Cerner System

1. Cerner System for Nursing Students

2. Welcome Welcome to the Legacy Health System. We hope that you enjoy your clinical experience on one of our many dynamic nursing units. The purpose of this presentation is two-fold: 1. To describe Legacy’s general principles for documentation of individualized, goal-directed care provided by the interdisciplinary healthcare team using a variance-based model. 2. To describe the core documentation components of Legacy’s electronic medical record-Cerner

3. Variance-based charting • LHS has a policy that defines variance-based charting and outlines documentation responsibilities (LHS.900.2114) • It is critical as caregiver that you follow the LHS policies • You put yourself at risk professionally when you do not follow the policies

4. Variance-based charting 1. A variance is a deviation from the expected outcome during the patient’s course of care. 2. A variance is also a deviation from the expected or standard interventions and those interventions that the patient actually received as listed in -Standards of Care (SOC) -Physician’s orders -Interdisciplinary orders -Clinical path/plan of care

5. Examples of a ‘variance’ 1. Using nursing judgment, you did not take the 0400 vital signs. You must document this variance, as it was part of the standard of care. 2. Your patient complained of severe pain after the urinary catheter was removal. You must document this variance, as it is not an expected outcome of urinary catheter removal.

6. Standards of Care Standards of Care The SOCs are a pre-printed “script” that describes expected, routine or basic care that the Interdisciplinary team provides for the patient. Each SOC is a POLICY, so as a caregiver, you are accountable to provide the defined care to the patient.      The SOCs are written to be population specific (e.g. Critical care, Pediatrics, NICU, Psych) and condition specific (e.g. Pulmonary, Surgical, Orthopedic).

7. Standards of Care There are 3 sections to each SOC 1.    PATIENT EXPECTATIONS: Care provided will assist the patient/family/guardian in meeting certain expectations. 2.    INTERVENTIONS: The RN coordinates the interdisciplinary plan of care and applies the nursing process. 3.    INTERDISCIPLINARY PLAN OF CARE: Within each discipline’s scope of practice, the interdisciplinary team collaborates in providing the following care as warranted by patient condition and caregiver judgment.

8. Word Definitions in the SOC What does assess and reassess mean in a SOC? DO IT (the ordered intervention) and DOCUMENT your findings @ the stated time frequencies. What does monitor, initiate & provide mean in a SOC? DO IT at the stated time frequencies, but, you don’t necessarily need to document the intervention unless there is a change from your baseline or significant additional information.

9. Standards of Care • The Standards of Care notebook is found at the nursing station. #This contains the LHS fundamental patient care directed policies (Standards of Care), complex identifiers, isolation signs and other unit specific information sheets.

10. Signing into Cerner Security/confidentiality. No employee/ student has the right to access or disclose patient information except as necessary to fulfill his or her job responsibility. Breaches of confidentiality might include: reviewing data of family, neighbors, co-workers, local celebrity, patients transferred out of your unit and looking up information about yourself. Help desk – 55888

11. Sign–In to either: 1) PowerChart; 2) PowerChart Physician; or 3) PowerChart Ed; or PowerChart Surgical – This will depend on the unit you practice

12. Sign-in Your User Name will be given to you by your instructor. Your first password is the same as your user name. Change your password and do not share it with anyone.

13. Patient Census screen After you sign in the census of your unit will appear. Please note visitor status. To open a patient’s chart, double click on the patient’s name.

14. Visitor Status (Release of Information) If a family member calls or comes to your unit, you may give out the following information depending on the visitor status. • Fullrelease– name and room number • Partial release– name only • Norelease – no name or room number (all ‘police holds’ and psych patients are no release)

15. Your own chart tab To make your own chart tab, click on the wrench

16. Click on ‘New’

17. Choose ‘Custom’ and ‘Next’

18. Type in a name for your list and click ‘Finish’

19. Highlight your list name, click on the blue arrow to make your list ‘Active’ then click ‘OK’

20. Your own chart tab Copy and paste to your chart tab by highlighting your patients and using copy/paste under ‘Edit’. Delete your patients weekly.

21. Patient’s chart Patient Info chart tab – lists demographic information. Banner bar (yellow bar) contains admit date, time and allergy information.

22. Patient’s chart The Tool bar is above the banner bar. All patient information is listed below. To view an allergy, click on ‘Allergies’.

23. Allergy screen View allergies and reactions here

24. Orders chart tab This is your Plan of care. Categories are shown in blue.

25. To read the SOC, double click on the icon in front of each SOC.

26. Review the SOC. Click on ‘OK’ when done.

27. Progress Notes Document patient activity to and from the unit: Include time/date/mode of transport. Document all calls made to the MD, include summary of conversation, even if orders were not received. Document Code/Emergency situations or expanded narratives.

28. Notes Chart tab Rt click here To make a progress note, right click on the white screen.

29. Note Chart tab Fill in ‘Type’ with ‘Nursing Progress note. Fill in the subject line and body of the note with information. When finished, click on sign.

30. Note Chart tab Review completed Progress notes by double clicking on the folder in the left column.

31. Shift Assessment • Every nurse should be using the same criteria to guide the type of data they collect for their patient assessments. Literature finds that this does not occur without guidelines. • Therefore, Legacy has created system-wide assessment statements that act as guidelines to ensure that the patient data collected during a shift assessment is consistent and covers the parameters of a minimum assessment. These are called Norm Statements.

32. Norm Statements Norm statements define baseline criteria required to be assessed with ANY assessment or reassessment of a particular category. Norm statements help define consistent assessment parameters.

33. Systems that the Norm Statements cover • Neurological • Cardiovascular • Pulmonary • GI • GU • Skin/wounds/drains • Psych/social/spiritual • Pain

34. Example of a ‘Norm Statement’ **Norm statements reflect subjective and objective assessment findings. Neuro Norm statement – Alert/attentive, oriented X 3, follows complex commands, clear thinking. MAE with symmetry of strength, facial symmetry. Speech clear and appropriate. Sensation intact.

35. Each clinical area has specific ‘Norm Statements’ that guide the shift assessments. • Adult Critical Care • Adult Med/Surg • Peds • NICU • Newborn • Postpartum • Antepartum • PACU/SSU

36. Met Norm Statement • FIRST-assess your patient. * Read the norm statement criteria* Ask yourself “ Does my patient look at least like the norm statement criteria?” • If you can answer “yes”, then chart “MET” You have just saved yourself the time of charting the information contained in the norm statements. You may also add additional assessment findings that are not included in the norm statement. (Decreases the amount of narrative charting needed).

37. Unmet Norm statement • FIRST-assess your patient. * Read the norm statement criteria* Ask yourself “Does my patient look at least like the norm statement criteria?” • If your patient does not look like the ENTIRE norm statement, then you must chart “UNMET”- >>you must also describe how your patient assessment is different from the norm statement. (This is your documentation of variances from the norm statements)

38. INET Chart Tab – Shift Assessment To view the norm statement for each assessment, right click on line below each assessment, e.g. Neuro norm.

39. Neuro Norm statement The norm statements for all disciplines are listed here. When done, click on ‘OK’

40. INET Chart tab - VS Double click on the time to start charting. When charting is complete, click on the green check.

41. I & O Chart tab To begin charting, click on the ‘start charting’ icon. When done, click on the green check.

42. I & O Chart tab To add more categories, click on the ‘ display hidden category’ icon.

43. Display hidden categories icon Double click on the folder and click on the category to add.

44. MAR Chart tab The yellow vertical line shows current date and time. The red box is a late med. To give a med, click on the box with the dosage.

45. Charting a med Change the time if needed, then click on the green check to sign the document.

46. Documenting the prn response When you give a prn med, a ‘prn response’ box will appear. After sufficient time, click on the ‘prn response’ box to document the patient’s response.

47. Prn Response box Fill out response boxes and sign (green check)

48. Charting an IV on the MAR This form needs to say ‘begin bag’. If it says ‘infuse’, click on begin bag above to change. Then click on Apply and sign (green check)

49. Recent Results You can see all entered data here except medications. Right click on the green bar to change the date of the results.

50. Task Chart tab Choose ‘All continuous tasks’ to sign to your ‘SOC’ . Double click on Standard of Care Charting.