Você está na página 1de 46

Cook County Health and

Hospitals System

PowerNote
Participant Guide
PowerNote
Table
of
Contents


Overview.......................................................................................................................................................1

Objectives.....................................................................................................................................................2

Key Points ....................................................................................................................................................3

Creating Notes..............................................................................................................................................4

Toolbar Icons ...........................................................................................................................................5

Point and Click .........................................................................................................................................7

Links .......................................................................................................................................................10

Free Text Documentation.......................................................................................................................11

Auto Text Entry ......................................................................................................................................13

Comments ..............................................................................................................................................15

Create a New Note from an Existing Note .............................................................................................16

Saving/Signing Notes .................................................................................................................................17

Modifying Notes..........................................................................................................................................20

Deletions ................................................................................................................................................22

Filtering Unsigned Notes ............................................................................................................................23

Searching for Specific Notes ......................................................................................................................24

Viewing the Audit Trail................................................................................................................................25

Images........................................................................................................................................................26

Inserting an Image .................................................................................................................................26

Using Image Drawing Tools ...................................................................................................................27

Editing an Image ....................................................................................................................................29

Deleting an Image ..................................................................................................................................29

Macros........................................................................................................................................................30

Creating a Personal Macro ....................................................................................................................30

Macros........................................................................................................................................................31

Using a Personal Macro .........................................................................................................................32

Editing a Personal Macro .......................................................................................................................33

Deleting a Personal Macro .....................................................................................................................34

Precompleted Notes ...................................................................................................................................35

Creating a Personal Precompleted Note................................................................................................35

Precompleted Notes ...................................................................................................................................36

Using a Personal or Shared Precompleted Note ...................................................................................36

Editing a Personal Precompleted Note ..................................................................................................37

Deleting a Personal Precompleted Note ................................................................................................37

Favorites.....................................................................................................................................................38

Adding Favorites ....................................................................................................................................38

Accessing Favorites ...............................................................................................................................38

Deleting Favorites ..................................................................................................................................38

Preferences ................................................................................................................................................39

Personal Document Types List ..............................................................................................................39

Glossary .....................................................................................................................................................42

Icons ...........................................................................................................................................................43


Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct.18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without
the express written consent of Cerner.
Overview


This course introduces basic concepts for creating a PowerNote. A PowerNote is a template
created for specific documentation needs. These templates allow the user to create a note by
selecting responses from lists of choices, adding comments where needed, or pulling in
information such as allergies, medications, and results.

Physicians may use a PowerNote to document visit information.

The PowerNote section of a patient’s chart will display signed PowerNotes, signed Clinical
Notes and text-rendered PowerForms.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 1 of 45
Objectives


When you complete this course, you will be able to:

• Create and save a new PowerNote document


• Correct a signed document
• Modify a signed document
• Delete an unsigned document
• Create and use a precompleted PowerNote.
• Delete a precompleted PowerNote
• Save a PowerNote template as a favorite
• Locate and sign unsigned documents
• Create a personal documentation type list

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 2 of 45
Key
Points


1. Signed PowerNotes can NOT be deleted.

2. It is important to select the correct document TYPE prior to saving a PowerNote.


Documents saved with the wrong document type will be stored in the wrong folder and
may be difficult to locate.

3. Do NOT enter anything in the TITLE field. The correct information will automatically
default into this field. If it is replaced with free text, it may be difficult to locate.

4. When given a choice, always select the *2G PowerNote type. This is the latest
PowerNote version CCHHS will be using.

5. Always search for, and sign, your unsigned notes at the end of the day.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 3 of 45
Creating
Notes


Cerner Millennium has a PowerNote feature that can be accessed from PowerChart or
FirstNet. The PowerNote feature allows documentation of patient’s visits.

Completed PowerNotes may also be located in the Clinic/Hospital Flowsheets and the Clinical
Notes section of the patient’s chart.

To add a new PowerNote:

1. In PowerChart, open the patient’s chart and verify the right encounter has been
selected. Change the encounter if necessary as documentation must be done on the
correct encounter.

2. Using the Menu, click on the Documentation – PowerNotes option.

PowerNote Toolbar

Note Navigation

Note List Most recently


displayed note

Page Navigation

Creating Notes
Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 4 of 45
Toolbar
Icons


Common toolbar icons that will be used in PowerNote are described as follows

Add a new Forward a View a note’s Display the


PowerNote note audit trail preview pane

Electronically Make View an


sign a note changes to image
a note linked to a
note

Note! Dithered icons (gray in color) are not available.

When a new PowerNote is opened, the following tabs are used to locate the correct template:

Search all Search all Search all Search for Display Note
available saved previously available notes most templates
templates, and/or saved templates recently that have
signed partially organized created by been
notes in completed by the logged selected as
this notes to category. on user. favorites
patient’s reuse on for quicker
chart. other access.
patients.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 5 of 45
Creating Notes
1. Click the icon on the PowerNotes toolbar.

2. In the new note window, select the correct document Type. This field is yellow, indicating it
is a required element. It is important to select the correct document type before opening a
PowerNote template.

3. Change the date/time if necessary.

Note! Do NOT enter text in the Title: field. This field will automatically default from the
PowerNote template selection. If text is entered in this field, it will affect where the note will
be saved and may make it difficult to find the note.

4. Select the corresponding tab to search for the correct PowerNote template.

5. If necessary, change the filter options.

6. Select the template.

7. Click the OK button or double-click on the template to open a new PowerNote.

2 3

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 6 of 45
Creating Notes
The PowerNote template will open in structure view. To display the template in full screen
view, click on the Full Screen Mode icon on the Documentation toolbar. To exit this view,
click on the icon in the upper right corner of the screen.

Point
and
Click

1. The Auto Populate Document will display. This functionality provides the ability to
automatically add patient information to your PowerNote, based on the content version of
the particular note selected.

Select or deselect the items applicable to the PowerNote and patient.

2. Click OK.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 7 of 45
3. In the navigator on the left, single-click on the paragraph to display the options in the
workspace on the right.

Asterisk indicates 2G note

Paragraph

Sentences

Navigator

Terms

Workspace

Hides the structure of a paragraph including sentences and terms.


Displays the structure of a paragraph including the sentences and terms.
expanded Blue Chevrons indicate a sentence can be expanded to show additional terms or collapsed to expose
collapsed only the common terms.
Selected term will be circled with bold text.
Negated term will appear with a slash mark.
The + sign indicates here are additional terms that can be selected to further describe the term.
=== Indicates a term where a number will need to be entered.
Launches a box that allows for freetext to be entered into the note.
Launches a provider search window.
An asterisk indicates the term and its associated terms are set to repeat when selected.

Insert Image icon found on the PowerNote toolbar.

4. In the workspace on the right, single-click on the appropriate sentences and terms to
select. Selected options will display circled with bolded text.
• To delete a selection made in error right-click on the item and select Clear
• To notate a pertinent negative, click on a term a second time. You can also right-
click on the item and select Negate – the item will appear with a slash through it.
Not all items can be negated.
Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 8 of 45
Creating Notes
Note! Required paragraphs or sentences will be highlighted in yellow. All required items must
be completed before the note can be signed.

5. To preview the note before signing it, click the Note View icon above the scroll bar on
the right. Click the Template View icon to close this view.

Term Selection Mouse Action


Select a Term Single Click
Negate a Term Double-Click
Clear a Negated Term Single Click

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 9 of 45
Creating Notes

Links


Links to import patient information may be available in some PowerNote templates. Examples
of information that can be imported using links are: allergies, current medications, lab results,
vital signs, etc.

To use a link:

1. Point and single-click on the sentence that starts with Include…

2. In the example below, the Include allergy profile option is used which opens the Allergy
Profile section of the patient’s chart.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 10 of 45
Creating Notes

Free
Text
Documentation


Free text entries may be added to any section of a note using the OTHER option.

Example of “OTHER”
option for free text.

Example of “OTHER”
option for free text.

To add free text in the OTHER field:

1. Right-click on OTHER and select Enter your free text here.


Open.

2. Type the information.

3. Click the OK button to save the


information and close the window.

The new information will display as a selection.

Note! Do NOT double-click on the free text entry after closing the window. This will delete the
entry. If this happens, from the Menu bar, click Edit and then Undo.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 11 of 45
Creating Notes
To modify free text entries in the OTHER field:

1. Right-click on the entry and select Open.

2. Make any necessary changes.

3. Click the OK button to save the information and close the window.

To delete free text entries added using the OTHER field:

1. Right-click on the entry and select Clear.

Single-Click = Open OTHER


Double-Click = Delete OTHER
Right-Click = Menu > Clear

As notes are being created, a check mark appears to the left of each section in the navigator
indicating documentation is present.

A yellow highlight indicates the current section that is being displayed.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 12 of 45
Creating Notes
Auto
Text
Entry

Auto Text entries allow for freetext to be saved and inserted into a note, saving time when
entering redundant text or large amounts of text. Auto Text is created, managed and inserted
in areas of the note that allow for free-texting - the white space found after the note heading or
before and after text within the textual rendering of the note.

Create an Auto Text Entry


1. Click in the area of the note that allows for free text.

2. Click the Manage Auto Text button on the toolbar.

3. Click the Add Text… button.

4. Enter the text the Formatted Text Entry dialog window.

5. Click OK.

6. Enter an abbreviation and description in the Abbreviation and Description boxes.

Tip: Since Auto text is available within any section that allows free-text such as an
OTHER/WHAT box or free-text area within the note; the tip is to utilize "ZZ" or a special
character such as a period (.) or asterisk (*) in front of your auto text. This will help in
eliminating your auto text to not pop up continuously as zz is not a common letter used.

7. Click Create.

8. The abbreviation and the description will display as an available phrase.

9. Click Close.

Insert an Auto Text Entry


1. Click in the area of the note that allows for free text.

2. Enter the abbreviation of your auto text. A list of abbreviations will appear.

Place the mouse pointer over the entry will display the description of the Auto Text.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 13 of 45
Creating Notes

3. Double click on the entry or press ENTER to insert into the note. The special characters are
replaced with the Auto Text.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 14 of 45
Creating Notes

Comments

Comments may be added to a selected terms.

To add a comment:

1. Right-click on the selected term.

2. Select Comment.

3. Type the text of the comment in the corresponding window.

4. Click the OK button.

5. The comment displays in (parenthesis) to the right of the selected term.

To modify a comment:

1. Right-click on the comment in (parenthesis).

2. Make the necessary changes in the corresponding window.

3. Click the OK button.

To delete a comment:

1. Right-click on the comment in (parenthesis).

2. Delete the comment from the corresponding window.

3. Click the OK button.

4. The comment is now deleted and only the term is left as a selected item.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 15 of 45
Creating Notes

Create
a
New
Note
from
an
Existing
Note


There may be times when it is beneficial to copy forward the contents of a previous PowerNote
into a new one. For example, a patient being seen for their annual general medical exam
when little has changed from the previous year. Copy forward the old note into a new one and
then review and change documentation as needed.

To get started: click the button.

1. Select the Existing tab.

2. Change the filters as needed.

3. Single-click on the correct note from the displayed list.

4. Select the Copy to new note option.

5. Click the OK button.

6. Review and change content as necessary.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 16 of 45
Saving/Signing
Notes


Once a note is complete there are four options available:

Signs and Saves and


saves the note closes the note

Saves note and Deletes note


leaves it without saving
displayed changes

To sign a note:

1. Click the Sign button.

2. In the Sign Note window, verify the


document Type: field is correct. Make sure this
is correct!
3. Change the date/time if necessary.

4. Click the OK button.

5. Refresh when prompted.

6. The note will display in text-rendered


format.

Note! Do NOT sign PowerNotes in full screen mode as this will result in PowerChart
spontaneously closing.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 17 of 45
Saving/Signing Notes
To forward a note for co-signature:

1. Click the Sign button.

2. In the Sign Note window, verify the


document Type: field is correct.

3. Change the date/time if necessary.

4. Select Request Endosement.

5. Click in the field under the Endorser


column and type in the name of the
appropriate Provider.

6. Click in the field under the Type


column and select Sign.

7. Click in the field under Due By column and assign a due date of necessary.

8. Click in the field under the Comment column and type in a comment if necessary.

9. Click the OK button.

The completed PowerNote will be forwarded to the designated Provider’s Inbox.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 18 of 45
Saving/Signing Notes
To save a note:

1. Click the Save button to save the note and leave it displayed.
~ OR~
2. Click the Save & Close button to save the note and close it.

To delete a note:

1. Click the Cancel button.

2. Select Discard Changes when prompted.

Signing vs. Saving


Signing Saving
Notes that have been electronically signed Notes that have been saved but not
display in the patient’s chart with a status of electronically signed display in the patient’s
Auth (Verified). chart with a status of Active.
Signed notes are viewable immediately. Saved notes are viewable only in PowerNote
via the Existing tab.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 19 of 45
Modifying
Notes


To modify unsigned saved notes:

1. To find unsigned saved notes in PowerNote, click on the icon on the PowerNote
toolbar.

2. Click the Existing tab.

3. Select the Unsigned notes only option. Authors searching for their own unsigned notes
may also select the My notes only option. Change the encounter selection if necessary.

4. Double-click on the unsigned note from the displayed list. Unsigned notes have a status of
Active.

Users who attempt to open unsigned notes they are not the author of will receive the following
prompt:

5. Make the necessary changes to the note.

6. Click the Sign button when all changes are complete.

7. Select Yes when prompted to refresh.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 20 of 45
Modifying Notes
For notes that have already been signed, PowerNotes contains a modify feature that utilizes a
strike through function along with an addendum. Signed notes may be modified multiple
times.

To modify signed notes:

1. In PowerNote, select the note from the displayed list.

2. Click the icon on the PowerNote toolbar.

3. You are presented with the option to either Modify or Correct the document.

Modify Document – Allows the user to add an addendum to the note. This option does not
allow changes from within the note. When signed, the note status will reflect, Document Has
Been Updated And Contains Addenda.

Correct Document – Allows changes to made from within the note. This option will display
what the corrections were made and by whom. Click the Display Contributor View icon to
view the changes.

4. Make the appropriate corrections and click Sign

5. Authorize your signature by enter your password and click OK.

6. Select Yes when prompted to refresh the list.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 21 of 45
Modifying Notes

Deletions

Notes that have been saved but not signed may be deleted.

Important Note! Notes that have been signed cannot be deleted. However, you can mark
your own signed note as “In Error”.

1. To find unsigned saved notes in PowerNote, click the icon on the PowerNote
toolbar.

2. Click the Existing tab.

3. Select the Unsigned notes only AND My notes only options. Change the encounter
selection if necessary.

4. Select the unsigned note from the displayed list. Unsigned notes have a status of Active.

5. Click on the Delete button.

6. Click Yes to continue with note deletion.

7. Click Yes when prompted to refresh.

Note! Be careful not to delete another


author’s unsigned saved note. If another
author’s note is opened in error, the
following prompt will display:

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 22 of 45
Filtering
Unsigned
Notes


If notes have been saved in PowerNote but not signed, there is a way to locate all unsigned
notes.

1. In PowerNote, click the icon.

2. Select the Existing tab.

3. Select Unsigned notes only AND My notes to display all unsigned notes authored by the
logged on user. Change the encounter selection if necessary.

4. Select the unsigned note from the displayed list. Unsigned notes have a status of Active.

5. Click the OK button to open the note or double-click on the note to open.

6. Review and edit as needed. Make sure the document Type is correct.

7. Click the Sign button when finished.

8. If the document Type is missing, a prompt will display. Select the correct document Type if
prompted

9. Select Yes when prompted to refresh.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 23 of 45
Searching
for
Specific
Notes


PowerNotes may be filtered to find specific notes as needed.

1. In the PowerNote List tab, click the Display drop down. The default is set to display All
text-rendered notes.

2. Select the Only option.

3. A new field displays, click the drop down to select another level of options.

4. Another new field displays, select the third drop down to narrow the search further.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 24 of 45
Viewing
the
Audit
Trail


If it becomes necessary to view the audit trail of a corrected or modified note, this can be done
through PowerNote.

1. In PowerNote, select the patient’s note from the displayed list.

2. Hover the cursor over the solid grey line below the bottom scrollbar until it displays as a
two-sided arrow.

3. Click and drag the drag the two-sided arrow toward the top of the note to size the new
viewing pane.

Selected note

Audit trail

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 25 of 45
Images


Inserting
an
Image


PowerNote allows users to insert images.

1. In the PowerNote template, click on the paragraph or sentence where the image needs to
be inserted.

2. Click on the Contributor View icon.

3. Click the correct location for the image inside the note.

4. Click on the Insert Image icon to open the Drawing Box.

5. Inside the Drawing Box, click the Folder icon to locate the image.

6. Find and open the corresponding folder that contains the correct image.

7. Select the image and click on the Open button.

8. The image will display in a drawing box. In the drawing box, enter an Image Title. The title
will display along with the image in the note. Use the drawing tools to add detail to the
image as needed (see the next page for directions on using this functionality).

9. Click the OK button to view the selected image in the note.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 26 of 45
Images

Using
Image
Drawing
Tools


PowerNote drawing tools offer a variety of options to assist with adding detail to inserted
images.

A B C D E

A. Insert B. Drawing Tools C. Enhance


• Open Image File • Draw • Color
• Capture Image • Annotate • Resize
with Camera • Zoom • Rotate Left
• Crop • Rotate Right
• Ellipse
• Line
• Rectangle

D. Edit E. Size
• Undo • Reset Zoom
• Redo • Size to fit Screen

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 27 of 45
Images
To use the drawing tools:
1. In the Drawing Box, click on any one of the drawing shapes.
2. Change the Brush Width if needed.
3. Click on the Color Chooser icon to change the color of the drawing shape if needed.
4. Click and drag the cursor over any part of the image to make the necessary shape.

Note! The Ellipse Tool takes a little finessing to get the shape right.
• Click and drag the ellipse on the image.
• When the ellipse is the right length, release the left mouse button.
• Move the mouse to move the cursor and shape the ellipse.
• Click the left mouse button again to save the shape.

5. To clear the image of any drawings to start over, click the Clear Drawing button.
6. Click the OK button when finished.

Drawings

Annotations

To use the annotation tool:


1. In the Drawing Box, click the Text Tool icon.
2. Click on the Color Chooser icon to change the color of the drawing shape if needed.
3. Click and drag the cursor over any area around the image to size the text box.
4. Type the necessary text in the text box. The text color will appear black until finished.
5. When finished making the notation in the text box, left-click to display the text in the image.
The text color will display correctly if the Color Chooser was selected prior.
7. To clear the image of any annotations to start over, click the Clear Drawing button.
6. Click the OK button when finished.
Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 28 of 45
Images
The completed image will display in the PowerNote document like the example below.

Editing
an
Image


1. In PowerNote, click the Contributor View icon.

2. Right-click on the image.

3. Select Open.

4. Add further details.

5. Click the OK button.

Note! It is not possible to edit any detail that is already present on the image.

Deleting
an
Image


1. In PowerNote, click the Contributor View icon.

2. Right-click on the image.

3. Select Clear.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 29 of 45
Macros


A macro is a helpful tool used for documenting repetitive information across patient charts.
When certain sentences, and /or paragraphs are used frequently, a macro can be used to
automatically inserts terms in the note.

There are two types of macros in PowerNote:


1. A shared macro is available for multiple people to use.
2. A personal macro is saved at the individual level and can only be used by the person who
created it.

Creating
a
Personal
Macro

Best practice is to create macros at the paragraph level. Macros created at the paragraph
level can be utilized within any PowerNote that has that same paragraph level available.

To create a personal macro:

1. Open a patient’s chart. It is necessary to use an actual patient to create the macro.
Nothing will be saved to the patient’s chart.

2. Select the PowerNote option form the Menu.

3. Click the icon.

4. Select the appropriate note template.

5. Navigate to the paragraph where the macro is needed.

6. Complete the section of the note as you normally do; each term that is selected will be
saved in the marco If OTHER is used, type the required text in the box.

7. After completing, right-click on the paragraph or


sentence and select Save Macro As.
bh010671 10/5/10 1:20 PM
Deleted: text

8. In the Save As window, enter a name for the macro


in the Title: field.

It is the user preference to determine the naming


convention for the marco.

The macro can be saved as a public or shared macro.


If so, it is visible to other providers.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 30 of 45
Macros


9. Click the Create New button when finished.

A blue M now appears on the note identifying that a Macro is available

10. Click the Cancel button to exit the PowerNote or complete the note.

11. If you Cancel the note, click the Discard Changes button when prompted.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 31 of 45
Macros

Using
a
Personal
Macro


To use a personal or shared macro:

1. Open a patient’s chart.

2. Select the PowerNote option form the Menu.

3. Click the icon.

4. Select the appropriate note template.

5. Navigate to the paragraph where the macro is needed.

6. Right-click on the (blue) M and select the appropriate macro. If the necessary macro is not
displayed, select the More option to view a complete list of macros.

7. Select the appropriate macro. Once the macro is selected, the designated choices and text
will pre-populate automatically.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 32 of 45
Macros

Editing
a
Personal
Macro


To edit a personal macro:

1. Open a patient’s chart. It is necessary to use an actual patient to delete the macro.
Nothing will be saved to the patient’s chart.

2. Select the PowerNote option form the Menu.

3. Click the icon.

4. Select the appropriate note template.

5. Navigate to the paragraph where the macro is saved.

6. Make the necessary changes the information in the paragraph.

7. After all changes have been made, right-click on the paragraph text and select Save Macro
As.

8. Select the macro from the list and click the Update button.

9. Click the Cancel button to exit the PowerNote.

10. Click the Discard Changes button when prompted.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 33 of 45
Macros

Deleting
a
Personal
Macro


To delete a personal macro:

1. Open a patient’s chart. It is necessary to use an actual patient to delete the macro.
Nothing will be saved to the patient’s chart.

2. Select the PowerNote option form the Menu.

3. Click the icon.

4. Select the appropriate note template.

5. Navigate to the paragraph where the macro is saved.

6. Right click on the paragraph text and select Save Macro As.

7. In the Save As window, select the personal macro.

8. Click the Delete button.

9. Click the Cancel button to exit the PowerNote.

10. Click the Discard Changes button when prompted.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 34 of 45
Precompleted
Notes


Whether you are a surgeon, specialist in allergy and asthma or a family practitioner, your
particular patient encounters may have common characteristics. For example, a family
practitioner may see several patients daily with hay fever during the fall months, or the flu
during winter months. These types of recurring illnesses result in repetitive data entry when
you create encounter notes. In PowerNote you can document such an encounter once and
then save it as a precompleted note, which can then be used as a template for future use.

Precompleted notes will contain pre-populated sections that are always documented the same.
Information in the precompleted note may be changed as necessary to accommodate
variations in documentation needs. The intent of the precompleted note is to provide 80% of
the needed information so only the remaining 20% requires actual documenting.

Creating
a
Personal
Precompleted
Note


1. In PowerNote, click the icon.

2. Select a note template from one of the tabs.

3. Complete the sections of the note with the appropriate information.

4. From the Menu bar, click Documentation.

5. Select the Save as Precompleted Note option.

In the Note title: field enter the name of the precompleted note.

6. Click the Save as New button.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 35 of 45
Precompleted
Notes


Using
a
Personal
or
Shared
Precompleted
Note


1. In PowerNote, click the icon.

2. Select the Precompleted tab.

3. In the Search: field, type in part of the note name.

OR

4. In the Restricted display by section, select My notes only to narrow the search.

5. Complete the sections of the note with the appropriate information.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 36 of 45
Precompleted Notes

Editing
a
Personal
Precompleted
Note


1. In PowerNote, click the icon.

2. Select the Precompleted tab.

3. Select the note.

4. Make the necessary changes to the note.

5. From the Menu, select Documentation.

6. Select Save as Precompleted Note.

7. Click the Click the Update Exisiting.

Deleting
a
Personal
Precompleted
Note


1. In PowerNote, click the icon.

2. Select the Precompleted tab.

3. Select the note.

4. Click on the Delete button.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 37 of 45
Favorites


PowerNote templates may be added to the Favorites for easier and faster selection when
starting a new note on a patient. Maintaining a list of favorites allows frequently-used notes to
be located quickly.

Adding
Favorites


1. In PowerNote, click the icon.

2. Select the tab where the note template is located.

3. Select the note.

4. Click the Add to Favorites button.

Accessing
Favorites


1. In PowerNote, click the icon.

2. Select the Favorites tab.

3. Select the note.

Deleting
Favorites


4. In PowerNote, click the icon.

5. Select the Favorites tab.

6. Select the note to be deleted.

7. Click the Remove from Favorites button.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 38 of 45
Preferences


A document type must be selected for all new PowerNotes. Selecting the correct document
type determines where the note will be saved in the patient’s chart. This can be changed to
narrow the number of choices for faster selection.

Personal
Document
Types
List

By default, all available document types are displayed. Each user can create a personal list of
frequently used document types. A default document type may also be set, however, this is
discouraged due to the fact once a note is saved, it cannot be moved to a different folder if it
was saved incorrectly.

To create a Personal Document Type list:

1. In PowerNote, click icon.

2. From the Menu bar select View and then


Customize.

3. In the Customize window, select the


Document Types tab.

4. Select the Personal Note Type List from the


Default List Type field.

5. In the All Available Document Types


column, select the needed option.

6. Click the single right arrow to move it to the


Personal Document Type List column.

7. Repeat steps 7 and 8 until all needed options have been selected.

8. To remove an option from the Personal Document Type List, select the option and click the
single left arrow to move it back to the All Available Document Types column.

9. Click the Apply button.

10. Click the OK button.

11. Close the patient’s chart and reopen to refresh changes.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 39 of 45
Preferences
To use the Personal Note Type List:

1. Open a new PowerNote.

2. In the Type: field, right-click and select Personal Note Type.

3. Make the appropriate selection from the list.

To use the All Note Type List:

1. Open a new PowerNote.

2. In the Type: field, right-click to access the All Note Type List.

3. Select the All Note Type List.

4. In the Type: field, click the drop down arrow.

5. Make the appropriate selection from the list.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 40 of 45
Inbox
The In-Box is where you will find PoweNotes that have been sent for your signature or review.
Med students will be allowed to save a note and will need to forward the note the
attending/resident for signature.

1. To access your Inbox, from the PowerChart toolbar, click the In-Box button.

If you don’t see the In-Box button, click the black down arrow and select In-Box.

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 41 of 45
Glossary


Term Definition

*2G The newest version of a PowerNote. ALWAYS select this when


there is more than one note of the same title displayed.

Contributor View How a PowerNote will display once saved. The individual selections
and comments are combined into a more readable note format.

Macro A small selection of documentation that has been saved for future
use. Macros are maintained at the level they are created within the
PowerNote. Macros are available within any PowerNote that
contains the level. Macros can be built up to a paragraph level.

Negate Allows a term to be included in the note as a negative finding. Used


for pertinent negatives. Not available for all terms.

Pre-Completed Note A note saved as precompleted has already had results entered and
has been saved to use repeatedly when only minor edits are used
from patient to patient. Use of pre-completed notes reduces
documentation time.

Document Type This will be the “label” for the folder in which the note will be stored.

Paragraphs First level of documentation in a PowerNote

Sentences Second level of documentation in a PowerNote

Terms Third level of documentation in a PowerNote

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 42 of 45

Icons


PowerNote Description
Toolbar Icons

Create/Locate a template, favorite, precompleted or existing note

Full screen mode

Save

Submit an unsigned document for signature or review

Sign the displayed document

Forward/Refuse a document for signature or review

Review a document

Display the audit trail (history) of a document

E & M assistant

Modify order details if orders are placed from documentation

Used to make corrections or modifications to a document

Copy

Paste

Dictate using Dragon

View an image linked to a document

Find next structured item

Find/Move between required terms

Document has been marked as an error and cannot be opened

Open preview pane

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 43 of 45
Icons

Documentation Description
Icons

Insert canonical sentences into terms

Negate term and deselect all subsidiaries

Set the term to normal and deselect all subsidiaries

Add or view comment associated with term

Make a copy of term and all subsidiaries

View reference information related to term

Not available

Note available

Deselect term and all subsidiaries

Enter a reason for not documenting a required element

Display the insert macro dialogue

Display the save macro dialogue

Relocate the term upwards by one position

Relocate the term downwards by one position

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide
Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number]
©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express
written consent of Cerner.
Page 44 of 45

Você também pode gostar