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Navigating PowerChart for ED, OB, OR Documentation

HQIT Learning Services
2/25/14 v1
Did you know
Documentation from the Emergency Department, OB, and Surgical Services will flow
over and be viewable in Cerner PowerChart?
Examples include:
Allergies, Height/Weight and Meds by History
Orders, Assessments
Problems/History/Procedures
IV site documentation and fluids
Medications Administered
Advanced Directives

Where can documentation from the Emergency Department, OB,
and Surgical Services be found in PowerChart?
Documentation Location in PowerChart
PowerForms:
ED Triage Form (PowerForm)
ED Complete Assessment (PowerForm)
Surgical Services Preadmission Visit Assessment
Form (PowerForm)
PreOp Ambulatory Intake Form (PowerForm)
PreOp Check List (PowerForm)
OB Nursing Assessment (PowerForm)
Fetal Well Being Note (NST PowerNote)
ED/OB Physician Documentation (PowerNote)


Form Browser (to locate PowerForms)
Notes (to locate PowerNotes)
Results Review
Able to view PowerForm details in addition to
information from IView

NOTE: As of January 11, 2014, the Emergisoft Summary will
not display in Notes. Prior Emergisoft encounters can be
viewed by changing the Date Range.
Surgical Documentation:
IntraOp Nursing Record
PreOp Nursing Record
PACU Nursing Record
Anesthesia PowerNotes
Anesthesia Record
Anesthesia Blood Administration

Notes




I & O
IView Documentation:
OB/ED System Assessments/Reassessments
ED/PACU/PreOp Procedures/Lines,Tubes,Devices
PACU Assessments

Results Review (Preferred view)
IView (i.e. Peripheral IV Dynamic Group will be pre-
populated from the ED documentation)
Medications Administered in the
Emergency Department, OB & Surgical Services
MAR
MAR Summary (Preferred Method)
Perform single patient search to locate
the patients chart


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Navigating PowerChart for ED, OB, OR Documentation
HQIT Learning Services
2/25/14 v1
Paper Documentation/Records Scanned into PowerChart

HIM (Health Information Management) is scanning paper documents into Cerner PowerChart. Paper documents
prior to January 10, 2014, will remain in paper format and available through HIM.

Scanning of documents must take place within 30 days after Discharge to meet requirements.

Scanned documents will be available in PowerChart under Notes or Documents.