hello everyone um i am going to go over some cerner charting with you today this will be a very brief tutorial just to get you jump started for your first day of clinical on where to chart where to find things in the patient's chart just the basics uh to get you through your first clinical day so to start off we will log into powerchart now this is a training environment that i have said but still you will still see a power chart when you first log in with your user id and password so you will select power chart when you first go in so it's taking a minute to load up for me and i have to type my username and password in again okay so now we are in power chart um however you may not see this screen to begin with i have selected a care area that is giving me a list of patients so when you first log on you likely will not have this when you first log in you can either go to this list maintenance button right up here or you will have an option right in the middle of your screen that same list maintenance button will be like a blue hyperlink to link you to your patient care area so what you're going to do is you're going to go to that little wrench there pick your list maintenance and you're going to likely not have access and you're going to need to create so here you're going to go to the new button and in the new area you're going to pick your location and in your location then you're going to go to next and then you're going to go up here again to your location and hit that little plus sign right next to it that opens up all the different lhn facilities and areas and where you're going to scroll to is gonna go down we're gonna go to lutheran hospital as soon as i can find it and here we are here's lutheran hospital we're gonna hit the plus button again and one more time and then it opens up all of our units um so for today you know you could be going to various different locations whether it's telemetry or med surge or any of those but today i am going to go ahead and choose neural med surge so you often see that they start with inlh but then after that will be the abbreviation for the unit that you're on so i'm going to go ahead and pick the entire neural med surge i'm not going to hit the plus sign and just pick the patients i have today because if you're going back to the same unit week after week you're going to want the whole patient the whole unit census so i'm going to click that box for neuromed surge and then it's going to put that right down there at the bottom it's going to say i know i nlh neuromed surge you can change the name of that if you'd like you could change it to just make it say nmf you know you can abbreviate it whatever way you'd like i'm just going to leave it the way it is then i'm going to go to finish now i do have it over in my available list but in order to be active i need to put it into my active list so i'm going to click on my available list of neural med surge and push my blue arrow and put it over here to my active list so i now have that as my active list then i'm going to hit ok so it takes a couple minutes and now i have so here was the list i already had but i'm going to go to my neural med search since that's the one that i had picked and now i have this here's what you might see as well so you have your whole list here um on your initial screen you might have this list maintenance so that's what i had mentioned that you can go back and forth to either one you know what i'm wondering if there is just no active patience there must not be any patients in my neuromed surge so um i'm going to go back to my med surg 4a list since i did have some training patients in that area so when you go back to that i'm going to go back here now i have um my had already established relationship with this but so you will not see all this but so what you would want to do is click this establish relationship button and then that will give you the option to pick your role you know as a student nurse or patient care tech um you know for rns it either will be primary secondary nurse that will help you establish that relationship because then you can open up your patients chart and start charting so here is your is your beginning care compass screen so here in the care compass screen is where you'll see your list of patients now like i had mentioned i've got the entire unit showing up here but you can establish a relationship with just only your patients so that way um you know not all of them will be active so in this screen then you have these um exclamation points that will show you you know new orders or new results that have come in on your patient that you can pick and just see real quickly what it is so there is new order for just peripheral iv care um you know those type of things and then you can click down here that you've reviewed it so that just shows you real quick kind of new things like that that can alert you that there's new things that have occurred with your patient then this little arrow here if you click over on that arrow it will open up your like to-do list so here it'll show you current medications that are due this patient in particular has an admission history that needs completed also shows you medications that are due you know in the next two hours so you can either if you don't want to see meds you can unclick it so then it takes meds off you know if there's certain things that you don't particularly want to see you can unclick those things i recommend just keeping them all highlighted so you can see all the things on your to-do list also the another nice thing with this screen if you go to your 12 hours if you're there for a 12 hour day if you click on that then it will show you everything you know all the way through until midnight now this particular patient is only showing that they have a cephazolin do and then they don't have uh you know there's a levaquin that's due at 2200 but if you only have the two hours open it's not going to show you what's due later in your shift so if you do the four or two 12 hours there again that shows you everything that is due on your 12 hour shift so you can make notes and write down you know when your medications and such are due so it's a handy little tool to have there now once something is complete now this will be very dependent upon you know your nurse may not want you as the student to complete items because once you um complete items on the to-do list it no longer shows up so then she you know may want to have known that you know may want to take care of it herself so that would be something you want to be in communication with your nurse um or your instructor regarding um so like this one here consult is social services so if i oh it doesn't let me not letting me click it bad example all right so here here's a med history reconciliation so if that was something maybe you went over medication with your patient to make to you obtained a list of their home medications or something like that you can click on that and it does need to be charted so that's not something that you as a student would necessarily be charting in the medical record so that would be an example that you wouldn't want to necessarily just click the done button because then it will clear that from the to-do list well and it'll prompt you to go in into addressing that as well if it is a certain thing so that may or may not be something that you would want to complete for your nurse but again just communication with your nurse regarding that all right let me get out of this screen okay so now i'm going to go into the actuals patient chart so here on your care compass screen it just again it shows your you your to-do list and the different things that you have to do for the day and can show you brief little orders that have recently been put in if you want to look at them by clicking on those exclamation points down at the bottom it gives you your timeline so if you hover over it and click on it it will show you all the things that you have overdue for all the patients that you have assigned yourself so you can see here it shows me all my patients and the things that are overdue for all those patients so that's what that big red box is for all right so now we're going to go ahead and go into a patient chart we'll go into this inlh acute rn2 um there's no active patient status order on this um so this patient has no active order for inpatient status but here is your once you go into your patients chart this is a nice overview of labs vital signs there is medical history in this screen let me tab down here so it shows you know their most recent lab values shows both their medications and their home medications so that's useful if you have papers right or something you can see a brief overview of what they're on currently and what they were on at home any procedures they may have done their social history if those have been charted you know as far as their um if they're on on you know their smoker or and then also family history as well and then also in here it will show you um some notes so this one here is oxygenation and ventilation so there's some notes on blood gases so and then patient assessment so as long as an assessment has been charted you know if you want to see what the previous nurse charted you can see you know those things that the patient um was you know experienced in the last assessment you know if they have uh crackles or any differences in the previous assessment to the assessment that you've done you can easily see that right there as well and then also here under this document section is where you can find a lot of your progress notes your history and physical so if you want to look up more information on your patient this is just a great area to find all that info information in this inpatient summary so that right there that screen is what it defaults to it brings you to your care nurse patient summary so it gives you lots of good useful information there then up here the first tab that's your mar so your medication administration record so there is your mars where it shows you what medications are on when the last time was they had them it will show you all your prn meds or continuous infusions all those needed things that you need to know as a student nurse if you're going to be passing medication so that's a useful tab as well and then our eye view our interactive view and ino so that is where you will be spending a majority of your time with your charting so in your eye view if it will let me oh it's telling me to associate a device so that is more so if they have a monitor that will activate their vital signs for you that's more so in the icu setting because the vital signs will be slaved over into the patient's chart from the monitor when you associate the device but we're not going to go through that today because that's not something you necessarily need to know just for day to day on a med surg floor but here is your adult quick view here is where you are going to be charting um you know a lot of your initial assessment stuff and your vital signs so here's where you're going to chart your vital signs you can pick a time so now my times are set up for every 15 minutes i am a critical care nurse so that um you know i often am charting vital signs every 15 minutes so but for you um that most likely won't be as necessary so all you have to do if you don't like this time frame of what it's showing you right here all you have to do is right click it and pick something different we'll say you know maybe we can do every two hours so it doesn't show it quite as frequently so then you can when you go into chart you can chart under that hour now you want to char in real time as much as possible so when you're charting then you can double oops i'm sorry let me stop that you can start right here and put insert date and time so then we can do our actual date and time that you're charting so right there it's putting in 16 12. so then i can document during that time frame all my vital signs and you know pain assessment modified early warning system so that's our muse scale so um with that after you chart your vital signs you want to go in and chart your muse scale scale as well and that's something you want to be in in contact with your nurse about if they're scale if they're mu scale it kind of can show big changes in their vital signs and what you need to be addressing so that again if you know that mu score starts to go up that's something you want to be in contact with your nurse about so when you're charting in cerner one thing you have to know is that only the things that are highlighted over here on the left hand pane that's the only thing that's going to show up over here for you to chart so you can see the only thing there's nothing down below that i have charted or highlighted so it's not showing up over here on the right hand side so you have to go through and pick and highlight everything that you want to chart now i recommend um in the quick view you do your vital signs and then your screening tools that we have to do once a shift so those things that we have to do once a shift our sepsis screening tool our brayden our fall risk and then coming down here further frequent documentation so that's another our frequent documentation is the tab that we use to chart our hourly rounding so you want to do that and then you have your vte risk assessment is there as well so i recommend in the quick view charting some of those things because even though there is some things here with the systems assessment it's not everything in total so i recommend just doing those things that you do at least once a shift and then your like i said your frequent documentation your hourly rounding doing it in this quick view tab so then once you have all those things opened up now let me make sure that and also if you double click where your time frame is it'll then highlight you know check box put a check box over all the things that you've highlighted on the left hand pane so once you do that you can start going through and charting those things you just click and push the button and that's it pain level acceptable and a quicker way you know instead of like clicking and then clicking away to get that box to go away if you just hit enter it'll put that there so you can just go through and you know real quickly chart the different things so i'm just clicking i'm not charting anything in in particular but it's going to give me you know my new score so this then my mu score popped up let's see what it'd give me a four so that indicates that you know we probably need to need to do something about it so you might need to start checking your vital signs more routinely or if it is a normal baseline for this patient again just be in contact with your nurse regarding that then you have your sepsis tool you want to have to go through and you know just assess all these things all these things are at least once a shift or braid in assessment so that's assessing their skin and how at risk they are or developing skin issues or skin breakdown and wounds fall risk assessment we always want to assess if our patient is a high risk for falls and if we need to initiate further intervention our frequent documentation so there again you're going to be charting your frequent documentation at least every hour because that's our hourly rounding safety watch would only apply if they are on a safety watch where they're needing to be watched like every 15 minutes or something you know in lieu of starting um using a sitter so but otherwise you know pain their position potty personal items and if their bed alarm is all on you're going to want to make sure you're charting all those things and then our vte risk assessment is there as well so once you've decided okay i've got all that charted then you come up here to your little check box and sign it so i'm going to sign what i have charted now i'm going to go to my systems assessment now here is where you're going to go through and pick all the things so it gives you a big list of things that you can chart on now again i am a critical care nurse so mine is defaulted to icu systems assessment yours likely will just be your your basic systems assessment but here um is where then i go through and i pick what you know of all my head to toe stuff the things that i need to turn i'm going to chart on my neural status my glasgow coma scale may not necessarily do need to do neurological checks unless they are an actual you know stroke or neural patient that you're wanting to perform neuro checks on mental status you know diet check their pupils cranial nerve assessments you're likely not going to be doing neurovascular checks you know checking their cap refill that sort of thing siwa so that's if you have a patient that's going through delirium tremens that might be something that you and the nurse might be needing to address of course respiratory if they're on a cpap or bipap again in the med surgery you're not going to have mechanical ventilation and those type of things but then we have our breath sounds and cardiovascular are pulses edema gi you know a gi tube do they have like an ng tube or a peg tube or something you'll be charting in that assessment genital urinary you know assessing their urine nice green flipped um if they have a catheter integumentary so you know checking their skin color temperature turgor if they have a wound starts out there so in this section so when you get to some of these sections that have these little boxes that means it's a um you know you have to open it up in order to actually take what you're going to charge so it's a dynamic group is what it's called so we'll say this patient has a word or tactic and then you're going to say let's see we don't need to say it's laterally because it's on there toxic and we can just say like a sacral so then you pick it and then it opens up and then you can start charting on it so then um once you start charting it you know you just go through and describe the type of wound it is which we'll say it's a parasima i don't think that's okay not crushing us and then you just go through you know every little thing so quite quite a few things open up when you pick a wound so you may not necessarily have to chart every single one of those things but just the things that lisa apply to that particular patient with their wound so if you come across anything like that where there's a dynamic group you can see there like so this patient um it does have a fully but if you are charting on the fully for the first time this wouldn't be open up and you'd have to pick these little boxes here to open it up so you just want to go through and like i said pickle highlight all the things that you're going to be charting first and then come over here and you know click on the time that you charted it and then go through and start your charting so then your lines tubes and drains i'm going to go here now so i forgot to save it so it came up and said you have unsigned results in the adult iq systems assessment would you like to save them yes i do want to save them nine of my students so here's where you're going to chart your peripheral iv or if they have a central line or any of these other things so they have a chest tube or a catheter you know gastric tube you know some of this stuff might have already prompted you to chart in the systems assessment but your ivs will be specifically right here so here's where you will chart on your ivs now your ivs you want to chart on at least every two hours making sure that they're you know you've been assessing them and that they're patent and no signs of infiltration and again if you're charging on it for the first time it's going to be a dynamic group that you have to open up and say where it's at once someone has done that once though it's already done and it's charted so then you just have to fill in the areas of where the charting you know everything that pertains to that particular patient so again all that stuff is in there and then you have your inos so your i knows uh pretty self-explanatory at the end of your shift you should be charting you should be clearing your iv pumps which that's something your instructor should be able to go over with you and then you chart the amount of iv fluids that they've had in for that day so you know we'll say that patient had 200 about 2 200 ml of that normal saline infusion you also want to chart that at the end you know when a bag has finished you clear your pump and stuff and how much ever amount has left then here is your urine voided so where it says ml that's where you would be measuring it so we'll say they avoided 500 mls but then they had one incontinent episode so we put that under urine count because that's how many times they had a incontinent urine same with stool and anything else if they were to have drains or something that you charted on that would pop up right here as well in the intake and output so we're going to save that and then restraints if your patient is in restraints more so probably if your patient is in the icu on a ventilator or something would you be more likely to be charting your restraint but that is something that needs to be charged every two hours as well so that's the main thing as far as as a student nurse those are the type of things that you're going to be charting and the most important things after that also you have your medication administration wizard so or the maw you'll sometimes hear it referred to as that um so here you'll click on your met admin and here's where you scan your patient's wristband and i have nothing to scan on today so i am going to click next and it's going to give me a warning that i didn't scan my face you know shame on me i would always be scanning on my patients but i'm going to say it's not scanning so then it pops up the medications that are due so here's where you would scan your meds and you know sign them separately have them double signed by your instructor and all that information is here so the nice thing with this if you're giving pr or i'm sorry scheduled medication it does also come up and show you the different things that they have do or have a prn so if maybe you're in there and your patient's like oh but you know i'm having a headache too can i have something for pain you can look right there and it'll show you what they have that they can have prn now you would have to go back into the mar and see if when the last time was that they had had it but at least you can see here what they have available for them but in a lot of these areas here so i'm going to hover over this good oh that's just i thought it was a sliding scale so here so there's 10 units that this patient has due and if they do have a sliding scale and you hover over that it will show you the sliding scale as far as what their blood sugar is and what is due but that is the medication wizard it lives out of that now all these other tabs there's a lot more information over here so i'm not but i'm not going to go through a lot of them because a lot of it is not necessarily something that you as a student nurse would need to be worried about but one thing is your results review so here if you don't see on this initial care nurse patient summary if you're not finding some of the things that you want to see in this screen you can go to this results review and you can look up you know maybe you want to see how far back you know some labs that they've had done but here you can scroll through and see like they're all their hematology so if we go to like last seven days so this patient only has had something on the 25th but these are all uh practice patients so um but like microbiology if they had like blood cultures or you know any any other type of culture is done will be here diagnostics if you want to look at a chest x-ray and you just double click on the result and it should pull up and there it gives you your report of your chest x-ray so your result review is a useful tab as well to look up more information if you're needing to dig a little bit deeper for your patient um let me see let me think if there's anything else i can tell you so again yeah your eye view is going to be your biggest screen for that you're going to be spending a lot of time in as far as charting goes um and then with your one nice thing with sterner um once you have put in your initial um head to toe assessment when you go to your systems assessment when you you know go back you check on your patient in a couple hours listen to the breast sounds again and kind of do another focused assessment you can go to your reassessment tab and instead of having to chart all that all over again you can just you know double click here we'll say four o'clock and as long as nothing has changed in your assessment you can do that you can just chart no change from previous assessment so it saves a lot of time with having to go you know you don't have to go back through and chart all that all over again generally like on the floor you want to be reassessing doing your focused assessments at least every four hours if you're in the icu you're definitely going to be doing it more frequently you know minimum of every two hours or so um but that is just as long as nothing has changed then you can just put no change now let's say your respiratory system um let's say earlier they were clear and now they're sounding more crackly so if i right click here i can i can clear my respiratory system and then i can go down into my actual respiratory area and you know chart maybe now they're maybe now they're labored or they're you know gasping you know things aren't looking good and now their breath sounds um you know they have more crackles in their in their lungs so i can go through and change that and you know just not put anything in that that particular area as far as their reassessment but everything else was okay so those are the main things i'm going to chart and the other thing too you can also add notes to any of your charting so anywhere where you've charted you know in particular let's say you know gi no real changes but we can add a comment and say um i'm just trying to think of an example i don't know kub confirmed tube placement if they have you know an ng tube even though that is an option in your charting anyway so you shouldn't really necessarily have to document something like this but if you want to put a note anywhere you can put that or maybe like in your neuro you know they're alert and oriented but you have to but they're forgetful you know so maybe you can put under their mental status you know alert fully conscious but we can say just add something simple forgetful you know so you can add anything to your charting if if the charting itself doesn't have everything that you want to chart so that's you know all there that you can do in the charting then we're going to go back to saving it and then one last thing so on the notes over here um so if all this charting if you want to do more than just add a simple little comment like you want to write a paragraph of something that maybe occurred for you know if your patient um you know just had an episode of you know forgetfulness and you want to document more than just let a little bit longer even out that you contacted the family and spoke with the family and it's you know it's a normal finding family states that you know that is something that is not new for the patient you know whatever the case may be if you want to document something a little bit longer a longer note you can go to your notes and click on here and then you can just type in a free text not rehab a free text nursing note you can put the subject here and then you can just document your full free text nursing note again on that students i would just you know just make sure it's something that you're in communication with your nurse that you're not over documenting to maybe some things that don't necessarily need to be a part of the medical record so but those are all options there and when you are in one more thing i'm going to mention you as a student nurse and charting needs to be cosigned so after you chart this little box right up here and all your charting is going to have like a little red check mark or red kind of this little symbol right here it's like a check mark with a line through it and it does and i think i believe it's red if i remember correctly so that if you hover on it see it says authenticate so your charting needs to be authenticated um or confirmed you know it needs to be cosigned essentially so the nurse um caring for the patient that day or your instructor should be co-signing your charting so at the end of the day if you still see that your charting has not been co-signed um especially like data signs and stuff because that's very important to be a part of the patient's record um you might just want to make a make a note like um i i see that my charting school is not co-signed today would you be able to verify that for me so because from what i have been told that if things are not so signed it still is not a part of the medical record so just a few tips and tricks of course if you have any other questions concerns regarding your charting i'm sure your instructor will be able to assist you with that or the nurse that is working with you that day i hope that everyone has a good semester and good luck with everything to come thank you