Escolar Documentos
Profissional Documentos
Cultura Documentos
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.
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
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
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.
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.
PowerNote Toolbar
Note Navigation
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
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.
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.
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.
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.
Paragraph
Sentences
Navigator
Terms
Workspace
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.
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:
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.
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:
3. Click the OK button to save the information and close the window.
As notes are being created, a check mark appears to the left of each section in the navigator
indicating documentation is present.
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.
5. Click OK.
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.
9. Click Close.
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:
2. Select Comment.
To modify a comment:
To delete a comment:
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.
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
To sign a note:
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:
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.
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:
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
1. To find unsigned saved notes in PowerNote, click on the icon on the PowerNote
toolbar.
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:
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.
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.
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.
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.
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.
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.
8. If the document Type is missing, a prompt will display. Select the correct document Type if
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 23 of 45
Searching
for
Specific
Notes
1. In the PowerNote List tab, click the Display drop down. The default is set to display All
text-rendered notes.
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.
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
1. In the PowerNote template, click on the paragraph or sentence where the image needs to
be inserted.
3. Click the correct location for the image inside the note.
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.
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).
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
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
Editing an Image
3. Select Open.
Note! It is not possible to edit any detail that is already present on the image.
Deleting an 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.
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.
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.
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.
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
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
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
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.
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.
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
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.
6. Right click on the paragraph text and select Save Macro As.
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
In the Note title: field enter the name of the precompleted 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 35 of 45
Precompleted
Notes
Using a Personal or Shared Precompleted Note
OR
4. In the Restricted display by section, select My notes only to narrow the search.
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
Deleting a Personal Precompleted 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 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
Accessing Favorites
Deleting Favorites
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.
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.
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:
2. In the Type: field, right-click to access the All Note 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 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
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.
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.
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
Save
Review a document
E & M assistant
Copy
Paste
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
Not available
Note available
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