CERNER MILLENNIUM Basic Workflow & Documentation in PowerChart

1. CERNER MILLENNIUMBasic Workflow & Documentation in PowerChart In this demonstration we’ll review creation of documentation in PowerChart. This example will be for an outpatient visit note, but the process is similar for an admission H&P, consult, daily inpatient progress note, etc. It will utilize the Dynamic Documentation approach, which is the way most users will create notes. (An older method of note creation, called PowerNote, is still used in a few settings; that is not reviewed in this lesson.) This has been prepared for Millennium code level 2015.01.15 & mPage 6.0. Subsequent updates may display cosmetic & functional changes. Use the keyboard or mouse to advance.

2. Introduction • There are several variations in how an encounter can be documented using DynDoc. We’ll first present here the basic Cerner-recommended approach using workflow tabs, or mPages. • Then we’ll mention a couple variations. • We’ll assume here the user has a basic knowledge of entering structured data (meds, allergies, past histories, problems, etc.), so we won’t go into great detail on those here. An online lesson titled Abstracting Old Records Into Unity reviews this workflow in more detail.

3. In this example, the nurse has recorded vital signs, chief complaint, & reviewed medical histories. The provider begins on the Clinic Workflow tab. Remember that you can drag the navigational links up & down to suit your workflow, but we’ll present one logical arrangement here.

4. After reviewing vital signs & chief complaints, document the HPI. This can be done via typing, text shortcuts called AutoText, or through Dragon voice transcription. For help in creating AutoText or learning how to use Dragon voice transcription, please review the other training materials on these topics.

5. Next review the Problem List. The Problem List can be a little confusing, because it serves two different purposes in the Cerner EHR. The first, as the name implies, is to document a history of chronic problems. Here we see Allergic Rhinitis listed, with the designation of Chronic.

6. For the purpose of this example, we’ll record migraines as another chronic problem. Change the Add new as selection to Chronic. Then in the search box start to type migraine. A list of results will appear as you type. Click on the desired item as it appears.

7. Migraine now appears as a chronic problem. We’ll get to the second use of the Problem List section a bit later.

8. Next review the past procedural, family, social, & OB histories as desired. You can tell by the numbers on each tab that they contain data. If you need to add any additional entries here you can click the Histories heading to have an opportunity to do so.

9. This is the same as going to the Histories tab on the Table of Contents. Go to each of the 4 tabs to enter those histories as necessary. We won’t do that in this demonstration, but you’ll find detailed examples in the Abstracting Old Records Into Unity online lesson. When done, click the Home Button to return to the workflow mPage.

10. Moving down, review the home medications & allergies. Clicking the + sign next to each heading would allow you to make additional entries. For this demonstration, we won’t do that.

11. Next we’ll record ROS & physical exam. Both can be done via typing, AutoText, or Dragon transcription. A common approach is to apply your usual normal language via AutoText, then change the positive findings as necessary.

12. While there are none to see on this demo patient, you could review previous lab & imaging results from here.

13. An even more complete tabular view is available on the Table of Contents Results Review heading.

14. Perhaps by now you’ve formulated a diagnosis. This is where the second use of the Problem List comes in. Navigate back to the problem list, & select This Visit in the Add new as dropdown list. In the search box start to type bronchitis, & click on the desired diagnosis as it appears.

15. Bronchitis is now on the list, labeled as This Visit. “This Visit” is Cerner’s term for a billing diagnosis, or ICD 10 diagnosis, in contrast to “Chronic,” which designates an item on the Chronic Problem list.

16. You can also click both This Visit & Chronic, to indicate a diagnosis is both a chronic problem & also a billing diagnosis for today.

17. Now we’ll move down to the Assessment and Plan section. You’ve actually just added your billing diagnoses for today, so this is mainly a discussion of your plan. You can type or use AutoText—which is especially useful for common problems. But this is also a good spot for Dragon voice transcription, so you can “tell the story.”

18. We need to order the chest X-ray, CBC, & azithromycin we just mentioned, as well as enter a visit charge. An easy way to do those things is to go to the Quick Orders tab; for the provider in this example, that is called Family Med Orders.

19. The CBC, chest X-ray, & visit charge are easily located. Click on each one.

20. The 3 items you just ordered are queued for signoff, in what is sometimes referred to as the checkout cart. To prescribe the azithromycin, in the New Order Entry search box start to type azithromycin, & click on the desired selection as it appears.

21. While not applicable to this example, note that you can also search for orders not available on the Quick Orders page, as well as order sets (aka PowerPlans) in the same manner.

22. If you don’t see what you need, click the New Order Entry + sign to perform a more detailed search. That’s the same as clicking Orders +Add on the Table of Contents Menu.

23. Back on our example, all orders have been added to the cart. Now click on the checkout cart.

24. The orders in the cart are shown. You can associate diagnoses with each order, then click Modify to review order details.

25. The Orders for Signature list appears. Often there will be additional details to complete. You could click on each individual order to do that, or click the 5 Missing Required Details button to work through those details.

26. Required fields are usually highlighted in yellow or have an asterisk. For azithromycin, we need to Select Routing for the prescription.

27. In actual usage this would usually not be a problem, since the patient’s pharmacy would have been entered, & the default would be to electronically transmit to the pharmacy. Since we can’t do that in this demo environment, I’ve made another selection. (Controlled substances will be sent to a printer for the time being.) The Missing Required Details count has decreased to 4. Click it again.

28. The CBC Collection Priority is also required. After selecting Routine, the Missing Required Details count dropped to 1. (Sometimes the count is just a little screwy that way.) Click the Missing Required Details button again.

29. The final missing detail was a reason for the chest X-ray. After selecting one, there are no more missing details, so click Sign.

30. When you’ve placed all your orders, return to the workflow tab. You drop back to the Quick Orders tab. Before we go, notice another order you can place here, either now if you’ve already made a decision, or later. Clinic Follow-Up sends an order to your staff to schedule the patient’s next appointment during checkout.

31. In the Patient Education section, you’ll see several suggestions based on your diagnoses. Select one or more.

32. The selected education can be previewed, edited if desired, then printed by you or your staff. It is also sent to the patient portal. (You could manually search for additional patient education if desired.)

33. There is also a Follow Up component here, not to be confused with the clinic follow up order mentioned above. This just gives your patient instructions on when to follow up, & who to see. (This will be included in visit summaries.) However, if you’ve used the follow-up order above to schedule the next visit, there’s no need to repeat yourself here. But if you need to change the PCP, or recommend that the patient also follow-up with additional doctors, this gives you an opportunity to do that.

34. The final step is to create your note. You can do that under the Create Note section at the bottom, where you can select the default note type if one is shown, or Select Other Note. Clicking the + Sign next to Documents at the top does the same thing. For this demo, we’ll click the Documents + Sign.

35. The first thing you’re required to do is select a Document Type. From the dropdown list we’ll pick Family Medicine Office Clinic Note.

36. Then double-click on the desired Note Template. Here we’ll take Office Visit Note. Tip: Clicking the Star next to a template adds it to the Favorites tab at the top.

37. Your note is generated. You can scroll up & down to review. You can also directly edit or make additional entries here via typing, AutoText, or Dragon voice transcription. When done, click Sign/Submit.

38. You can generate a letter about the encounter if desired. You could forward the document to others to review as an FYI, or to cosign (something residents & students will need to do). Search for the name, then select Sign or Review. But if you don’t need to do any of those things, just click Sign.

39. Lagniappe • The above illustrates the Cerner-recommended approach of using mPages to review data & create a DynDoc encounter note. • But here are a couple of variations on the theme you may find useful.

40. After your staff as roomed the patient, instead of entering HPI, ROS, etc. via the workflow mPage, you could go straight to generating the note. For this example, we’ll use the direct link to Family Medicine Office Visit.

41. The note generates with what’s available thus far: The nurse/MA entries. You have a chief complaint, an ROS if the nurse did one, & vital signs. You also have all the structured data (med list, allergies, past history, etc), that has been entered on the chart, either previously or by the nurse today.

42. Rather than using the mPage, you can directly make your entries here, via typing, AutoText, or Dragon dictation. An HPI entry is illustrated here. Many people may prefer this, since you get immediate feedback on what your note will look like.

43. In the course of your encounter, you may discover other historical details you need to enter into the record, such as additional meds, allergies, past histories, problems, etc. If that happens, you can return to the mPage, or use the Table of Contents to add those details. For example, suppose the patient adds that he has hypothyroidism, & is taking Synthroid. Click Problem List.

44. Search for & add hypothyroidism to the Problem List. Then go to Medication List.

45. Click Document Medication by Hx.

46. Click +Add.

47. Search for & select Synthroid 100 mcg daily. Then click Done.

48. There are no details that need changing, so click Document History.

49. Now go back to your document. The easiest way is to click Documentation on the Table of Contents Menu.

50. Click the Refresh button for the Problem List. (Do the same thing for the Medications section.)