CLINICAL DOCUMENTATION – Powerforms, powernotes, iviews & mpages 

USAGE

Electronic clinical documents are a key part of any EHR system. These allow physicians and nurses to easily locate, view and record clinical details as part of the patient’s treatment.

Extensive functionality is available in Oracle Cerner, and this can be customised to meet the specific requirements for clinical staff. For a tailor-made approach, rules logic (e.g. alert prompts) and custom views can be incorporated.

BENEFITS

  • Incorporate rules logic to provide more enhanced functionaility
  • Consulting, analysis review and recommendations
  • Advice and lessons learnt on similar functionality used at other trusts
  • Improve usability, efficiency and recording of patient clinical data
  • Ease of access to key clinical data and alerts prompts
  • Expert clinical-document solution architects within e-Health team
  • Preconfigured MPage catalogue available (see MPage solutions catalogue)

SCOPE

Powerforms                                                                                      PowerForms are custom designed for different types of charting: in this case, patient information charts. Once a form is signed, the information is committed to the chart. The completed form is listed in the Form Browser and can be reviewed from the patient’s chart.

Powernotes                                                                                      PowerNotes are recommended for health care providers – such as physicians, registered nurses and technicians – to perform the following tasks:

  • Create clinical notes related to care delivery in the patient care setting
  • Use symptom-focused content templates (Care Designs) to document and manage clinical encounters

Clinical Notes                                                                                                    The Clinical Notes tab allows you to view and enter information that is stored in the patient’s chart. Authorised individuals can enter clinical documents into the system. You can access Documents View from the Patient Chart window of Cerner PowerChart, providing ready access to a patient’s entire clinical documentation.

Smart Templates                                                                                        Smart Templates allow you to quickly insert data from other areas of the chart into your clinical notes. Inserting a smart template into a note displays the patient’s data as it currently exists in their chart. Updating the patient’s data and refreshing the patient’s chart does not update the smart templates.

iViews                                                                                                          Interactive view is a software-only application that allows clinicians to view a wide variety of patient information in a single area. Interactive View also allows clinicians to write directly to the chart, forward results, and view result details.

MPages & Workflow MPages                                                              Software application intended to provide a consolidated, real-time view of patient information from various components. Workflow components provide the actionable functionality required for clinicians to deliver care directly within the Workflow view.

Dynamic documentation                                                                              Pulls data from the patient chart (for example, allergies, chief complaint, diagnosis, medications, measurements, orders, problems, and vital signs) and allows you to create free-text entries, alongside chart data, for flexible and efficient clinical documentation.

SUPPORTED CODING LANGUAGES:

EKM Rules                                                                                                  Create and maintain Expert Knowledge Modules (EKMs). An EKM is an IF/THEN type logic statement, or action plan, which defines an action the system should take when certain conditions are met.

Discern Visual DeveLoper – Cerner Command Language (CCL)                  Oracle Cerner specific coding language to create programs, run queries and compile reports. In the Discern report output, new queries and prompt programs are executed by DVDev. The extracted data can be viewed on a screen, printed, saved to a file, or downloaded to another computer for analysis and formatting.

Enterprise Java Server (EJS)                                                                    Oracle Cerner specific coding language to create programs, run queries and compile reports. In the Discern report output, new queries and prompt programs are executed by DVDev. The extracted data can be viewed on a screen, printed, saved to a file, or downloaded to another computer for analysis and formatting.