’ll see something similar to
this: Note: no names appear.
2.
Select Patient from the drop down menu at the top of the screen and click on Patient
Management Conversations > Add/Modify Encounter.
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3.
The Person Search window will open
on your screen. Type the patient’s
name (Lastname, Firstname) that you
would like to add into the Name field
and click Enter on your keyboard.
4.
After you click Enter on your keyboard
and the system searches for your
patient’s name, the Add Person button
will light up on the bottom of the screen.
PowerChart
Click on the Add Person button.
4.
On the bottom half of the screen under
the Facility Name tab. Type a * into the
search field and click Enter on your
keyboard. This will give you a list of all
Facility options available to you.
Choose your school’s Medical Center
by double clicking on it.
5. The AES Common registration
window will open. If this is your
first time using this screen right
click anywhere on the screen and
select Highlight Required
Fields.
All required fields will now have a
yellow background. These fields
must be satisfied in order to
register your patient.
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6.
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The Name fields, MRN, Financial # and Facility fields will automatically populate.
The remaining required data fields can be filled out as you deem appropriate. The
drop down boxes will give you options to choose from. Do not enter personal
demographic data into the AEHR, such as your own birth date or SSN. See the
table below for more information on the different fields.
Registration Fields
Registration Date
(Required)
Current date: Enter a T to populate today’s date.
Historic date: You can enter a past date into this field.
Future date: You are able to enter a future date but will not
be able to see any information entered on that encounter
until that date and time. Any information entered on a
future encounter will not be viewable until that date.
Registration Time
(Required)
Enter N for now or type in a specific time of your choosing
Future time: Any information entered on a future
encounter will not be viewable until that date/time.
Enter birthdates as mm/dd/yyyy. Once the birthdate is
entered the age field will automatically populate.
If you would like your patient to be a certain age for
example 56; simply type the age into the age field and the
birthdate will automatically populate.
This is a required field where you designate the encounter
status. The status refers to the encounter being; active,
cancelled, discharged, transferred, etc.
This is a required field where you designate the encounter
type. Here you can choose if the encounter is inpatient,
outpatient or emergency, as well as other options. This
choice will affect the entry of orders and other data.
In the medical setting the building would correspond to a
specific hospital or clinic location. In the Academic EHR the
building typically corresponds to your discipline such as
nursing, HIM or Physical Therapy. Populating this field can
help you organize your students working in the AEHR
through the use of patient lists. (see chapter five for more
information on patient lists)
In the medical setting this would correspond to a specific
nursing unit or department in the Academic EHR this field
typically corresponds to your class list. Populating this field
can help you organize your students working in the AEHR
through the use of patient lists. (See chapter five for more
information on patient lists.)
Birth Date
Age
Encounter Status
(Required)
Encounter Type
(Required)
Building
Nurse\ Ambulatory
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7.
Once you have entered all of your patient’s information click OK.
8.
When you open a patient’s chart for the first time,
a patient relationship query box will open.
Highlight the most applicable option and click OK
and the patient’s Chart will open.
Opening the same chart on subsequent logons
Will not open this box again.
Modifying your Patient’s Registration
You may wish to make changes to a patients registration. Maybe an incorrect date was
entered or you would like to change the encounter type or status. You can easily do
this right from the patients chart.
1.
While you are in your patients chart, from the
toolbar select Patient > Patient Management
Conversations > Add/Modify encounter.
Or if you are an HIM student, reopen
PMLaunch > HIM Registration and use the
search box to find your patient.
2.
Once the AES Common Registration window opens you can make your
desired changes. Click OK to save your changes.
Adding a New Encounter
You may wish to give your patient more than one encounter. Maybe the patient you are
creating was seen at the clinic or in the emergency room before they were admitted to the
hospital. You can depict this scenario in the Academic EHR by entering multiple encounters.
1.
2.
3.
Make sure all patients charts are closed
and go to Patient > Patient Management
Conversations > Add Modify
Encounter, or if you are an HIM student,
open PMLaunch > HIM Registration.
In the Person Search window type your
patients name (last, first)
When your patient appears highlight and
click the Add Encounter button.
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In the Registration screen, many of the fields will default to previous values, and the user can add
the info for the new encounter, and then click OK.
Back on the Chart Summary screen, you will know that you are in the new encounter by checking
the Demographics bar data.
Chapter 4 - Practice Exercise:
Objective: To create a new patient in the AEHR and to modify that patient’s registration.
Registering your patient
1. Make sure that all patients’ charts are closed. No names visible on the screen.
2. Think of a name for your patient and write it here:________________
3. Select Patient from the drop down menu at the top of the screen and click on Patient
Management Conversations > Add/Modify Encounter.
4. When the Patient Search window opens on your screen. Type in your patient’s name (Last,
First) and click enter on your keyboard.
5. Click on the Add Patient button.
6. The organization window will open, under the Facility Name tab search for your school’s
Medical Center Name.
7. Write your school’s Medical Center Name here: __________________
8. The Common Registration window will open.
Note: If required fields are not highlighted right click anywhere on the form and check the
Highlight Required Fields option.
9. Select Active under the Encounter Status field.
10. Select Outpatient under the Encounter Type field.
11. Type a T in the Registration Date Field.
12. Type an N in the Registration Time Field.
13. Click OK to complete registration.
14. Click yes to open up your patient’s chart.
Modifying your patient’s Encounter
1. While your patient’s chart is open go to Patient > Patient Management Conversations >
Add/Modify Encounter.
2. Under the Building field select one of the options for your school. Write your selection here:
________________
3. Under the Nurse\ Ambulatory field select one of the available options. Write your selection
here: __________________. Faculty may ask you to use a specific location for this entry.
We will use your Patient’s Name, Medical Center or Facility Name, Building and Nurse\ Ambulatory
options for the exercise in the next Chapter. (Chapter 5 – Patient Lists.)
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Chapter 5 – Patient Lists
In a hospital, patient lists are used to help healthcare providers organize the patients that they will
be caring for. In the Academic EHR patient lists can be used to help faculty organize the “patients”
they or their students are using in their curriculum. You have a few options available to you when
deciding how patient lists might work best for you
Location List
A location list is a great tool to use when you have a class where each student is registering
and working with their own patient. When a patient is registered into Cerner they can be
registered to a specific Nursing Unit or Department. In the Academic EHR we can create a
department that has your course name or number associated with it. Once a location list is
created at the department (or course) level all patients registered under that course will
automatically show up on your list allowing you quick access to review your student’s
assignments.
Custom List
A custom list is your best option if you are working with a random grouping of patients.
Maybe you are routinely working with a few pristine patients in addition to cases that you’ve
created. A custom list allows you to manually add or remove patients from your list.
Creating a Location Patient List
1. The Patient list activity is the first screen you
see when you logon. Click the wrench icon
on your patient list toolbar (top left of the tan
area) to access the Modify Patient Lists
wizard.
2. When the Modify Patient List screen opens
click on the New button.
3. On the Patient List Type window highlight
Location and click Next.
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4. In the Location Patient List window click
the plus sign next to your facility or
Medical Center and drill down until you
find the department or class name where
you would like to track your student’s
patients.
on
5. Highlight your class name and click
Finish.
Note: If you would like to track your student’s patients and your class number is not
listed as an option, contact the CHI staff to add it.
Advanced Options:
You can apply additional filters to your patient list if you select the
Next button in the previous step (step 5) instead of Finish. An
example of a filter that you may wish to use is to select a status of
Not discharged. If you have your students discharge their patients at
the end of each class, when a new class starts you will only see the
patients that your current students are using during that class period.
6. On the Modify Patient List window move
your newly created list from Available
Lists to Active Lists by highlighting the
name, clicking on the appropriate arrow
icon and click OK.
7. If any patients are registered under the
class you selected in step 4 you will see
them on your home screen.
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Creating a Custom Patient List
8. The Patient list activity is the first screen
you see when you logon. Click the
wrench icon on your patient list toolbar
(top left of the tan area) to access the
Modify Patient Lists wizard.
9. When the Modify Patient List screen opens click on the New button.
10. In the Patient List Type Window click on
Custom and click Next.
11. In the Custom Patient List Window enter
a name for your list and click the Finish
button.
12. On the Modify Patient List window
move your newly created list from
Available Lists to Active Lists by
highlighting the name, clicking on the
appropriate arrow icon, and clicking
OK.
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13. To add patient to a custom list click on the Add Patient Icon on the patient
list toolbar.
14. The Patient Search window will open, enter the patient’s name that you
would like to add and click enter on your keyboard. When your Patient’s
name appears highlight and click the OK button. The patient will display on
your list.
15. To remove a patient from a custom list click on the Remove Patient Icon on
the patient list toolbar.
Note: If a patient has been selected on a patient list (highlighted yellow) it is like having a patient’s
chart open. You can go to the Patient drop down menu and under Patient Management
Conversations Add/ Modify, Discharge or Transfer a patient’s encounter while the patient is
highlighted. If you would like to create a new patient you will need to clear any patients currently
highlighted on your patient list before doing so.
This can be done under the Patient List dropdown menu by selecting clear all patients or by
selecting the clear all selections icon on the patient list toolbar.
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Chapter 5 - Practice Exercise:
Objective: To practice creating a system list and a custom list.
Getting Started:
Patient Name from Ch. 4 Exercise: _______________
You’re Schools Medical Center Name: _________________
Building used to register your Ch.4 patient: ______________
Nursing Station/Ambulatory department used: _____________
Create a Location List
1. Make sure that you are on the patient list view (home screen view).
2. Select the Wrench icon on the Patient List toolbar.
3. On the Modify Patient Lists window select the New button.
4. On the Patient List Type window select location.
5. On the Location Patient List window find your schools Medical Center and drill down to
find the Building and Nursing Station (class) that your patient was registered to in Chapter 4.
Highlight and click Finish.
6. Move your list from Available lists to Active list and click OK.
7. What happened to your patient list screen? ____________________
8. Aside from create the list did you do anything to add your patient to your list?
Create a Custom List
1. Follow steps 1-3 above.
2. On the Patient List Type window select custom and click Next.
3. Name your patient list and click Finish.
4. Did your patient automatically populate this list?
5. Use the Add Patient icon to add your neighbor’s patient to the custom list.
6. Use the Remove Patient icon to remove your neighbor’s patient from your list
Chapter 6 - Procedures and Diagnoses/Problems and Diagnoses
The Procedures and Diagnoses activity tab is where you enter and view the patient’s diagnosis
or problems being addressed during the current stay and any applicable procedures. This section
includes a tool to help students and faculty research their patient’s diagnosis further by launching a
pub med search directly from this activity.
The Problems and Diagnoses activity tab is where you can enter and view the patient’s problems
being addressed during this visit as well as all chronic problems that have been documented for
this patient.
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Adding a Diagnosis for this visit
1. Click on the Procedures and
Diagnoses or Problems and
Diagnoses activity tab on
the menu. From the section
titled Diagnosis (Problem)
being Addressed this Visit
click the Add icon.
2. You will see three yellow required fields that must
be filled out. Diagnosis, Type and Confirmation.
3. In the Diagnosis field type in your patients diagnosis and click enter on your
keyboard. Keep in mind this field is searching a database so typing less can result in
a better search then typing in a full diagnosis.
4. After you click enter on your keyboard the Diagnosis
Search window displays.
Highlight the best option for your patient and click OK.
5. All yellow *required fields must be filled out to file your diagnosis. Once the required
fields are filled out you can click OK to file.
*Type
*Confirmation
Automatically populates. Click on the dropdown box to change the
type of diagnosis (working, discharge, reason for visit, etc.)
Must be filled out to file diagnosis. Click on the dropdown box to
select an option for Confirmation.
The following fields can be updated to provide more detail on your patient’s diagnosis.
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They are not required to file your diagnosis.
Responsible
Provider
Display As
Clinical Service
Classification
Ranking
Comments
The provider who has responsibility for that portion of the
patients care.
You can change the way the diagnosis displays. This is done if
the selected diagnosis is not as clear as you would like it to be.
This indicates the Department or Discipline where the diagnosis
is being treated for instance; a diagnosis of Diabetes may be
treated in endocrinology.
Indicates if the Diagnosis is Medical, Nursing or Patient
Reported.
Is the diagnosis primary, secondary or tertiary?
A place to add any comments related to the patients diagnosis.
Entering Procedures
1. From the Menu click on the Procedures and Diagnoses activity tab. In the bottom half
of the Procedures and Diagnoses screen you will see the Procedures section.
Click the blue Add icon to add a procedure to your patients chart.
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2.
PowerChart
The Procedures and Diagnoses screen opens.
You will see one yellow required field, the
Procedure field.
Type the procedure you would like to document
into this field and click Enter on the keyboard.
When searching a database typing in portion of
the procedure can yield better search results than
typing in the full procedure name. (For example,
type Append instead of Appendectomy for
ruptured appendix).
3.
The Procedure Search window displays a list of options.
Highlight the appropriate option and click OK.
1.
2. 4
.
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The following fields can be updated to provide more detail on your patient’s procedure:
Provider
Display As
Date
Clinical
Service
Comments
Indicates the person who performed the Procedure
The procedure name automatically defaults in this field.
You can edit the procedure name to precisely match
what was performed on the patient.
The date the procedure was performed. Click on the
blue Date hyperlink to select an option of week of, month
of or year if the exact date is not known when doing a
historic entry.
Which clinical service performed the procedure? For
example an appendectomy may have been performed by
general surgery.
Any comments related to the documented procedure.
Adding a Chronic Condition or Problem
The Problems and Diagnosis menu tab contains the Diagnosis (Problem) being
Addressed this Visit section that was addressed earlier in this chapter. It also contains a
section for Problems or the patient’s problem list. This Problems section lists all of the
patient’s lifetime health issues and may contain chronic conditions such as Diabetes,
Asthma or Pregnancy. These are ongoing issues that should be noted on the patient’s chart
until they are resolved.
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1. To add a new problem, click the blue plus sign or Add button in the problems section.
2. Type the Problem that you would
like to document into the search
field and click Enter on the
keyboard. Remember: when
searching a database, typing just
a portion of the problem you are
searching for can yield better
search results than typing in the
full name.
3. On the problem search window highlight the problem
that you would like to add and click OK.
Once your problem field is populated on the Problem screen you can either click OK to add
the problem to the patient’s chart or add additional details in the following fields. The more
detail you give on a patient, the more complete his or her medical picture will be.
Responsible
Provider
Display As
At Age
Indicates the provider working with the patient on that particular
issue.
The problem you selected automatically defaults in this field.
You can edit the problem name to precisely match the patient’s
issue
This indicates the age of the patient when the problem was first
diagnosis. The blue After hyperlink gives you option when you
need to indicate that the age is an approximation.
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Onset Year
Confirmed
Classification
Status
Comments
PowerChart
This field depicts the year in which the patient was diagnosed.
Click on the blue Month hyperlink for more or less specific data
entry. Note: The Onset year works with the At Age field so if
you fill out one you will not need to fill in the other
Indicates if this problem has been confirmed, is probable, etc.
Is this problem or diagnosis a medical, nursing or patient
reported?
Is this problem Active or has it been Resolved. If a status of
canceled is chosen a reason must be entered in the next field.
Any additional comments related to the documented problem
Chapter 6 - Practice Exercise
The practice exercise for chapter 6 (Procedures, Diagnosis and Problems) will be combined with
chapters 7 (Allergies) and 8 (Immunizations) and can be found at the end of Chapter 8.
Chapter 7 Allergies
The Allergies tab is a place to document your patient’s allergies and also an area where decision
support is built into Power Chart. When you add a drug allergy using the Multum vocabulary
PowerChart can check the patients allergies against the patients Medication list to see if any
contraindications exists.
When documenting an allergy on a patient you have the option to use the Search tab to conduct a
database search or go to the Catalog tab to find the most common Drug, Environmental and Food
Allergies.
Adding an Allergy on a Patient
1. To add a new allergy click on the blue plus sign or Add icon. You can do this right from the
Allergies menu tab or from the Allergies screen.
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Using the Search tab to document Allergies
2. On the Add Allergy/Adverse Effect screen the Search tab gives you the option to search for
the Substance and the Reaction Symptoms. You can also choose to search by Name or a
Code depending on your preference.
To begin, type the Allergy or Adverse effect you would like to document into the Search field
and click Enter on your keyboard.
A list of options will display.
3. Double click on the best option for your patient. The Substance field will populate with your
selection. Once the Substance field is populated your search criteria on the Search tab will
automatically change from Substance to Reaction.Select a reaction type in the Reaction type
field.
4. You can now type a reaction
symptom into the Search field. When
you double click on the best symptom
choice the Reaction Symptoms field
will populate.
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Using the Catalog tab to document Allergies
The Catalog tab enables you
to quickly search for the most
common Allergies and Allergy
Reactions. The catalog tab
includes folders for Common
Drug Allergies, Environmental
Allergies and Food Allergies.
1. Click the plus sign next to
the folders to see a list of
Allergens. Double click on
the allergen that you would
like to document for your
patient to populate the
Substance field.
2. Select a Reaction Type for your Allergen and click in the Reaction Symptoms
field. The Catalog tab will automatically update to display a folder containing
Common Allergy Reactions.
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3. Click on the plus sign next to the Common Allergy Reactions folder to see a list of
options. Double click on the appropriate selection for your patient to document the
Reaction symptoms.
4. The Allergy details section provides additional fields for detailed documentation
see the table below for details.
Status
Severity
Is the documented allergy active, proposed, resolved or
canceled. You will be prompted to fill in a reason when a
status of cancelled is selected.
Indicate severity level of the allergen
Info Source
Onset
From whom was this allergen reported?
The approximate age or year when this allergy was first
noted.
Comments
Any additional information related to the documented allergy
Chapter 7 - Practice Exercise
The practice exercise for chapter 7 (Allergies) will be combined with chapters 6 (Procedures
Diagnosis and Problems) and 8 (Immunizations) and can be found at the end of Chapter 8.
Chapter 8 - Immunizations
The Immunization Schedule is where you can document immunizations being given during this
encounter as well as historic immunizations for your patient. With pediatric patients you can view
the Childhood Immunization Schedule and see when the next immunizations are due for your
pediatric patient as well as what is overdue.
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Immunizations – Historic
1. When you click the Immunization Schedule tab on the bottom left you can see all of the
patients previously recorded immunizations. To chart a Historic Immunization click the
History button.
2. When the Immunization Details, Historical Entry window opens click the Add to
Selections Button.
3. A new window with a list of immunizations will open. You
can click on one or multiple immunizations to document on
your patient. Click Add to add these immunizations to your
patient’s history.
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4. In the Immunization Details screen, highlight one of your selections and document the
required fields Source of Historical Info and the Administration Date.
5. If you are documenting more than one Immunization highlight your next immunization and
repeat step 4 for all Immunizations listed.
6. Click Chart to add the historical Immunizations to your patient’s chart.
Immunizations – AdHoc Charting
1. From the Immunization tab on the
bottom right of the screen, click
the AdHoc charting button.
2. When the Immunization Details window opens click the Add to Selections button.
3. Highlight the Immunizations that you are administering from the
Add to List of Immunizations window and click Add. Just as with
historic Immunizations you can click multiple Immunizations on this
screen.
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4. On the Immunization
Details screen several
required fields (in
yellow) must be filled
out for each
Immunization
administration.
5. Once all required fields are populated click Chart to document giving your patient his/her
Immunization.
Childhood Immunization Schedule
The Childhood Immunization Schedule is a graphical representation of the recommended
Immunizations Schedule for children age five and under. If you hover over any of the
Immunization boxes on the schedule you will see recommendations for that particular
immunization.
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1. The bottom of the Childhood Immunization Schedule is similar to the Adult Immunization
view with some decision support built in for Future Immunizations.
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2. Immunization due dates are color coded to help clinicians define which vaccines are due or
past due during the present encounter.
Gray due dates
Due dates with a gray background are all future due dates. If you
attempt to register a future vaccine a warning message will prompt
you that “it is too early to safely administer. “ You will need to
override this warning to continue and administer the child’s vaccine.
Green due dates
Due dates with a green background indicate that the associated
vaccine is due and can be administered.
Red due dates
This vaccine is significantly overdue for the patient.
3. Double click on a green or red vaccine due date to administer. The selected Immunization
will pull into the Immunization Details window. Fill out all required fields and click Chart to
administer.
Practice Exercise
Objective: Incorporate Lessons learned in Chapters 5-8. To add pertinent information to your
patients chart.
Problems and Diagnosis
1. Search for the patient you created in Chapter 4.
2. Double click on the outpatient encounter for this patient.
3. The patient is presenting at the clinic today for a cough they have been having for the last 2
weeks. Document this reason for visit under problems and diagnoses.
4. This patient who is new to your clinic also mentions that they were diagnosed with asthma 5
years ago. Add this to the appropriate section of the Problems and diagnosis tab.
Allergies
1. Your patient has cat and pollen allergies. Both allergies make him/her have itchy watery eyes
and frequent sneezing. S/he also breaks out into hives around cats.
2. Search the catalog tab to document the pollen allergy. Pollen has affected him/her for 7 years
and symptoms seem to act up each year in April. S/he treats with an over the counter allergy
medicine but has never been formally diagnosed.
3. Use the search engine to find the cat allergy.
4. Your patient was diagnosed with her cat allergy 2 years ago.
Immunizations:
1. You patient does not remember when they had each of their childhood immunizations but they
stepped on a rusty nail last year in June and received a tetanus shot at that time. You
document this historically
2. The patient also wished to have his/her flu shot today. Your computer savvy physician ok’s the
request and places the order herself. You go to the immunization schedule and administer the
flu shot for your patient.
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Chapter 9. Orders
Placing an Order
1. Click on the listing Orders on the Navigator Menu on the left side of the screen. The
Orders screen will open. Click on the icon labeled “+Add” in the upper left of the Orders
window to open the Order Search window
2.
At the top of the Order Search window, type HIV in the field labeled Find. The system will
display a list of orders that begin with HIV.
3.
Select the appropriate order from the list. Click DONE at the bottom of the Order
Search window to close the order selection screen
4.
If a ‘page’ icon appears next to the name of the order indicates reference text is available,
when you right click on the entry and select Reference Text from the list a reference
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window will open. Read the reference text for additional details about the order and close
the reference text window.
5. The order detail screen allows you to enter details for the order you have selected, in this
case it is HIV. The details are first hidden in the bottom half of the Orders screen. Bring
up the bottom part of the screen by expanding the window (grab and hold the mid-line
and pull it up.) The bolded items required answers to complete this order. When you
click on each item, the options are displayed for your selection in the right hand pane of
the Details window. Different types of orders will have different details required IE: lab
orders vs medications. Note the BLUE X at the top of the Details pane. The BLUE X
will disappear when all required details have been completed. You will also see the
number of missing order details in the field under the orders
Order details should be filled out from the top down because they ask sequential
questions such as the dose, and then the frequency. Use theScroll bar on the right to
scroll through the detail entries..
6.
Click on the Sign button
located on the lower rt. corner of your screen. This will bring
you back to the Orders screen where the HIV order that you placed is displayed in the list
with a status of Processing. Click the refresh button and it will turn to Ordered status.
Add more orders if you would like by repeating steps 1-5 with a new item.
Decision Support: Failure to complete all required details will result in an error message
popping up on the screen – click as indicated to display the missing required details for
your order, complete them, and then again click Sign.
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Medication Orders
Medication orders are unique in several respects:
Inpatient and Outpatient medication orders have order types which can be selected in the
upper right corner of the Order Search screen:
For Inpatient Medication orders, the choices include Inpatient and Discharge
Meds as RX. Inpatient meds will populate to the MAR, while Discharge Meds
as Rx will not, but the Discharge meds will prompt for prescription routing.
For Outpatient Medication orders, the choices are Ambulatory(Meds as Rx) or
Ambulatory – In Office. Ambulatory – In Office meds will populate on the MAR,
while
Ambulatory (meds as Rx) will create a prescription and will include a routing detail.
Using Order Sets
6Some orders are grouped in “order sets” or “PowerPlans” which are a set of usual orders
. for specific problems and diagnosis, or admissions to a particular unit. Order sets have a
Yellow Icon next to the order when you call up an order.
You can select the order set on the orders search screen, click Done, and see all of the
constituent orders on the order screen, usually with order details already completed.
One start date and time for the entire set can be specified
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Notice that the order set includes orders of several different types. You can deselect any
tests that are not needed by removing the check mark to the left of the order. (Order sets
may contain several alternative medications of which the ordering physician should select
only one.) Click the “Initiate” icon to begin the order entry.
Finally, click the icon ‘Orders for Signature’ and then “Sign” to activate the orders.
Orders populating to the chart: Once orders are placed to you will notice the chart is
populated with the information you ordered, depending on what is ordered. Review the
following tabs: Reports, form browser, MAR, medication list.
Chapter 9 - Practice Exercise
Objective: To practice placing single orders and using order sets
1. Open your practice patient you registered earlier. See opening a patient to be refreshed on
the process.
2. Select the order tab from the menu, then select Thyroid panel, then select done at the
bottom of the screen.
3. Pull up the screen if the bottom half of the screen is hidden. You should be able to see the
Bolded details that need to be completed.
4. Select the Bolded areas one at a time and fill in the details on the order. Note the field at
the bottom of the screen that shows the number of missing detail. You can select this field if
you cannot see the details that are missing.
5. When you are done, sign the order. Click the “As of” field to refresh the screen.
6. Note that you can view the medication list from this screen and you are able to document in
the chart regarding the order.
7. Now follow the same steps using by entering an order set. Use the Order set for Admission
orders Abdominal Pain. In the “find” field on the order screen (you can type the beginning of
the first word (Adm) and then enter. Select the desired order, click Done.
8. On the order screen, fill out any details needed to complete the order.
9. Saving to favorites – Any orders or order sets that you frequently use can be added to
favorites by right clicking on the order (order search screen)and selecting ‘add to favorites’.
Access your favorites by clicking on the favorite’s icon on the order search screen.
10. Orders can be further manipulated: Right click on an order in the list, and a drop down box
will appear which allows you to perform many actions. You can VOID an order entered on
the wrong patient. You can RESCHEDULE administration times for a medication order.
You can select MODIFY to change order details. You can DISCONTINUE an order which is
no longer needed.
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Chapter 10. Medications
Medication Administration Record (MAR)
The MAR is the inpatient view of the medications ordered for the patient from the orders
tab.
1.
The clinical range on this view defaults to the current date. The cases in the AEHR are
historical, so the clinical date needs to be adjusted. Right click on the date line in light
blue above the medications.
Select change the date range, and then manually input
the clinical date in calendar. This will give you a view of the medications administered
while the patient is in the hospital.
2.
On the left of the medications listed, several filters can be selected to view a therapeutic
class view, or a time view. All can be left open, or you can filter to reduce the
information needed.
3.
By right clicking on the medication name, several action options are given, including
quick charting, which will allow you to administer the medication. You can view order
information, add an additional dose, and many other options.
4.
After administering the medication and refreshing the screen, the medication will
populate to the line below the medication indicating it has been administered.
The option is also available to add information about the patient and the effects of the
medication such as pain intensity and follow up.
6.
When more data needs to be input into the chart, then clicking on the medication to
bring up an administration form to fill out and sign by clicking the green check.
7.
The MAR, Medication List and Orders all allow you to move between the orders, and
the medications and documentation by diagnosis using the tabs under the blue plus.
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The Medication List
The medication List allows you to View the patient’s medications, to filter
by encounter, or by history, and to perform Medication Reconciliation
appropriate to different points in the patient visit. The HELP menu on the top of the
PowerChart screen offers detailed assistance for this
Chapter 11. Reports
The reports section in PowerChart serves as a home for text entries into the patient. You can find
reports that have been written on a patient or add new reports to a patients chart through the
Reports tab on the Menu. The reports tab encompasses a variety of options such as nursing
notes, physician notes or diagnostic test results such as radiology or EKG’s.
Viewing Case Reports
1. Click on Reports from the Navigator menu on the left side.
2. The Reports window will open with a list of reports on the left and a display window on the right
Click the folders on the left to open, continuing until the colored reports appear
click the
colored box to open the report in the display window
Reports can be sorted and re-sorted by criteria listed on the lower left
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Adding a New Report
1. Click on Reports from the Navigator menu on the left side.
2. Click on the new report icon at the top of the Reports window. The Add Document
window will open.
3. When the Add Document window opens, it will be blank. To document you should select
a report type by opening the Type drop down menu. You can add a subject to the
Subject field and free text your nursing care specifics into the body of the document just
as you would a word document, entering headings with Bold and Underline features.
4. To change the type of report to something such as Radiology click the dropdown arrow
and select the type of report you would like to write or key the name of the report type into
the field.
5. You will get a popup message regarding uncommitted changes. Click yes to change the
document type and associated text.
Note: If you have spent time writing a report and then wish to change the type. Click no to
change the document type but not change the document text
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6. If you click the stamper icon on the Add document toolbar you will see any templates
associated with your chosen type. For example if the report type is Pharmacy Plan of
Care the default template is the Pharmacy Plan of Care template. The template is a text
outline associated with this document.
7. To use an associated template highlight and click:
Insert to add to the location of your curser.
Append to Insert at the end of your document
Replace to replace all unsigned text.
8. When you have completed with your documentation you can click the Sign or Save
buttons. Saving Information: Click save if you have additional work to do on the report
and you aren’t ready for others to see your document.
Signing information: Click sign if you have fully completed your documentation and you are
ready to add to your patients chart and have others view. Your report can be modified
after this time but all changes will be tracked and visible.
*NOTE*: CLICK SIGN in order for your faculty to see your documentation.
9.
Once you click sign you will be prompted to enter your password. This is the same
password you use to login with.
10. Once the report is signed, the system will ask you if you would like to see your newly
created document. Yes will open the document. No will return you to the Chart Summary
screen.
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Creating a Historic Report
1. You can add a historical report to a patient by using the Date and Time field on the Add
Document screen too enter a historic date and time.
Copying an Image or Text into a Report
1. It is possible to copy text from another case or a word document and paste it into your
report. This can be extremely useful when creating multiple copies of the same case.
2. To copy and paste in the AEHR you will need to highlight the text or picture you would like
to copy and click the Ctrl key and the C key on your keyboard. (Similar to using Microsoft
keyboard shortcuts for cutting and pasting.
3. To paste your text or picture simply place your curser on the report screen in the location
where you would like to transfer your text and click the Cntrl and V keys on your keyboard.
Remember to cite the entry.
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Power Note
PowerNote is another application which allows the user to create a formatted text document
directly into the chart. Using PowerNote, you can complete an entire patient encounter,
including reviewing results, writing documentation, assigning a diagnosis, and initiating a care
plan (placing orders).
1. To access power note click PowerNote in the Menu list. It will open in View mode.
2. The LIST window will display all existing case documents. Click on a document to
highlight and display it. Filter felds above the list allow the user to narrow which
documents are shown :
A ”Next >>” button at the bottom allows sequential
scrolling through the list.
3. The + Add button at the top of the PowerNote screen will open the New Note tab,
allowing the entry of a new PowerNote:
4. Enter a Note Type (drop down list), a date and time, and aTitle for your new Note. Next,
search for the appropriate pathway for your patient. In this example we will select a well
child exam for a 3 year old. Highlight the desired pathway and click OK.
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5. In the power note screen you will see a panel to your left that has a list of categories with
a + sign in front of each. Click on the plus sign next to Visit Information to open up
additional options for the visit information category. Highlight Visit type to begin
documentation.
6. Notice the options that display in the top panel to your left. Simply highlight to check and
document the appropriate options under each section for your documentation. In this
example we will choos a Visit type of well child exam (select OTHER and enter Well
Child Exam) and document that the patient was accompanied by his mother who is also
his history source. We will skip Referral source and history limitations since it is not
applicable to this patient. The Chief Complaint is WCC.
By clicking the icons on the right side of the window, you can view the emerging report
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Tips for navigating through a PowerNote
6. You will see several options with a > behind the word. This indicates that the selection is
cascading or that there is a list of additional selections to be made. You can think of this as
a list within a list.
7. If you would like to document something under a category that is not on your list select the
Other option and you will be provided with a free text pop-up box.
8. If you make a mistake simply highlight your error, right click and select the Clear option.
9. If we click on the category for Health Status and Click on Allergies, then select include
Allergy profile we can include previously recorded allergens into our documentation or add
new allergies directly to the patients chart from PowerNote.
10. You can click the blue plus sign to add a new Allergen, (See Chapter on Allergies for
Review) or highlight the information you would like to add and click Include Selected to
add to the patients note. In addition to allergies Current Medications, Problem List,
Histories and Immunization Schedules, Physical Exam are just some of the activities
that interact with PowerNote to provide integration of charting and documentation tools.
11. Professional Services - - E&M Assistant: This feature at the bottom of the topics list in the
PowerForm can be used to estimate the level of care delivered to the patient during this
visit.
12. Sign the PowerNote by selecting the SIGN/SUBMIT button in the lower right corner if you
have completed the entire note. If you are interrupted, and wish to finish the note later,
use the SAVE button. NOTE: saving your work for later completion will leave it invisible to
other users -- you must SIGN/SUBMIT the note in order for others to view it.
.
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Chapter 11. Exercise
Creating a new report
1. Close any Pristine patients you may have open. Search for and open your personal patient.
Select Reports under the Navigator menu list along the left side. The Reports window will
open.
2. Click on the New Report icon at the upper left corner of the Reports window.
The new
report window opens.
3. In the New Report window, you will see a drop-box labeled Type in the upper left corner.
Open the list by clicking the down-arrow. Choose a Type of document from the alphabetical list
(e.g. History and Physical Inpatient). Notice that your name (as author) and the current date
and time have defaulted in other fields at the top of the screen.
4. You can add an entry on the subject line also i.e. “Student H&P Exercise”.
5. Next, we will select a template for our text report. Look at the row of icons at the top of the
open white text window. Click on the stamper icon (15th icon from the left) . A new window
will open for Template selection.
6. In the bottom pane of the Template selection box, under “All Existing Templates”, scroll through
the alphabetical list and double click on “History and Physical Adult”.
7. The Title and the Section headings that comprise the Template will now appear in the new
report window.
8. Fill in the sections as desired. Click into the window on the line below a section heading and
type a free text entry.
Click the Sign button located in the lower right hand corner of the screen. The system will have
you ‘sign’ it by typing in your password (the same password as you have to sign into The Academic
EHR System). Sign the Note by selecting the green check in the upper left corner if you have
completed the entire note. If you document on specific parts of the note you can sign the
PowerNote by selecting the icon of the paper with the green check to the left of the green check.
*NOTE*: CLICK SIGN in order for your faculty to see your documentation.
9. The system will prompt you- if you would like to view the newly created note now. Choose yes.
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Chapter 12. Charting Patient Care & Assessments
In addition to the activities mentioned in the previous chapters you can also chart information
specific to the activity or procedure you are doing with your patient. The idea of an electronic form
is similar to the forms that you would use in a paper chart. For example you may have a paper
copy of an admission assessment where you cover a series of questions with a patient. An
electronic form has a similar layout but the data you input into an electronic form may be translated
to other areas of the chart for easy retrieval of important data. Such as the Result Review tab or
Chart Summary.
Forms cover a variety of disciplines and are categorized by Nursing, Physical Therapy, Social
work, etc. Some of these forms have been built specifically for schools where a similar form is not
available.
Ad Hoc Charting
1. To add a form to the chart: Select the dropdown “chart” on the tool bar at the top of the
screen, or select the
icon
2. The Forms Folder window will open. Select the folder from the list that meets the specific
problem you need to chart. You will need to drill down into the folder by continually
double clicking until you reach the AdHoc form, select the form and then select “chart” in
the bottom of the folder.
3. When your chosen form opens. Fill out each section necessary by navigating from one
section to another using the list on the left side of the form. Fill out all the yellow
highlighted areas.
4. Sign the form by selecting the green check mark on the upper left of the form window.
The form will close, and you should return to the Chart Summary View.
When you have completed with your documentation you can click the Sign or Save
buttons. Saving Information: Click save if you have additional work to do on the report
and you aren’t ready for others to see your document.
Signing information: Click sign if you have fully completed your documentation and you
are ready to add to your patients chart and have others view. Your report can be
modified after this time but all changes will be tracked and visible.
*NOTE*: CLICK SIGN in order for your faculty to see your documentation.
5. Update/Refresh the screen to get the most updated information by clicking on the
“refresh button” on the upper right hand side of the screen, just below the
colored demographics bar.
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Interactive Charting
The interactive flowsheet allows you to enter multiple vital signs or assessment data directly
into the chart without filling out a form. This view is helpful for bedside data collection. Times
are displayed as columns, data types as rows. Types of assessments are listed in a column
on the left.
1. To Input directly into the chart, first Select the Icon for the
date and time to the left of the first date on the interactive
chart. Change the date and time to
the correct date and time
2. Select the category of data to be inputted into the chart.
Options of vitals are on
the left and the selected category moves to the top to show the area being charted.
3. You can right click in the field to get the “add result” message, and then input the data.
Some fields provide options to select from, depending on the data to be added.
4. Views of the interactive chart can be changed by selecting the icons just below the
demographic bar.
5. Sign your data input by clicking the
Green Check Mark in the toolbar just
under the bar: It will then appear in
the Results Review Flowsheet
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Chapter 12 - Practice Exercise
AdHoc Charting
Objective: To chart patient information using a form.
1. Close any patients you may have open, and go to your personal practice patient.
2. Select the dropdown “chart” on the tool bar at the top of the screen, or select the
icon
3. The Forms Folder window will open, you should select the “All Items” folder in
the list on the left side of this window
4. Select the General Assessment folder by drilling through the folders.
5. Choose the Admission History Adult form. Select the Chart button.
6. Fill out something in each section – navigate from one section to another using the list on the
left side of the form.
Sign the form by selecting the green check mark on the upper left of the form window. When
you have completed with your documentation you can click the Sign or Save buttons. Saving
Information: Click save if you have additional work to do on the report and you aren’t ready for
others to see your document.
Signing information: Click sign if you have fully completed your documentation and you are
ready to add to your patients chart and have others view. Your report can be modified after
this time but all changes will be tracked and visible. *NOTE*: CLICK SIGN in order for your
faculty to see your documentation. The form will close, and you should return to the Chart
Summary View.
7. Update/Refresh the screen to get the most updated information
by clicking on the
“refresh button” on the upper right hand
side of the screen, just below the colored demographics bar
Modifying an existing form
Objective: To alter the form with updated or corrected information.
1. Select Form Browser under the menu list on the left side of the screen.
2. Right click on an existing form, and a drop down menu appears.
3. Select “modify” from the drop down menu. The form will open again.
4. Make the necessary changes or additions to the form and click on the green check mark
located in the upper left corner of the screen. This attaches the users name to the modified or
new form.
5. Update/Refresh the screen to get the most updated information
by clicking on the
“refresh button” on the upper right hand
side of the screen, just below the colored demographics bar
Note: If the modified form is not found, that means you may have exited your form without signing
it.
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Reviewing Forms Data in the Reports Tab
Objective: To view information from AdHoc forms in a textual view.
1. After completing AdHoc forms documentation, you can view results in several different places.
2. Select the Reports tab from the menu. Click on the sorting section to Sort by Type
3. Double click on the folder entitled PowerForm Textual Notes—you will see a listing of
the various categories of forms, you can click the Plus Sign to open any of the folders and
see the forms contained within.
4. Note the date and the information and then find the same results in the Forms Browser
tab from the menu.
5. See the same information on the Interactive charting for areas such as vitals.
Chapter 12 - Practice Exercise Continued
Documenting Patient information into the Interactive Chart
Objective: To become familiar with adding information directly into the record without using a form.
1. Open your practice patient and navigate to the Interactive view at the bottom of the Menu.
2. Hover your cursor over the icon for date time on the left of the input area; see the red circle
above, and select the option.
3. Change the date and time to fit within the current clinical range.
4. Select Vitals view and add a blood pressure using the cuff by right clicking into the field and
seeing the “add result”. See that you have the ability to put both pressure data into the same
field.
5. Right click in the “Mean Arterial Pressure” and select “add result” and see that the field
automatically populates the information.
6. Using the same practice patient, select “High Acuity Lines” and fill in the information under
Peripheral IV Catheter category by right clicking on the field information. See that this category
gives you options to select (the same information in the AdHoc form.)
7. Using the same practice patient, select the Intake and Output interactive charting and select the
type of intake and output to be charted. Follow the same right clicking and adding result
methods to input the information.
Chapter 13. Miscellaneous Exercises
Objective: To become comfortable accessing parts of the chart that provides Reference
information for AEHR users
Finding/Viewing Reference Text
1. Select the Reference Text Browser in the menu list along the left side of the screen; the
reference window will open.
2. Click on the Drug Reference sub-tab at the top of the reference window; type Acetaminophen
into the search box and click the Search button to the right. An information window will open,
review the contents.
3. To go back to the chart, click on the next desired entry on the menu list.
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Finding/Viewing Reference Sources for current health information and decisions support. Open
and look up one item under each category.
1. Med Dictionary
2. Drug Glossary3. Lab Test
4. Nursing Abbreviations
5. Health Line- Health Information by topic
6. Evidence Based Practice
7. Medline
8. Mayo Clinic Medical Information
9. PubMed – US library of medicine, Institute of Health
10. Help Place- The Center for Healthcare Innovations website with numerous helps and decisions
supports along with updated user guides
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Updated 09/09/2014 NS
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Troubleshooting, Navigation Tips & Computer Requirements
Issue
While accessing the system, you get
the error “ERROR: Logon failure due to
unknown user name, bad password, or
incorrect domain name.”
You are unable to get into Powerchart
using the password you have created
for yourself.
You have forgotten your password.
vWorkspace does not seem to be
loading correctly.
Your instructor cannot see the work
you just did on an AdHoc form or
Report
Solution
This means that the passwords are not
being put in properly. Make sure the
caps lock is set correctly and put in the
username and passwords just as you
see them in the Getting Started section
of this document.
Be sure you are using the exact/correct
URL including punctuation and
capitalization.
If you are still not getting in, email your
support representative to review the
process or get passwords reset.
Contact Cerner for a reset:
[email protected] (M-F 7-7)
The older computers with older
operating systems may need to be
updated.
You probably saved the form instead of
signing it. Go back to the form in Form
Browser, right click and modify, then
sign the form.
Reports: you need to start over, saving
is not an option.
Center for Healthcare Innovation Contact Information
Nancy Sivertson [email protected] ph 218-723-6180
Toni Pearson [email protected] ph 218-625-4933
Joe Janchar [email protected] ph 218-625-4974
Computer & Software Recommendations for Using the AEHR (Cerner
Millennium Software)
Minimum Hardware Requirements: Preferred configuration is a PC running MS Windows
OSX with an IE browser
 A processor (CPU) with 1 GHz frequency or above processor speed.
 Video capability of displaying at least 256 colors ++ Sound Card w/Speakers
 Network Card: Adapter for Ethernet connection (LAN) OR a wireless adapter (Wi-Fi) - High
speed.
 10 GB hard disk drive ++512 MB Memory (RAM) or above++CD-ROM or DVD-ROM Drive
 Valuable addition: Microsoft Office Software Suite
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Operating Systems & Browsers
Microsoft Windows Operating System
IE 8
IE 7
Firefox 3.6
Windows XP (32
Compatible Recommended
Compatible
bit)
Windows Vista (32 Compatible Recommended
Compatible
bit)
Windows Vista (64 Compatible Recommended
Compatible
bit)
Windows 7 (32 bit) Compatible Recommended
Compatible
Windows 7 (64 bit) Compatible Recommended
Compatible
Windows 8
Compatible
Firefox 3.5
Compatible
Compatible
Compatible
Compatible
Compatible
Apple Mac OS Operating System *
Safari
Firefox 3.6
Mac OSX 10.5
NOT Supported
NOT Supported
“Leopard”
Mac OSX 10.6 “Snow Compatible
Recommended
Leopard”
*NOTE: MAC use with vWorkspace is now supported by Cerner
Access to the Internet
CSS provides Internet accounts for students to use at hard-wired facilities on Campus. Each oncampus workstation is set up with high speed AEHR access. Off-site accounts to access the
AEHR must be purchased from outside service providers by the individual users and are the
responsibility of the user.
A High Speed internet connection is required to reliably connect to the Cerner servers via the
Internet!
.
General Statement of Responsibility
It is the student’s responsibility to obtain and maintain a computer workstation and internet access
in order to complete assignments utilizing the AEHR. Center staff is available to assist with logons,
system navigation, and password resets. We cannot assume responsibility for fixing the many
issues that may arise with a PC or laptop. We recommend that each student knows where they
can access PC support and/or an alternate workstation in case of PC issues. We recommend
users be familiar with MS Word, MS Excel, computer logon screens, printing documents, and
screen printing.
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Appendix A: Subscriber School Mnemonics and Web Addresses
Arapahoe Community College
Https://cernaesq.cernerworks.com/cernaes
The College of St. Scholastica
(CSS)
Concorde Community Colleges
(CCC)
Cuyahoga Community College
(TRIC)
MnSCU Schools
(MNSCU)
Southern University at Shreveport,
LA (SUSLA)
University of Portland
(UP)
WTCS Schools
(WTCS)
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
Https://cernaesq.cernerworks.com/cernaes
___________________________________________________________________________________
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Appendix B: Explaining the Toolbar Icons
This is the opening view for PowerChart. Some icons may be dithered (grayed out) based on user
privileges. Check below for an explanation of each icon . . .
PM Conversations
Ad Hoc Charting
Pt List
Find Patient
Binoculars
List Maint.
Help Place
Recent Charts
Refresh/Update
screen
Find Patient: Opens the Person Lookup dialog box to enable you to select a
patient by name.
Alternate route for this function: Select Patient on the Menu bar, then Search in
the Menu drop box.
Show me How: This excellent feature offers video and pdf instructions for
many system functions – click this icon to see the Show Me How window, then
click within the window to open the instructional pieces for each function
Recent Charts: Displays a listing of charts recently opened by this user for
“rapid return”
Patient List: Displays the list this user has defined for automatic display in
PowerChart for rapid access.
List maintenance & Properties: Opens the List Maintenance box where
the user can create & manipulate patient lists associated with their logon, or
maintain properties of their list.
Add’l. List Maintenance: These icons allow additional Patient list
maintenance functions.
Help Place: Launch web application to Academic EHR System Help Place
http://www.centerforhealthcareinnovation.com/helpplace
Change User: Suspends (but does not close) the application and displays
the Change User dialog box to allow another user to enter a user name and
password. The new user's patient lists and other defaults are then displayed.
Suspend Application: Suspends (but does not close) the application and
displays the Suspend User dialog box. A new logon is required to re-enter
Exit application- quits the current application, i.e.: PowerChart
Calculator: Launches the clinical calculator
Message sender: opens the message sender box to send a formatted or
free text message to a given destination
AdHoc: Ad Hoc charting icon opens the forms folders to select for charting.
PM Conversation: Patient management conversation
Print: causes a print screen window to open
Refresh: updates time of display to current time
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View charges: Green spectacles icon (does not open Pt Chart)
Explaining the Toolbar Icons: Patient view:
This view is seen when a patient chart is open. Some Icons may be dithered (inaccessible) based
on user privileges. See previous section for more explanation.
Menu: This serves as a header for the listing of different VIEWS of patient data
available to the user. The list can be minimized to a single orange Menu tab by
clicking the Map Tack at the right side of the box.
Find patient
Previous patient’s chart
Next patient’s chart : Used to move through a group of open charts
New sticky note: allows user to create a sticky note for this patient – visible to
users but not an actual part of the chart.
Attach to chart: allows the user to attach the sticky note to the patient’s chart
View sticky notes: allows the next user of the patient’s chart to view sticky notes
added by others.
Tear off this view
Change user: see previous section for full explanation
Suspend application: see previous section for full explanation
View charges: (does not open Pt chart) Not used in the AEHR
Launch charge entry: not used in the AEHR
Exit application
Launch web application to Academic AEHR Help Place
http://www.centerforhealthcareinnovation.com/helpplace
Launch clinical calculator
Message sender
Ad Hoc charting
Charge Entry
Patient management conversation
Print
Refresh – updates screen display to current time
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Results Review Flowsheet icons:
Graph: Seen on the upper left of the Results Review Flowsheet – triggers
display of a graphical presentation of selected results.
Seeker: This icon allows the user to see what portion of the total spreadsheet
they are viewing.
Bookmark: Sets the displayed date/time as the last date/time results were
viewed by the current user: results added after this date/time will be displayed as
“NEW” results by color and/or icon
Results Tabs: Tabs that define which sections of the results flowsheet are
displayed
Report View Icons:
New Report: opens the new report window
PowerNote: opens the PowerNote window for creation of a new PowerNote
Print: Causes the currently highlighted report to print to the default windows
printer
Text Color: sets the color of the text in a report being typed
View/Zoom: expand or contract the size of the text displayed in a report
Template Insert: opens the template selection box to allow insertion of a
template into the current report.
Misc. Icons
Add New: this icon opens appropriate windows for adding new orders, allergies,
problems, procedures or diagnoses
Quick Chart: on the Task List, this allows the user to chart the task using
Default time, dosage, etc.
Chart Details: on the Task list this icon opens the detail window for entering
details of the task
Reschedule: on the task list, allows the user to reschedule a Task to another
time slot.
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Appendix C: Physical Therapy
Physical Therapy Assignment #1 – Your Patient
1. Go into PowerChart and create a patient using your name. (reference page 21 –
Registering a Patient)
2. After your patient has been created, search for your patient.
3. Create a PT Daily Note by clicking on the Ad Hoc Charting option from the Chart pull-down
menu at the top of the screen.
4. Double click Physical Therapy folder.
5. Double click the CSS PT folder.
6. Double click on the PT Daily Note CSS.
7. Fill in the PT Daily Note using the following documentation. You will need to
reorganize the information to fit in into the computerized format. You do need
to include the data on the intervention flow sheet on the flow sheet in the
progress note.
Current Condition: Patellofemoral dysfunction, 1 wk reevaluation
OUTCOME GOALS
1. Ascend and descend 2 flights of stairs, pain free.
2. Run on level surfaces 2 miles in 20 minutes, 2x week, pain free.
S: “ My knee is hurting less when I’m not walking.” (0/10 on VAS)
O: Interventions as per flow sheet (see pg. 41). Ice applied to knee after ex. x 10 min.
Ambulation/stair climbing: Pt. able to walk ½ mile at comfortable speed (65 m/min). Able to ascend
2 flights of stairs pain free. Pain rated as 4/10 (sharp pain) descending 1 flight of stairs. Running:
Pt. has not yet engaged in running activity. Strength: L quadriceps: 4/5 L hamstrings: 5/5 R quads
and hamstrings: 5/5. Left unilateral stance time, static: 20 sec. Right unilateral stance time, static:
60 sec.
A: Pt. is exhibiting a steady improvement in eccentric control of left quadriceps when descending
stairs, indicated by an increase in control of descent and a decrease in reported pain. Patellar
taping techniques are being used to recruit left vastus medialis. Balance deficits are still apparent
indicated by limited unilateral stance time on the left. Steady progress is being made toward the
goal of pain-free stairs negotiation. Continued strength and balance gains are necessary for the
patient to achieve the second goal related to running. Cross-training has been emphasized as
well, with cycling being introduced to the pt.’s routine.
Note: For this exercise, you will have to add the stated outcome goals. Normally, the goals from
the initial evaluation would automatically show in the assessment section.
P: Continue current exercise regime, with progression in reps and weight as tolerated. Home
program, which consists of SLRs, squats, and step-ups, is to be completed daily. Physical therapy
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sessions will continue 2x week to include low impact activities (e.g., jogging on trampoline). Eval
for orthotics next session.
Material taken from Functional Outcomes Documentation for Rehabilitation – Jody Feld, MS, PT;
Karen D. Stutman, MS, PT,ATC; Janet Herbold, MA, PT
Saunders 2003
INTERVENTION FLOW SHEET
Modality/
Procedure
Date
9-27-01
Patellar taping (L)
Patellar mobilizations
(L)
EXERCISES
Lateral step-ups
Chair squats
SLRs
Left unilateral stance
Leg press
Stretching (ITB,
quad/hamstrings/calf)
0# 3x10
3 x 30 sec
9-28-01
Medial glide
Medial glide
10-1-01
Medial glide
Medial glide
4 inch, 2x10
4 inch, 3x10
0# 3x10
0# 3x15
L: 25 sec
B:80# L:40#
3x10
3 x 30 sec
0# 3x15
1# 3x10
L: 30 sec
B:80# L:40#
3x15
3 x 30 sec
Physical Therapy Assignment #2 – Your Patient
NOTE: This exercise is written in first person format because you will be entering the data in the
chart you created for yourself in the previous exercises. For the purpose of this exercise you will
be both the “patient” (entering data on your own chart), and the therapist (entering the data,
evaluating the data, and creating goals and plan of care).
1. Go into Powerchart and search for your patient.
2. Create a Physical Therapy Initial Evaluation by clicking on the Ad Hoc Charting option from the
Chart pull down menu along the top of the screen.
3. Double click the Physical Therapy folder.
4. Double click the CSS PT folder.
5. Double click on the Physical Therapy Evaluation CSS form.
6. Fill in the form using the following documentation. You will need to reformat
the information.
7. After entering the given data, complete the form by creating your own goals,
assessment, and treatment plan and entering those on the evaluation.
Right Cerebrovascular Accident
At the age of 58, you are quite pleased with how your life was going. You are one of the top 10
brokers in your firm. All was also well on the home front. Your wife/husband of 35 years,
Margie/Mark, had always stood by you and managed your home and community obligations.
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Things were not always this smooth. Your 25-year old son had a rough time “finding himself” after
high school and ran into some trouble with the law. Now he is working and going to college at
night. You are glad your son lived with you. It allowed you and your wife/husband to keep a close
eye on him. Also, your son was a big help. Margie’s/Mark’s mother had moved in with you about a
year ago because of her dementia. She is quite physically independent but requires supervision.
Over the years, you developed several medical problems. You have angina, atrial fibrillation (Afib), HTN, and insulin-dependent diabetes mellitus (IDDM). Three years ago you had a hernia
repair and you have not been able to quit smoking cigarettes (one to two packs a day since you
were 16). You take NPH insulin, Catapres, and nitroglycerin tabs prn.
Although you love your work, you also enjoy your leisure time. You can be found in your box seats
for all the baseball games. You also enjoy spending time with your wife/husband on your
powerboat during the summer season. At night, you can be found reading the evening newspaper
and listening to the news at the same time. You enjoy your contemporary ranch-style home. It
has four bedrooms and three bathrooms. The master suite has its own bathroom with a tub and
shower stall. The home has no architectural barriers once inside. The home can be entered by
four steps without a rail in the front or by the back, which has six railed (right side entering) steps.
One early afternoon while at work, you find yourself feeling dizzy and nauseated. You try to rest
but the feeling does not go away. All you can recall is all of a sudden not being able to feel
anything in your left arm and leg. You report falling over because of your lack of control over your
body. The next thing you remember is waking up in the hospital. Your wife/husband was there
along with your doctor, who was telling them that you had had a stroke. The CVA involved his
right middle cerebral artery.
At this point, you complained about feeling exhausted and your need to get back on your feet to
return to work. You have so much to accomplish.
After 10 days in acute care, you were transferred to your transitional care unit with orders for
evaluation and treatment to regain maximal functional abilities. Your wife/husband and son want
you to return home. They would like you to achieve at least moderate assisted transfers so you
can be assisted by them and whomever they may hire. You do not really appreciate many of your
problems and hope to return to work after a month of rehabilitation.
The results of the initial evaluation are as follows:
Perception/cognition: Severe left neglect complicated by hemisensory loss.
Cognition: Alert and oriented x 3 using environmental cues (i.e., room clock, calendar). Gives
global reason for why you are hospitalized but is unaware of the severity.
Attention: Demonstrates vigilance but easily distracted by the presence of others, especially
family.
Concentration: Inconsistent sustained concentration. Initially good but easily fatigues, as seen
with increasing errors in performance; little recognition of errors.
Memory: Long-term memory appears intact. Impaired short-term memory and immediate recall.
Sequencing: Impaired; more pronounced when task involves crossing midline or bilaterality.
Ability to follow directions: Impaired as evident by difficulty with immediate recall. Does better
with pictorial instructions.
Initiation: Impulsive.
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Insight/judgment: Poor; speaks of returning to home and work within 1 month as if nothing has
happened. Poor appreciation for his current deficits.
Problem solving: Poor. Has difficulty recognizing problems.
Neurology: There is no active return of either your LUE or LLE. Tone is
severely impaired with hypotonicity throughout the left extremities and trunk.
Sustained clonus is noted at the left ankle.
Sensation/pain: Sensation is severely impaired with zero out of 10 correct
responses during testing of proprioception, light touch, pain, deep pressure, and
hot/cold in left extremities. The patient has no complaints of pain.
Skin/edema: Stage II pressure sore is noted on the left greater trochanter. .
Otherwise, skin is intact with moderate left hand and ankle/foot edema
Balance: Balance is poor with the need for moderate assistance x 2 to
maintain upright sitting on the edge of the mat. Standing balance is not
appropriate to test.
Mobility:
Bed mobility:
Rolling: Moderate assistance with maximum verbal cues.
Bridging: Maximum assistance with maximum verbal cues.
Supine to/from sit: Maximum assistance with maximum verbal cues.
Equipment: Trapeze, rails.
Transfers:
Sit to stand: Moderate assistance x2 with maximum verbal cues because of impulsivity.
Bed to/from wheelchair: Maximum assistance x2 with maximum verbal cues.
Toilet (commode) to/from wheelchair: Maximum assistance x2 with maximum verbal cues.
Tub/shower to/from wheelchair: Maximum assistance x2 with maximum verbal cues.
Car: NT
Wheelchair mobility: You require total assistance for wheelchair propulsion
and maneuvering due to impulsive behavior and left neglect. You require wheelchair modifications
to maintain your upright positioning in your wheelchair.
Gait/functional mobility: You are able to take 5 steps in parallel bars with maximum assistance
requiring 2 people. You drag your left foot, leans to the right, has a step-to gait pattern, and has
increased flexion of the left knee and hip during stance.
Self-Care (right dominant)/ADL's: Most skills require moderate physical assist and max. cues.
Able to wash face after set-up; completes some grooming tasks and upper body washing, but not
thoroughly. Left neglect evident during all skills.
Toileting: Uses a urinal and bed pan. Maximum assistance required.
Home management: NT.
Leisure/community: Able to use portable programmed phone if in right visual field. He calls his
contacts and friends to assure them he plans to return to work.
ROM: See Table 2-14.
Strength: See Table 2-15.
Patient Goals
Return to prior level of functioning.
Family Goals
Self feeding with minimal assistance.
Functional transfers with minimal assistance. Family to hire a personal care attendant.
Moderate assistance with toileting.
Minimal assistance with self-care. Edema control.
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Table 2-14
Passive Range of Motion
Left
Joint/Joint Complexes
Neck
WNL
Flexion/extension
WNL
Rotation
WNL
Lateral flexion
Trunk
WNL
Flexion/extension
WNL
Rotation
WNL
Lateral flexion
Upper Extremities
155/WN Shoulder flexion/extension
L
135
Shoulder abd/add
WNL
Shoulder horizontal abd/add
WNL/-10 Elbow flexion/extension
WNL
Forearm pronation/supination
WNL
Wrist flexion/extension
WNL
Finger abd/add
WNL
Thumb opposition
Lower Extremities
WNL
SLR
WNL
Hip flexion/extension
WNL
Hip abd/add
15/WNL Hip IR/ER
WNL
Knee flexion/extension
WNL/-12 Ankle plantar/dorsiflexion
WNL
Great toe flexion/extension
Table 2-15
Manual Muscle Test
Left
Muscle/Muscle Group
Neck
G
Flexion/extension
G
Rotation
G
Lateral flexion
Trunk
F+
Flexion/extension
F+
Rotation
F+
Lateral flexion
F+
Pelvic elevation
Upper Extremities
Trace Scapular abd/add
Trace Scapular elevation
0
Shoulder flexion/extension
0/1
Shoulder abd/add
0
Shoulder IR/ER
0
Shoulder horizontal abd/add
1+/0
Elbow flexion/extension
PowerChart
Right
Comments
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
Right
Comments
G
G
G
F+
F+
F+
F+
N
N
N
N
N
N
N
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0
0
0
0
0
0
0
0
0
0
2-/1
2-/2
NT
1/2
2-/1
0
0
0
0
Forearm pronation/supination
Muscle/Muscle Group
Wrist flexion/extension
MCP flexion/extension
PIP flexion/extension
DIP flexion/extension
Finger abd/add
Thumb MCP flexion/extension
Thumb ICP flexion/extension
Thumb abd/add
Thumb opposition
Lower Extremities
Hip flexion/extension
Hip abd/add
Hip IR/ER
Knee flexion/extension
Ankle plantar/dorsiflexion
Foot eversion/inversion
Great toe flexion/extension
Toe MTP flexion/extension
Toe IP flexion/extension
PowerChart
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Material taken from Case Studies in Rehabilitation – Patricia A. Ghikas & Michele Clopper – 2001
Physical Therapy Assistants
Physical Therapy Assistant Assignment #1 – Your Patient
1. Go into Powerchart and create a patient using your name. (reference page 21 –
Registering a Patient)
2. After your patient has been created, search for your patient and bring up your
episode of care.
3. Create a PT Daily Note by clicking on the Ad Hoc Charting icon.
4. Double click Physical Therapy
5. Double click CSS PT.
6. Double click on the PT Daily Note CSS.
7. Fill in the PT Daily Note using the following documentation. You will need to
reorganize the information to fit in into the computerized format. You do need
to incorporate the data from the intervention flow sheet onto the flow sheet in
the daily note.
Current Condition: Patellofemoral dysfunction, 1 wk reevaluation
OUTCOME GOALS
1. Ascend and descend 2 flights of stairs, pain free.
2. Run on level surfaces 2 miles in 20 minutes, 2x week, pain free.
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S: “ My knee is hurting less when I’m not walking.” (0/10 on VAS)
O: Interventions as per flow sheet. Ice applied to knee after ex. x 10 min. Ambulation/stair
climbing: Pt. able to walk ½ mile at comfortable speed (65 m/min). Able to ascend 2 flights of
stairs pain free. Pain rated as 4/10 (sharp pain) descending 1 flight of stairs. Running: Pt. has
not yet engaged in running activity. Strength: L quadriceps: 4/5 L hamstrings: 5/5 R quads and
hamstrings: 5/5. Left unilateral stance time, static: 20 sec. Right unilateral stance time, static: 60
sec.
A: Pt. is exhibiting a steady improvement in eccentric control of left quadriceps when descending
stairs, indicated by an increase in control of descent and a decrease in reported pain. Patellar
taping techniques are being used to recruit left vastus medialis. Balance deficits are still apparent
indicated by limited unilateral stance time on the left. Steady progress is being made toward the
goal of pain-free stairs negotiation. Continued strength and balance gains are necessary for the
patient to achieve the second goal related to running. Cross-training has been emphasized as
well, with cycling being introduced to the pt.’s routine.
Note: For this exercise, you will have to add the stated outcome goals. Normally, the goals from
the initial evaluation would automatically show in the assessment section.
P: Continue current exercise regime, with progression in reps and weight as tolerated. Home
program, which consists of SLRs, squats, and step-ups, is to be completed daily. Physical
therapy sessions will continue 2x week to include low impact activities (e.g., jogging on
trampoline). Eval for orthotics next session.
Material taken from Functional Outcomes Documentation for Rehabilitation – Jody Feld, MS, PT;
Karen D. Stutman, MS, PT,ATC; Janet Herbold, MA, PT
Saunders 2003
INTERVENTION FLOW SHEET
Modality/
Procedure
Date
9-27-01
Patellar taping (L)
Patellar mobilizations
(L)
EXERCISES
Lateral step-ups
Chair squats
SLRs
Left unilateral stance
Leg press
Stretching (ITB,
quad/hamstrings/calf)
0# 3x10
3 x 30 sec
9-28-01
Medial glide
Medial glide
10-1-01
Medial glide
Medial glide
4 inch, 2x10
0# 3x10
0# 3x15
L: 25 sec
B:80# L:40#
3x10
3 x 30 sec
4 inch, 3x10
0# 3x15
1# 3x10
L: 30 sec
B:80# L:40#
3x15
3 x 30 sec
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Physical Therapy Assistant Assignment #2 – Joe Tester
1. Go into Powerchart and search for the patient: Joe Tester.
2. Click on Form Browser on the Navigator menu; find the initial Physical Therapy Evaluation
form.
3. Double click the PT Initial Evaluation to open the document. Review the document for any
information you, as the PTA assigned to see Joe, may need to know. After reviewing the
document answer the following questions (you may refer back to the chart as needed):
a. What is Joe’s medical diagnosis?
b. Are there any medical issues other than the CVA that may impact your
treatment?
c. How much help is Joe needing for transfers at this time?
d. What (other than the sensory motor deficits associated with the CVA) is
creating concern about Joe’s safety during mobility training?
e. What is Joe’s ambulatory status?
f. What is the strength of Joe’s left knee extension?
g. Based on Joe’s treatment plan and his STG’s, what kinds of
interventions might you choose to use during the first week of Joe’s rehab.
stay?
h. Was any treatment (other than evaluation) provided during Joe’s
first visit to PT?
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Appendix D. HIM – Profile
How to customize the application bar for HIM Users
Purpose: To create a customized application bar. This is a way of having all the apps you need
on an appbar using a single log in feature. It allows access to applications not included in
PowerChart.
Selecting the applications you want to see on your appbar
After logging in on the vWorkspace gray screen, you will see two icons on the next screen. We are
going to click on the icon labeled: AppBar
1. Click on the AppBar Icon
2. A small gray Bar will appear at the top of the screen. This is the AppBar. You will only see one
icon on the left end of the bar the first time you log in; once more icons are added, they will appear
here each time you log in...
3. Left click on that lone icon . . ..
4. Click on Customize in the drop down list. A new window will open entitled Customize Cerner
AppBar.
5. Click on the Buttons tab. You will see a list of available Applications, with two headers at the
top:
Application and Product. You can sort or re-sort the list by clicking on the two headers.
Application names are in the left column, Product categories in the right column.
6. Click on the header named Product to sort the applications by product.
7. Scroll down to the Profile product area.
For HIM Faculty/Students who wish to use the ProFile Suite
Check box the following applications (12 total):
Chart Abstracting
Chart Coding
Patient Information Request
Physician Deficiency Analysis
Letter Template
Letters
Master Patient Index
Reports
Request Manager
Request Queue
Patient Deficiency Analysis
Tracking
1. Click OK. Icons for the applications you selected should now appear on the gray bar.
Hovering over each icon will indicate which application it represents. Clicking on an Icon
will open the application.
2. In General, you can use the RED X in the upper right of the screen to exit from an
application when you are finished.
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HIM Use of App Bar applications
Chart Abstracting
1.
Your screen will look like this. Search for a patient by clicking the first icon (find patient).
2.
3.
4.
5.
Fill in the appropriate answers to the abstract boxes and click the save icon (disk).
The system will ask you if you would like to save a draft or final.
Click OK.
There will now be a blue check mark in the clipboard on the navigation bar in the left
hand column.
Search for another patient, if necessary.
6.
Chart Coding
1.
Your screen will look like this. Search for a patient by clicking the first icon (find
patient).
2.
3.
Fill in the appropriate answers to the abstract boxes and click the save icon (disk).
Right click in the white boxes to add codes.
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Letter Template
1.
Your screen will look like this:
2.
This application allows the user to create or manipulate existing HIM letters.
3.
Click on the arrow and drop down the Template list.
4.
Highlight and click Delinquency Letter – 15 days post discharge.
Notice that you can change the wording of the letter as well as the criteria for
this letter.
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Letters
1.
Your screen will look like this:
2.
Drop down the letter type list and choose Suspension Letter – 30 days post
discharge. Select your facility from the facilities field.
3.
4.
Click on Retrieve Physicians button in the middle of the screen.
Notice how you can email, fax or produce a paper letter for each individual
physician.
Master Patient Index
1.
Your screen will look like this. Search for a patient by
clicking the second icon (find patient).
2.
Double click the encounter to see more information
about this visit.
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Registering a New Patient for HIM Students
When creating your first patient in the EHR we suggest that you register yourself as a play
patient or have students register themselves (use their own names) for an assignment.
1.
To Register a new patient, make sure all other patients’ charts are closed and that you are
on the Organizer View of the application. You’ll see something similar to this: Note: no
names appear.
2.
Select
PMLaunch from the tool bar at the top of the screen
A new window will open. Click on the HIM Registration icon, then on OK.
3.
The Person Search window will open
on your screen. Type the patient’s
name (Lastname, Firstname) that you
would like to add into the Name field
and click Enter on your keyboard.
*Your instructor may give you unique
instructions here to assure that your
new patient can be easily found, ie all
patients created by one class may have
the same last name such as HIM264
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4.
PowerChart
After you click Enter on your keyboard
and the system searches for your
patient’s name, the Add Person button
will light up on the bottom of the screen.
Click on the Add Person button.
4.
On the bottom half of the screen under
the Facility Name tab. Type a * into the
search field and click Enter on your
keyboard. This will give you a list of all
Facility options available to you.
Choose your school’s Medical Center
by double clicking on it.
5. The HIM registration window will open.
If this is your first time using this screen
right click anywhere on the screen and
select Highlight Required Fields.
All required fields will now have a yellow
background. These fields must be
satisfied in order to register your patient.
For best results, please be sure to give
your patient a birth date, a sex, an
admitting & attending physician, a
reason for visit, & an admitting dx.
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6.
PowerChart
The Name fields, MRN, Financial # and Facility fields will automatically populate. The
remaining required data fields can be filled out as you deem appropriate. The drop down
boxes will give you options to choose from. Do not enter personal demographic data
into the AEHR, such as your own birth date or SSN. See the table below for more
information on the different fields.
Registration Fields
Registration Date
(Required)
Current date: Enter a T to populate today’s date.
Historic date: You can enter a past date into this field.
Future date: You are able to enter a future date but will not
be able to see any information entered on that encounter
until that date and time. Any information entered on a
future encounter will not be viewable until that date.
Registration Time
(Required)
Enter N for now or type in a specific time of your choosing
Future time: Any information entered on a future
encounter will not be viewable until that date/time.
Birth Date
Enter birthdates as mm/dd/yyyy. Once the birthdate is
entered the age field will automatically populate.
Age
If you would like your patient to be a certain age for
example 56; simply type the age into the age field and the
birthdate will automatically populate.
Encounter Status
This is a required field where you designate the encounter
(Required)
status. The status refers to the encounter being; active,
cancelled, discharged, transferred, etc.
Encounter Type
This is a required field where you designate the encounter
(Required)
type. Here you can choose if the encounter is inpatient,
outpatient or emergency, as well as other options. This
choice will affect the entry of orders and other data.
Building
In the medical setting the building would correspond to a
specific hospital or clinic location. In the Academic EHR the
building typically corresponds to your discipline such as
nursing, HIM or Physical Therapy. Populating this field can
help you organize your students working in the AEHR
through the use of patient lists. (see chapter five for more
information on patient lists)
Nurse\ Ambulatory
In the medical setting this would correspond to a specific
nursing unit or department in the Academic EHR this field
typically corresponds to your class list. Populating this field
can help you organize your students working in the AEHR
through the use of patient lists. (See chapter five for more
information on patient lists.)
Once you have entered all of your patient’s information click OK.
Go to Patient > Search to find your patient and open the chart.
To modify your play patient registration, you will need to return to PMLaunch.
Return to Page 32 to continue.
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Appendix E for HIM 6501
Introduction: This document walks you through loading vWorkspace, logging into the
system, adding an encounter on to an existing patient, and then performing EHR
functionality in the patient’s record.
Installing vWorkspace for Web Access
The Academic EHR is accessible via the internet. To obtain access to the
EHR, vWorkspace must first be installed. This will already be installed on
your school PCs. You will need to do this for your personal PC only. Go to
http://www.css.edu/AEHRUserGuides.xml You will find detailed directions
for the download for Windows PC’s, MAC’s, iPads’ and Android tablets.
To Start, navigate to https://cernaesq.cernerworks.com to reach the screen
below, then click on Downloads to get to the directions for each type of
device.
To Log in to Cerner using vWorkspace, click on the User Name field on the
vWorkspace screen, and enter your username as assigned by your instructor.
This is often your school email address or an abbreviation of your school
email address.
The default password for each user account, to start with is
Qbptzj29
enter this.
Now Click on LOGIN and your screen should flip over and show a
PowerChart icon Double-click on Power Chart:

Note: If you’ve logged into the EHR before, your password is one that
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you’ve created for yourself the first time you logged in. If you’re logging in
for the first time, your password is Qbptzj29. You’ll want to create your
own password by logging off, then clicking on the Change Password
button. You need to remember this new password for future login’s.
Creating your Play Patient
1.
DO NOT access the record of any patient within The Academic EHR
System that is not specifically assigned to you by your faculty or created
by you for a legitimate course assignment. This activity is monitored and
proper disciplinary action will be taken by your faculty and academic
department if you violate this rule and ethical responsibility.
You should now register and create your own play patient using your
name within The Academic EHR System. A play patient is a clinical case
you have completely made up on your own so you can practice on the
system outside of any course context. You MUST use “CSS” +
YourLastName (using proper capitalization) as the last name of your
play patient when you register it into the system and your own first and
last name as the first and middle name of the patient.
Example:
Last name = CSSJones
First name = Patty
2.
To Register your own patient, make sure you are on the
Units>View of the application (see below):
If you are not on this screen, click the icon Units.
Be sure to close out all patients in Powerchart.
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Now Click on:
 PM Launch
on the toolbar Log In with your personal
logon.
 In the Conversation Launcher, Select HIM Registration. Click OK.
3.




4.
Search for your PLAY patient. It is likely not there. Click on Add
Person.
Type an * (asterisk) in the Facility Name box.
Click the box with three dots (ellipse) to the right of the Facility
Name.
Highlight ATHENS Medical Center and click OK to start a new
person entry. You have now started an entry in this particular
organization.
Fill in these data fields (at a minimum):
 Last Name, First Name, Birth Date (note that an age will
default), Sex
 Encounter Status = Active
 Encounter Type = Inpatient
 Admission Date = Today’s Date (type T to default to today’s
date)
 Admission Time = Now (type N to default to the current time)
 Building = CSS Hospital
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
5.
6.
7.
8.
PowerChart
Nurse/Ambulatory = CSS 2 East
Note: This is where many duplicate medical record errors are
generated, upon registration. When you work in this area, it is critical to
follow policies and procedures when there is initial contact with the
patient. A couple of things to remember (there are many best practices
to follow): Ask if they have been seen in this facility before? Ask for
identification to avoid spelling errors.
Click OK.
Exit from PM Launch by clicking the Red X in the upper right corner.
Back in PowerChart, click Patient on the menu bar, and then Search in
the drop down menu to find the patient you have just created. Double
Click on your patient to open the chart.
If you are asked to assign a relationship to that patient, highlight HIM
student (or similar) and click OK.
Proceed to the next exercise.
Adding Form #1 in Ad Hoc Charting
Note: If you have to search for your patient again, go to the drop down menu at
the top of the screen, click Patient>Search. Type in the last name of the patient
and click search. Highlight the name and then highlight the episode of care (which
is the lower half of the screen). Click OK. This brings you into the patient’s chart.
1.
We will now start some documentation on this patient by adding a
structured form that has been built into the system by the vendor.
While in the patient’s chart (you will see the patient’s name across the top
of the screen), Click chart>Ad Hoc Charting.
2.
A screen like the one below will appear. These folders contain several e-
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forms (structured and non-structured).
3.
Click on All Items>General Assessment and check the box in front of
the Admission Assessment Adult. Click Chart.
4.
The form will open and it will look similar to the screen below. You will now
begin to enter information on your patient using this form.
Note ~ some definitions for you:
Discrete/structure data are the values of variables that the computer can
process. E.g Date of birth, the computer can process that entry and
calculate the age and display it for you. This type of entry is essential
when building in clinical support systems and quality reporting.
5.
Unstructured data include narrative notes, which may be typed into a
comment field, or dictated, transcribed or hand-written into an electric
system, as well as images. This type might be easier for the user on the
front end, but it is more difficult to get quality reporting out of this type of
entry.
The form has many sections, each listed along the left side of the screen
(called the Navigator/Menu column). The first section is Vital Signs, this
form defaults to this section when it is opened. Fill in the following fields:
Oral (Temperature) = 38 DegC
Systolic/Diastolic BP = 135 mmHg/90mmHg
Notice how it auto-calculates the mean atrial pressure for you.
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6.
PowerChart
Also notice the blue text along the mean arterial pressure. By rightclicking on that box, the user can see reference text that has been built
into the system for extra information. These types of “best practices” can
be incorporated into e-forms with your EHR and help provide better
patient care.
Go to the Subjective Section and scroll down to see this section in the
navigator column:

Gastrointestinal Symptoms section = Click on Constipation.
Notice once you click that particular check box, a corresponding
box, Constipation Duration, will open (turn from gray to white),
implying that you enter the appropriate answer in this area (e.g. 1
week, 2 weeks). Fill in that box with a duration period.

Still in the Gastrointestinal Symptoms section = Click on
Vomiting. Notice once you click that check box, two corresponding
boxes, Vomiting Frequency and Vomiting Duration will open (turn
gray to white) implying that you enter the appropriate answer in
these areas. Fill in these two boxes with answers.
7.
Still in the Subjective section, notice in the navigator column that the
next section below the Subjective section is Pain Assessment. It is a
darker color and you are not able to click into it at this time. This section
is a called a conditional section, meaning that this section is not available
until something triggers it open. We will do this in the next step.
8.
Scroll up to the top of the screen in the Subjective Section. Under the
header Pain Present, click “Yes actual or suspended pain”.
9.
Once you click on Yes in the Pain Present area, a pop up screen will
appear. Fill in using the following details:
 Pain Location = Neck
 Laterally = Left
 Quality = Burning
 Time Pattern = Constant
 Preferred Pain Tool = Numeric rating scale
 (notice how some more conditional boxes open up)
 Numeric Rating at Rest = 5
 Numeric Rating with Activity = 7
Click on the arrow circle icon (upper, left) to get back to your main form.
You have just completed information on where/how the pain feels to the
patient.
On the navigator, go to the Mental Status Section. Fill in the four
10.
11.
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sections listed below with information.
 Orientation
 Level of Consciousness
 Ability to Pay Attention
 Disorganized Thought Process
During this type of exploration exercise, you may choose the answers that
you wish. Just be sure to notice the different options in this area when it
comes to a check box or radial buttons. Check boxes allow you to choose
several options while a radial button would only allow one answer. This
form can guide a caregiver into grabbing quality documentation.
12.
Now to demonstrate a calculated field (using background formulas that
have already been built) within a form, complete the following steps:
On the navigator column:
Go to the section – Neurological. Find Sensory Perception and click on
the radial button that says Very Limited.
Go to the section – Musculoskeletal. Find Activity and Mobility and
click on the radial button that says Bedfast (Activity) and Completely
Limited (Mobility).
Go to the section – Gastrointestinal. Find Nutrition and click on the
radial button that says Very Poor.
Go to the section – Integumentary. Find Skin Integrity and click on the
radial button of Intact, no abnormalities.
Forms can be structured to help the new caregiver provide better care or
in our case; it helps the academic side understand new content.
13.
14.
To sign the document, you MUST click on the green check mark located
in the upper, left hand corner of your screen. This will sign AND save
your document.



You may get a pop up box that reminds you of the Fall Risk that
this patient has and provides more information to the provider in
this area.
You can click Task>Delete message once you have read the note.
Click on the X to close the message box.
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15.
16.
17.
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
You may get a pop up box that reminds you of the Fall Risk that
this patient has and provides more information to the provider in
this area.
 You can click Task>Delete message once you have read the
note.
 Click on the X to close the message box.
Click the Close button once the Ad Hoc Charting screen appears.
Viewing your newly created form.
There are three tabs where you are able to view your completed form:
Reports, PowerNote and Form Browser. We will use the Form Browser
for this example:
Click on the Form Browser from the Navigator/Menu column.
18.
To view: double click the line that the document is on
To modify: highlight the line that the documen is on, right click and
choose modify
To unchart: notice how you are unable to really ‘delete’ this document.
This creates a trail of what has been documented and by whom. In
each facility, there should be policies and procedures on how to amend
an entry in a EHR.
Troubleshooting tip: If you don’t see your document, click on the
Refresh button (two arrows followed by the # minutes ago) in the upper,
right-hand corner of your screen.
Adding Form #2 in Ad Hoc Charting
1.
We will add another type of note in your patient’s chart. An advanced
directive is a common form as it should be filled out on each patient at
your facility (or at least addressed in conversation).
Click:
 Chart
 Ad Hoc Charting
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2.
3.
4.
5.
6.
7.
8.
Click:




PowerChart
All Items
Admit/Discharge/Transfer
Check the box in front of Advance Directive
Click on the Chart button
Click the radial button of “YES” to the Advance Directive question.
Notice how boxes turn from gray to white when you choose it. Yellow
indicates to the user that the organization has deemed this element of
the form mandatory in order for the form to be properly completed and
published into the EHR.
Type in an advanced directive date – usually the date the document is
signed by the patient. You can make up a date for this assignment.
Click the check box in front of “Living Will”.
Click the radial button of “Copy obtained from previous record.”
Click on the green check mark to sign this form. (upper, left)
Click the Close button once the Ad Hoc Charting screen appears.
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Adding Allergies
1.
We will now add some allergies to your patient.
2.
3.
4.
5.
6.
Still in the chart ~ Click on Allergies + Add on the navigation column.
Click on the Search Tab and type in the drug “Aspirin” and click on the
search button.
Choose and double click one of the listed items that appear.
Your choice should now appear on the right side of the screen in the
Substance box.
You may get a pop up box similar to the one you see below. This is a
decision alert, indicating that there is a potential issue. This tells the
healthcare provider that this could be a allergy/drug interaction and may
cause issues for the patient (possibly even death). Click OK to move
on.
On the right side of the box, make entries for:
 Reaction type (#2) = allergy
 Reaction symptoms (#3) = Type in rash and click Add Free
Text
 Allergy details (#4)
 Status = Active
 Severity = Mild
 Onset = Type in Today’s date
 Click Apply
 Click OK
The newly created allergy should now be listed on your patient’s chart.
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Adding/Placing Orders
1.
We will now add in some made believe orders to your patient for exploration
sake.
2.
3.
4.
5.
6.
Click on the Orders + Add button on the Navigation/Menu column.
Place the cursor in the Find box and type in the lab test: CBC
Click CBC w/indices from the list when it appears in the box. You may be
asked to enter an ordering physician, if so add in your faculty’s name as the
acting physician.
Note: when you double click, the order will be added behind the Add Order
box, so it may be tough to see if it was added or not.
Click DONE to close this box and proceed with the order.
Your screen will look simialar to this image below.
You will notice some bolded items. These items are deemed ‘required’ by
the organizaiton and must be filled out properly so that the order can go
through to the lab/pharm, etc.
Fill in under the Details tab (middle of the screen):
Specimen Typer = Blood
Collection Priority = Routine
Fill in under the Diagnosis tab (middle of the screen):
Please make up a dx for your play patient by clicking the Add button and
selecting a dx.
7.
8.
Click the Sign button in the lower, right-hand corner to complete your order.
Still on the Orders Tab, click on the Orders + Add button on the Navigation
column and order the drug “Aspirin.”
Once you click on Aspirin, a decision support alert will pop up and notify the
care giver that this patient is allergic to the ordered drug and will ask the
user if they would like to proceed. (if this alert does not pop up, then
perhaps you didn’t save the allergy in the Adding Allergies section earlier in
this assignment).
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Updated 09/09/2014 NS
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9.
When this pop up screen appears, choose a current override reason
(located in the lower, left) of “deferring to other priorites.” This means that
you still want to override the alert even though the patient is allergic to it.
This might happen if the patient has a mild reaction to the drug, among
different scenarios. Click OK.
10.
On the Orders Tab, you’ll see that your order of Aspirin is incomplete (notice
the large, blue X?). Look at the Details tab and complete all bolded details
and selecting by filling in the answers on the right side of the screen: Dose,
Rt of Admin, Frequency, Duration, and Refill Use the small scroll bar to
move down through the list of details. There are several more.
10.
On the Orders Tab, you’ll see that your order of Aspirin is incomplete (notice
the large, blue X?). Look at the Details tab and complete all bolded details
and selecting by filling in the answers on the right side of the screen: Dose,
Rt of Admin, Frequency, Duration, and Refill Use the small scroll bar to
move down through the list of details. There are several more.
___________________________________________________________________________________
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Updated 09/09/2014 NS
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When all details are complete, the blue X should disappeaer, and the SIGN
button becomes available. Click the SIGN button at the bottom to complete
the process. Click on the Update box to update the orders list and see your
new orders.
Adding a PowerNote
1.
A different type of form can be added to your patient as well. This type of
form will build as you click through the process.
Click on the PowerNote + Add tab on the Navigation Column. (click
specifically on the word “Add” to get the screen below).
2.
3.
Use the drop down menu and highlight: Admission Note – Physician
On the Enter Pathway Tab, search for SOAP.
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4.
Highlight SOAP Note General and click OK.
5.
6.
A note will open with several options.
Start with Results Review. If you click on the plus + to open that next level,
you will see you can document on General results with various data
elements to pick from on your right. Begin selecting information on your
‘patient’ and notice how the note will build as you click through the criteria.
7.
8.
9.
10.
Note: During this exercise, your cursor will often turn to a plus+ sign
to ADD something to the document/note you are building on this
patient. After it is added, you can hover over it again and your cursor
becomes a minus- sign to take the content away.
Click on + sign before the Subjective section. This opens up more
information to be answered to the right.
Continue clicking/adding all the way throught the
Objective/Assessment/Plan sections, adding in information on your ‘patient’.
This information can be fictional.
Once your note is complete, click the Sign/Submit button on the lower, right
hand corner.
The note will be saved and should be listed on the screen. If you wish to
view the document, highlight it and it will appear on the right hand side of
the screen.
___________________________________________________________________________________
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Updated 09/09/2014 NS
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11.
There is another place you can view your completed form, in an integrated
way. Click on the Chart Summary tab on the Navigator column, refresh the
screen if necessary (upper, right) and review all the data that you have
entered on your patient on the flow sheet and in the forms area (upper right)
12.
Notice all the kinds of information that can be entered into a patient’s chart.
Structured, un-structured, free text – all of them serve a purpose and can be
used in many places. The main goal is that you collect the information
once and have the system work for you, building it to have all information
available at all times to used by different users to improve patient care.
___________________________________________________________________________________
The College of St. Scholastica
Updated 09/09/2014 NS
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