Cerner Charting Tutorial

Introduction

• Purpose of tutorial: Introduction to Cerner charting for clinical practice.
• Focus: Navigating PowerChart and charting basics.

Logging into PowerChart

• Access with your user ID and password.
• Initial screen setup may vary.

Setting Up Patient Lists

• List Maintenance: Navigate via the wrench icon or hyperlink.
• Creating a New List:
  • Click 'New', select location, and add to active list.
  • Choose full unit if returning to the same unit frequently.

Establishing Patient Relationships

• Click 'Establish Relationship' to choose role (e.g., Student Nurse).
• Access to patient charts for charting.

Care Compass Screen

• Displays list of patients and new alerts (e.g., orders, results).
• To-Do List: Shows current and upcoming tasks (e.g., medications, admissions).
• 12-Hour View: Displays all tasks for the shift.
• Communicate with your nurse about completing tasks.

Navigating the Patient Chart

• Patient Summary: Overview of labs, medications, procedures, and history.
• Medication Administration Record (MAR): View all medication details.
• Interactive View (I-View): Main area for charting, especially assessments.

Charting in Cerner

• Vital Signs: Chart in real-time using 'Insert Date and Time'.
• Screening Tools: Include sepsis, Braden, and fall risk assessments.
• Highlight items to chart; only highlighted items appear for charting.

Systems Assessment

• Navigate through and select relevant systems to chart (e.g., neuro, respiratory).
• Dynamic Groups: For detailed charting like wounds.

Lines, Tubes, and Drains

• Chart IVs, central lines, and drainage specifics regularly.
• Ensure IVs are documented at least every 2 hours.

Intake and Output (I&O)

• Chart end-of-shift I&O, clearing IV pumps as needed.
• Document urine, stool, and drainage metrics.

Medication Administration Wizard (MAW)

• Scanning Process: Scan patient and medications.
• PRN Medications: Check availability and timing.

Additional Features

• Results Review: Access detailed lab and diagnostic information.
• Reassessment Tab: Chart changes or confirm no changes efficiently.
• Adding Notes: Use comments for additional details, or create detailed notes in 'Notes'.

Authentication

• Student charting requires co-signing by the nurse or instructor.
• Ensure all charting is authenticated to be part of the patient's medical record.

Conclusion

• Remember to communicate with your nurse or instructor for guidance.
• Best of luck with your clinical practice!