PowerChart Basics for Clinical Users

Transcription

1 PowerChart Basics for Clinical Users The information within this reference is intended to provide a basic understanding of PowerChart for users with CLINICAL access. CLINICAL access allows the user READ ONLY access to information within PowerChart. Logging In... 2 The PowerChart Organizer Window... 4 Opening a chart using the Find Patient Icon... 5 Opening a Chart Using a Location List... 6 The Patient Chart Tabs: Patient Information... 7 The Patient Chart Tabs: Clinical Notes... 9 The Patient Chart Tabs: Form Browser The Patient Chart Tabs: Flowsheet The Patient Chart Tabs: List View Flowsheet First Revision 6/00 Second Revision 1/01 Third Revision 1/02 The Center for Education and Development 1

2 Logging In 1. From your Windows Desktop, double-click on the PowerChart icon. (If the icon is not found on the desktop, click the Start button, and select Applications.) The Novell Login vx.xx window will appear. 2. The location 1. UMHS-Users ID will appear by default. This location is the most common for hospital and clinics employees. MU students will need to change to location 3. To change the location, click the down arrow to the right of the Location field, press the number of the location desired from the keyboard, then press ENTER button on the keyboard. 3. Type in your (Outlook) username in the Username field. 4. Type in your (Outlook) password in the Password field. 5. Click the OK button. The Cerner Login window will appear. 2

3 6. Type in your CERNER user name in the User Name field. 7. Type your CERNER password in the Password field. 8. PROD will appear in the Domain field. You cannot change this setting. 9. Click the OK button. 3

4 The PowerChart Organizer Window The Organizer is the first window that appears when beginning a new PowerChart session. The PowerChart Menu Bar The Refresh Button The PowerChart Tool Bar The PowerChart Tool Bar displays clickable icons that perform many of the functions in PowerChart. Some icons are common throughout PowerChart, while others are specific to a particular tab or window. The commonly used icons are shown below. Find Patient Print Open Additional Chart List Maintenance Change User Add Patient Suspend Application Remove Patient Exit Launch Clinical Calculator 4

5 Opening a chart using the Find Patient Icon 1. From the Organizer window, click on the Find Patient icon. The Patient Search window appears 2. Enter the information that you are using to perform the search into the appropriate field (ex: Name, MRN, SSN, or FIN NBR). 3. Click on the Search button. The search results will appear in the upper right panel. The lower panel displays all encounters/financial numbers associated with the highlighted patient in the upper right panel. NOTE: If your access level allows ORDER ENTRY, you MUST select the appropriate FIN number to open the patient chart. If your access level is Clinical (read-only), then proceed to step 4. 5

6 4. Click the OK button. The patient chart will open in an additional window. Opening a Chart Using a Location List If you are using a computer located in a UHC inpatient nursing unit, the Location list for that unit will appear under your Patient List tab by default. To open a patient chart from a list, double-click on the patient name within the list. The patient chart will open in an additional window. 6

7 The Patient Chart Tabs: Patient Information The Patient Information tab is divided into three sub-tabs: Patient Demographics, PPR Summary, and Visit List. The Patient Demographics tab displays basic demographic information. The PPR Summary tab maintains a list of all users who have a relationship with the patient or have accessed the patient s chart. 7

8 The Visit List tab displays all visits (financial numbers) assigned to the current patient. Each line represents a different encounter. The selected encounter appears highlighted with an X in the Selected column. To change to a different encounter, double-click on the encounter you would like to select. (You may also right click on the highlighted encounter and select Change encounter from the list that appears.) Click Yes to change to the selected encounter. 8

9 The Patient Chart Tabs: Clinical Notes The Clinical Notes tab displays both electronically charted and transcribed notes of physicians and other caregivers. Navigator Viewing Panel By default, clinical notes within the Clinical Notes tab are organized by date. To view a clinical note: 1. Double click on the folder within the Navigator to the left that corresponds with the date of the note. 2. Double click on the note you would like to view. The note will be displayed in the viewing panel. 9

10 The Patient Chart Tabs: Form Browser The Form Browser tab allows you to view and/or print details of any current charted documentation that was entered on a form. Banner Bar Documentation within the Form Browser can be sorted by using the Sort by drop down menu. There are four ways in which the information can be sorted: By the date the data was charted on the form By the name of the form By the encounter date By the encounter form The date range of charted information displayed can also be changed. To change the date range: 1. Right click on the teal banner bar to display the selection menu. Click on Search Criteria. 3. Enter the desired date range in the fields provided and click OK. 10

11 Viewing Form Data Documented forms within the Form Browser will display with one of the following status types: To view form data: Final The form has been signed and is complete. Modified The form has been modified and signed again. In Progress The form is not yet complete or signed. 1. From the Form Browser tab, highlight the form you would like to view by clicking on it. 2. Right-click on the form and select View from the menu that appears. (Double clicking the selected form will also open the form in View mode.) The selected form will be displayed with the charted information. Note: You cannot change or modify any information within the form using the View function. 11

12 The Patient Chart Tabs: Flowsheet The Flowsheet tab organizes clinical data including laboratory tests, radiology reports, dictated documents and information charted on forms. Search Criteria Bar Lab values that are critical, high, or low are identified with the letter C, H, or L next to the value. To view results by category: Click on the result category on the left side of the screen to bring the category to the top of the list OR click the checkboxes next to the result category to remove the checkmark and hide the unwanted results. To review results by time frame: Right click on the search criteria bar to display the selection menu. Click on Change Search Criteria. Then click the circle next to Clinical Range. 12

13 Enter the desired date range in the fields provided and click OK. To view the details of a result, double-click the result. The Result Detail window is displayed. To graph a numeric result or results: 1. Click on the box next to the result name(s) you would like to see graphed to select that result. (You may select up to 8 results.) 2. Click on the Graph icon. The graphed results are displayed in the Flowsheet Graph window. (Click Combine to see combine multiple graphs into one.) 13

14 The Patient Chart Tabs: List View Flowsheet The List View Flowsheet tab provides an alternative view of the patient s clinical data. Just as with the Flowsheet tab, data can be viewed by time frame by changing the search criteria within the search criteria bar (see page 17). To view individual result details, double-click on the desired result. NOTE: Result Details may only be viewed from the List View format of the flowsheet. Document View will not allow result details to be displayed. 14