Cerner Intro
Use this to leave/exit powerchart.
What is the "Exit Door"
Tool that contains 4 tabs
1st Tab= overall summary of why patient is here
2nd Tab= Some of the information displayed in this tab include: Labs, Provider Documentation/Notes, Protocols, all active orders
3rd Tab=shows the RN powerplans/IPOC statuses, overdue tasks, lines/tubes/drains/devices and assessment information.
4th Tab=Quality Measures information/needs are found here
What is SBAR?
This order communication type should only be used in a critical situation, when patient safety requires. Otherwise the provider should enter orders themselves.
What is "Verbal Order/Read Back"?
The provider needs to stand nearby when this type of order is placed so the RN can read back the order prior to signing the order and so the provider can give direction if alerts are presented.
What is 4 hours?
Charting should be done in this time.
What is "actual time"?
This list is used for the RN to view only the patients that are assigned for the shift.
What is "Custom List"
Used to see general patient information, new orders/results, view and manage tasks and helps the RN keep organized through the shift
What is CareCompass?
True or False: The RN must keep the provider on the phone when taking orders until all orders are entered in powerorders and signed.
True.
This is a Joint Commission requirement that the RN reads back the order to the provider prior to signing the order. This also ensures the provider is still available should an alert pop-up upon order entry.
What is "Patient State" goal?
This is where we document critical results.
Iview--> Patient Care Band--> Special Charting--> Critical Results Received?
This helps make TJC Surveys go smooth.
Used anytime you are not seeing something you should be seeing.
What is the "Refresh" button?
Components required for proper, best practice medication history documentation
What are the:
Preferred Patient Pharmacy (for eRX)
Dose, Frequency, Route
Indication
Compliance
Remove all pill bottles
Orderset placed by provider which contains evidence based, disease specific orders proven to provide the best patient outcomes.
What is a Core Content Powerplan?
What is duration?
This type of component must be started every time a line/tube/drain or device is placed. Must be inactivated after the item is discontinued.
What is a repeatable group?
Used for things like urinary catheters, IVs, Chest Tubes, Drains, Wounds, etc
Percentage of required scanning for mPPID, sPPID and tPPID.
What is 95%
This should almost NEVER be used when documenting an allergy
Reminder: Use "other food allergy" when entering a food allergy that cannot be found in the catalog.
This folder should be used when the RN has a protocol order on the chart and the protocol needs to be used.
What is the Protocol Orders/Care Sets folder?
Note: these orders can only be used if there is first an active order for protocol on the chart. See SBAR Assessment Tab to view active protocols on the chart.
What are:
Assess patient
Choose and Initiate IPOCs
Set up goals, indications and interventions
Document admission assessment
What is the Checkmark with Question Mark icon in the I and O iview band?
Use this to prepare to receive new patient, for handoff, to get full picture of what is going on with the patient, one stop shop for almost ALL patient information.
What is "SBAR"
Each page of this powerform must be completed fully from top to bottom and left to right. The RN should manually drag down the scrollbar on each page to ensure all components are completed.
What is the General Admission Data Form aka GADF?
Don't forget PCP documentation
This type of orderset is used to order a group of like orders needed for patient care.
What is a subphase?
Examples: transfusion subphase, bowel prep subphase, insulin subphase, Sepsis Bundle Subphase, etc
IPOC steps that must be done upon discharge
What are: Document on goals (met, not met, etc), discontinue active IPOCs and reject suggested IPOCs?
What is the Iview Assessment Band?