for Nursing Students

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Cerner System

• for Nursing Students

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Welcome

• Welcome to the Legacy Health System. We hope
• that you enjoy your clinical experience on one
• of our many dynamic nursing units.
• The purpose of this presentation is two-fold
• 1. To describe Legacys general principles
  for documentation of individualized,
  goal-directed care provided by the
  interdisciplinary healthcare team using a
  variance-based model.
• 2. To describe the core documentation
  components of Legacys electronic medical
  record-Cerner
  

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Variance-based charting

• LHS has a policy that defines variance-based
  charting and outlines documentation
  responsibilities (LHS.900.2114)
  
• It is critical as caregiver that you follow the
  LHS policies
  
• You put yourself at risk professionally when you
  do not follow the policies
  

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Variance-based charting

• 1. A variance is a deviation from the expected
  outcome during the patients course of care.
  
• 2. A variance is also a deviation from the
  expected or standard interventions and those
  interventions that the patient actually received
  as listed in
• -Standards of Care (SOC)
• -Physicians orders
• -Interdisciplinary orders
• -Clinical path/plan of care

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Examples of a variance

• 1. Using nursing judgment, you did not take the
  0400 vital signs. You must document this
  variance, as it was part of the standard of
  care.
• 2. Your patient complained of severe pain after
  the urinary catheter was removal. You must
  document this variance, as it is not an expected
  outcome of urinary catheter removal.

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Standards of Care

• Standards of Care
• The SOCs are a pre-printed script that
  describes expected, routine or basic care that
  the Interdisciplinary team provides for the
  patient.
• Each SOC is a POLICY, so as a caregiver, you are
  accountable to provide the defined care to the
  patient.
  
•      The SOCs are written to be population
  specific (e.g. Critical care, Pediatrics, NICU,
  Psych) and condition specific (e.g. Pulmonary,
  Surgical, Orthopedic).
•  

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Standards of Care

• There are 3 sections to each SOC
• 1.    PATIENT EXPECTATIONS Care provided will
  assist the patient/family/guardian in meeting
  certain expectations.
  
• 2.    INTERVENTIONS The RN coordinates the
  interdisciplinary plan of care and applies the
  nursing process.
  
• 3.    INTERDISCIPLINARY PLAN OF CARE Within
  each disciplines scope of practice, the
  interdisciplinary team collaborates in providing
  the following care as warranted by patient
  condition and caregiver judgment.
•  
•    

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Word Definitions in the SOC

• What does assess and reassess mean in a SOC?
• DO IT (the ordered intervention) and DOCUMENT
  your findings _at_ the stated time frequencies.
  
•  
• What does monitor, initiate provide mean in a
  SOC?
  
• DO IT at the stated time frequencies, but, you
  dont necessarily need to document the
  intervention unless there is a change from your
  baseline or significant additional information.

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Standards of Care

• The Standards of Care notebook is found at the
  nursing station.
  
• This contains the LHS fundamental patient care
  directed policies (Standards of Care), complex
  identifiers, isolation signs and other unit
  specific information sheets.

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Signing into Cerner

• Security/confidentiality. No employee/ student
  has the right to access or disclose patient
  information except as necessary to fulfill his or
  her job responsibility.
• Breaches of confidentiality might include
  reviewing data of family, neighbors, co-workers,
  local celebrity, patients transferred out of your
  unit and looking up information about yourself.
• Help desk 55888

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SignIn to either 1) PowerChart 2) PowerChart
Physician or 3) PowerChart Ed or PowerChart
Surgical This will depend on the unit you
practice
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Sign-in
Your User Name will be given to you by your
instructor. Your first password is the same as
your user name. Change your password and do not
share it with anyone.
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Patient Census screen
After you sign in the census of your unit will
appear. Please note visitor status. To open a
patients chart, double click on the patients
name.
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Visitor Status (Release of Information)

• If a family member calls or comes to your unit,
  you may give out the following information
  depending on the visitor status.
  
• Full release name and room number
• Partial release name only
• No release no name or room number (all police
  holds and psych patients are no release)
  

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Your own chart tab
To make your own chart tab, click on the wrench
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Click on New
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Choose Custom and Next
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Type in a name for your list and click Finish
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Highlight your list name, click on the blue arrow
to make your list Active then click OK
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Your own chart tab
Copy and paste to your chart tab by highlighting
your patients and using copy/paste under Edit.
Delete your patients weekly.
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Patients chart
Patient Info chart tab lists demographic
information. Banner bar (yellow bar) contains
admit date, time and allergy information.
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Patients chart
The Tool bar is above the banner bar. All patient
information is listed below. To view an allergy,
click on Allergies.
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Allergy screen
View allergies and reactions here
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Orders chart tab
This is your Plan of care. Categories are shown
in blue.
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To read the SOC, double click on the icon in
front of each SOC.
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Review the SOC. Click on OK when done.
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Progress Notes

• Document patient activity to and from the unit
  Include time/date/mode of transport.
  
• Document all calls made to the MD, include
  summary of conversation, even if orders were not
  received.
  
• Document Code/Emergency situations or expanded
  narratives.
  

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Notes Chart tab
Rt click here
To make a progress note, right click on the white
screen.
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Note Chart tab
Fill in Type with Nursing Progress note. Fill
in the subject line and body of the note with
information. When finished, click on sign.
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Note Chart tab
Review completed Progress notes by double
clicking on the folder in the left column.
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Shift Assessment

• Every nurse should be using the same criteria to
  guide the type of data they collect for their
  patient assessments. Literature finds that this
  does not occur without guidelines.
• Therefore, Legacy has created system-wide
  assessment statements that act as guidelines to
  ensure that the patient data collected during a
  shift assessment is consistent and covers the
  parameters of a minimum assessment. These are
  called Norm Statements.

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Norm Statements

• Norm statements define baseline criteria required
  to be assessed with ANY assessment or
  reassessment of a particular category. Norm
  statements help define consistent assessment
  parameters.

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Systems that the Norm Statements cover

• Neurological
• Cardiovascular
• Pulmonary
• GI
• GU
• Skin/wounds/drains
• Psych/social/spiritual
• Pain

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Example of a Norm Statement

• Norm statements reflect subjective and
  objective assessment findings.
  
• Neuro Norm statement Alert/attentive, oriented
  X 3, follows complex commands, clear thinking.
  MAE with symmetry of strength, facial symmetry.
  Speech clear and appropriate. Sensation intact.

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Each clinical area has specific Norm Statements
that guide the shift assessments.

• Adult Critical Care
• Adult Med/Surg
• Peds
• NICU
• Newborn
• Postpartum
• Antepartum
• PACU/SSU

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Met Norm Statement

• FIRST-assess your patient. Read the norm
  statement criteria Ask yourself Does my
  patient look at least like the norm statement
  criteria?
• If you can answer yes, then chart MET
• You have just saved yourself the time of
• charting the information contained in the
• norm statements. You may also add additional
  assessment findings that are not included in the
  norm statement.
  
• (Decreases the amount of narrative charting
  needed).
  

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Unmet Norm statement

• FIRST-assess your patient. Read the norm
  statement criteria Ask yourself Does my
  patient look at least like the norm statement
  criteria?
• If your patient does not look like the ENTIRE
  norm statement, then you must chart UNMET-
  you must also describe how your patient
  assessment is different from the norm statement.
• (This is your documentation of variances from the
  norm statements)
  

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INET Chart Tab Shift Assessment
To view the norm statement for each assessment,
right click on line below each assessment, e.g.
Neuro norm.
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Neuro Norm statement
The norm statements for all disciplines are
listed here. When done, click on OK
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INET Chart tab - VS
Double click on the time to start charting. When
charting is complete, click on the green check.
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I O Chart tab
To begin charting, click on the start charting
icon. When done, click on the green check.
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I O Chart tab
To add more categories, click on the display
hidden category icon.
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Display hidden categories icon
Double click on the folder and click on the
category to add.
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MAR Chart tab
The yellow vertical line shows current date and
time. The red box is a late med. To give a med,
click on the box with the dosage.
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Charting a med
Change the time if needed, then click on the
green check to sign the document.
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Documenting the prn response
When you give a prn med, a prn response box
will appear. After sufficient time, click on the
prn response box to document the patients
response.
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Prn Response box
Fill out response boxes and sign (green check)
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Charting an IV on the MAR
This form needs to say begin bag. If it says
infuse, click on begin bag above to change.
Then click on Apply and sign (green check)
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Recent Results
You can see all entered data here except
medications. Right click on the green bar to
change the date of the results.
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Task Chart tab
Choose All continuous tasks to sign to your
SOC . Double click on Standard of Care Charting.
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Signing to the Standards of Care

• Signing the SOC/Ordered Interventions is the only
  way care providers at LHS can permanently record
  that they provided care according to the
  patients plan of care and the timeframe that
  they cared for the patient.
• At the end of your shift you document to your
  SOCs. If everything was completed, you document
  SOC Met. If you cant get something done at
  the time frequency stated in the SOC INTERVENTION
  section, this is a VARIANCE to the expected
  course of care, and the RN/LPN/Interdisciplinary
  staff member MUST chart that the SOC was Unmet
  and chart what intervention was not completed.

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Sign to the SOCs
Sign SOC Met or SOC Unmet, type in the time you
took care of your patient. If you choose SOC
unmet, document the variance. When complete, sign
the document by using the green check
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Goals

• Evaluation statements of how the patient is
  expected to progress
  
•   The State Board of Nursing dictates that we
  have a method of evaluating the patient progress
  against the Plan of Care and adjust that plan
  accordingly. 
• How often do patient goals need to be
  addressed?
  
• At least ONCE each 24 hours
• Who can address patient goals?
• An RN. Student,(not an LPN) or other licensed
  healthcare team member (e.g. RT, PT, OT).
  

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Sign the Goals
Goals are found in the Task chart tab under
All continuous tasks. Goals are completed by
2400 each day. When done sign with the green
check.
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Forms Chart tab
You will find most forms here, such as the
nursing admit, blood transfusion record, pre-op
check list, standard of care and goal forms once
complete. When a form is complete, the box in
front of the form will be blue. (red is not
complete)
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Legacy Intranet
Click on the world to get to the intranet.
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The Intranet
Hover over clinical resources and drop down to
knowledge base. Click on Carenotes.
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Care Notes
Care notes are teachings sheets for your patient.
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Care Notes
Example of teaching sheet
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To view policies and procedures
To pull up this screen, click on LHS Applications
at the bottom of the screen.
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General Policies 100-800
Double click on the blue link to view.
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Patient Care Policies
If Legacy does not have a policy, you should
refer to the Text book listed above.
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Policy LHS 900.2282
Example of a policy. You may print out the
policies for reference.
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Congratulations

• You are now prepared to document your
  patient care in Legacys Electronic Medical
  Record