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Cerner Chart Review Guide

The following items are sorted alphabetically.

How Do I Find:

From The Patients Chart - Go To:

Administered Medications
MAR Summary

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Click MAR Summary from the Navigation Menu


Change the date range by right clicking on blue date bar and
selecting Change Properties

Admission History
(Nursing)

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Click Notes from the Navigation Menu


Click + to expand folders or change the filters on bottom
Locate and double click PowerForm Textual Rendition folder
Click + next to PowerForm Textual Rendition Forms
Double click on date of Patient History note to view

Blood Transfusion Documentation

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Open Results Review from the Navigation Menu


Click Blood Transfusion tab
Click the Navigator band (if needed)
Double click or hover over the cell to view education

Charges
IV Team, Respiratory, Outpatient areas, ED

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Open Results Review from the Navigation Menu


Click Assessments tab
Click appropriate band to view specific charges

Charges (Infusions)

Open Infusion Billing from the Navigation Menu


View only shows charges that have been documented

Clinical Range Bar


Display documentation/results for specific
dates

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On a given view:
Change the date range by right clicking on gray date bar
Click Change Search Criteria
Select the date/ posting/ results or other criteria
Click OK

Consults (Provider)
Dictated and transcribed by physician

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Open Notes from the Navigation Menu


Locate and double click Consultation Notes
Click + next to Physician Consults
Double click on date of physician consult

Consult (Nutrition)
Assessment completed by Nutrition

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition
Click + next to Nutrition Forms
Double click on date of Nutrition note to view documentation

Co-Signatures
Telephone/written orders require a physician
to electronically verify and sign the order
Date Bar
Display documentation/results for date range
Diagnoses & Problems list

Open Orders section from the Navigation Menu


Right click on order in question
Click on History tab to view details
See Clinical Range Bar

Health Quest |IT Learning Services


Rev. 09/19/2013 v.2.1

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Open Diagnoses & Problems from the Navigation Menu


Right click on specific classification type and click View Details
for additional information

Cerner Chart Review Guide


How Do I Find:

From The Patients Chart - Go To:

Dialysis Flow Sheet

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Open Results Review from the Navigation Menu


Click drop down arrow to change Flow sheet from Quick View
to Dialysis View

Dietary Care History/ Dietary Consult/


Nutrition Care History
Assessment completed by Nutrition

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition
Click + next to Nutrition Forms
Double click on date of Nutrition note to view documentation

Discharge Clinical Summary


Content appropriate for next care provider

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Open Notes from the Navigation Menu


Locate and double click Discharge Documentation
Click + next to Inpatient Clinical Summary
Double click on date of Inpatient Clinical Summary

Discharge Medications (Med Rec)

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Open Orders section of the chart


Click + next to Reconciliation History
Click on Discharge Med Rec to see discharged meds
Discharge meds can also be viewed in Notes section on
the Discharge Patient Summary

Discharge Notes (Nursing)


Nursing Discharge arrangements and home
instructions

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition Notes
Click + next to Patient Discharge Summary
Double click on date of Patient History note

Discharge Notes (Provider)


Provider discharge note including diagnosis

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Open Notes from the Navigation Menu


Locate and double click Discharge Documentation
Click + next to Discharge Notes
Double click on date of Inpatient Clinical Summary

Discharge Summary (Patient)


Content appropriate for patient

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Open Notes from the Navigation Menu


Locate and double click Discharge Documentation
Click + next to Inpatient Patient Summary
Double click on date of Inpatient Patient Summary to view

Discharge Summary (Physician)


Dictated by Physician

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Open Notes from the Navigation Menu


Locate and double click Discharge Documentation
Click + next to Discharge Summary
Double click on date of Discharge Summary

Discontinued Meds/IV

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Open MAR Summary from the Navigation Menu


Adjust date range by right clicking on blue date bar and
selecting Change Properties.
Click Discontinued band
All discontinued items show in gray

Health Quest |IT Learning Services


Rev. 09/19/2013 v.2.1

Cerner Chart Review Guide


How Do I Find:

From The Patients Chart - Go To:

Education (Patient)

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Emergency Room Report


Notes or forms completed in the Emergency
department

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HIPAA Compliance to record

Open Results Review from the Navigation Menu


Click Patient Education tab
Click the Navigator band (if needed)
Double click or hover over the cell to view education

Open Notes from the Navigation Menu


Locate and double click Emergency Documentation
Click + next to Emergency Documentation
Double click on date of Emergency Documentation
ED Report opens for viewing
If Emergency Documentation is NOT listed, right click on
blue Date Range bar and change date to reflect the time
the patient spent in the ED
o Open Patient Information from the Navigation Menu
o Click PPR tab
o Lower part of screen displays all who have touched the chart

History & Physical


Dictated and transcribed by physician

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Open Notes from the Navigation Menu


Locate and double click History and Physical
Click + next to History and Physical
Double click on date of History and Physical

IV Stop Times/ IV Billing

Open Infusion Billing from the Navigation Menu


View only shows charges that have been documented

Laboratory Results
Examples: CBC, Urine Culture, and blood
transfusion

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Open Results Review from the Navigation Menu


Click Lab or Micro tab
Click the Navigator band (if needed)

MAR Summary

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Open MAR Summary from the Navigation Menu


Adjust date range by right clicking on blue date bar and
selecting Change Properties.

Medical History
Social and procedural histories

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Open Histories from the Navigation Menu


Click on the tab desired
Note: Medication History can be found in Medication List

Medication List
Displays home and previous medications

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Open Medication List from the Navigation Menu


Click + next to Medication List in the navigation to filter
All Home meds have a scroll icon
Medication History can be found in Medication List

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Meds Rec (Discharge)

Health Quest |IT Learning Services


Rev. 09/19/2013 v.2.1

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Open Orders section of the chart


Click + next to Reconciliation History
Click on Discharge Med Rec to see discharged meds
Discharge meds can also be viewed in Notes section on
the Discharge Patient Summary

Cerner Chart Review Guide


How Do I Find:

From The Patients Chart - Go To:


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Click appropriate band from the navigation menu


Scroll to view items

Expand/Collapse Views as needed

Notes (PT/OT/SLP):

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition
Click + next to desired specialty
Double click on date of note to view documentation

Notes (Speech/Language Therary

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition
Click + next to Speech Therapy Forms
Double click on date of note to view documentation
Open Notes from the Navigation Menu
Locate and double click PowerForm Textual Rendition Notes
Click + next to Patient Discharge Summary
Double click on date of Patient History note

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Open Notes from the Navigation Menu


Locate and double click Progress Notes folder
Click + next to Nursing Progress Notes and/or Physician
Progress Notes
Double click on date of note

Notes (Operative/ OR)


Notes by the OR Physician

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Open Notes from the Navigation Menu


Locate and double click Operative Documentation
Click + next to Operative Report
Double click on date of Operative Report

Nursing Documentation
(including Variance notes)
Includes all nursing assessments and nursing
progress notes

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Open Results Review from the Navigation Menu


Click Assessments tab
Click the Navigator band (if needed)
Double click or hover result cell to view variance note

Nutrition Care History/ Dietary Care History/


Dietary Consult
Assessment completed by Nutrition

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Open Notes from the Navigation Menu


Locate and double click PowerForm Textual Rendition
Click + next to Nutrition Forms
Double click on date of Nutrition note to view documentation

Orders

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Open Orders from the Navigation Menu


Click the area in the orders navigation to view specific
information or plans.

Order Co-Signatures/ Nurse Review


Telephone/written orders require a physician
to electronically verify and sign the order

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Open Orders from the Navigation Menu


Right click on order in question
Click on History tab to view details

Newborn/ Prenatal/ Pregnancy Summary

Notes (Nursing Discharge)


Nursing Discharge arrangements and home
instructions
Notes (OB/Gyn)
Notes by the OB/Gyn Physician

Health Quest |IT Learning Services


Rev. 09/19/2013 v.2.1

Cerner Chart Review Guide


How Do I Find:

From The Patients Chart - Go To:

Order Details/ History


Display information on the order including
who ordered, verified, or modified.

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Open Orders from the Navigation Menu


Right click on order
Click on History tab to view details

Patient Education

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Open Results Review from the Navigation Menu


Click Patient Education tab
Click the Navigator band (if needed)
Double click or hover result cell to view education

Patient Information

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Open Patient Information from the Navigation Menu


Click the tab desired
Demographics address, emergency contact, etc
Visit List displays all previous visits
PPR displays all those who have touched the chart

Patient Search (Single)

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Single Patient search box is on the upper left of the screen


Type patients name
Click binoculars
Enter additional information if needed
Select the patient from the results
Encounter/visits show in the lower panel
Click the correct encounter from the lower panel

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Plan of Care (Interdisciplinary IPOC)
Document all plans of care on the patient
Print Patient Chart (MRP )
How to print specific components of the chart
For example: Laboratory - chemistry,
hematology, urinalysis, blood bank
Radiology X-ray, EKG, Echocardiogram, MRI

o Open Plan of Care Summary from the Navigation Menu


o Click Task on the Menu Bar
o Click on Print
o Choose MRP
Under Print What on the left, place a check mark in box
Note: Use + next to category open specific components
o Under Visit List/ Print Detail select correct encounter OR
enter specific date range for view (bottom of screen)
o Complete Purpose section
o Enter Printer Name
o Click OK

Problems/ Diagnosis list

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Open Diagnoses & Problems from the Navigation Menu


Right click on specific classification type and click View Details
for additional information

Radiology Results:
Examples: MRI, EKG, Ultrasound, Cat Scan

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Open Results Review from the Navigation Menu


Click Radiology tab
Click the Navigator band (if needed)
Double click result cell to view report

Click the View Image if needed/ available

Requisitions (Reprinting)
Health Quest |IT Learning Services
Rev. 09/19/2013 v.2.1

o Click Orders from the Navigation Menu


o Right click on the lab/ blood/ specimen
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Cerner Chart Review Guide


How Do I Find:

From The Patients Chart - Go To:


o Click Reprint and select the printer
o Click OK

Variance Notes
Includes nursing progress notes
Visit List

Health Quest |IT Learning Services


Rev. 09/19/2013 v.2.1

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Open Results Review from the Navigation Menu


Click Assessments tab
Use Navigator to choose
Open Patient Information from the Navigation Menu
Click Visit List tab
Upper part of screen displays all visits
Date/Reason is listed
Double click to open the encounter/ visit
If warning appears, click OK to change encounter

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