Physician Office Schedulers - Adding Orders and History & Physicals to Cerner

Link to Step-by-step video of Orders/H&P https://youtu.be/psTKkCSRBsc

Search for your patient in Appointment Inquiry

The Appointment Inquiry screen opens:

Click button with 3 dots
Enter patient identifying data, the more specific then the easier to find. For example – entering the patients SSN or Name with Date of Birth (DOB).
Click on the patient you want to select it
Click Ok button
Click Find button to pull up all of the encounters (visits) for that patient

All encounters populate into the white space of the Appointment Inquiry screen – see below.

Select the patient and then open PowerChart

The patient’s chart opens up and looks like below:

One Time Set up – then all charts will look like above when opening

Remove all other Tabs except Nursing Workflow
Click tiny down arrow and remove all components except New Order Entry and Order Profile
Drag and drop to move New Order Entry to the top of the list (these settings will stay until you change them)

Finding and Entering the Physician’s order set:

New Order Entry is selected when the blue bar is to the right of the words
Click the blue link labelled “Shared”
Type in physicians name to search. It should populate for you to select or you can click the magnifying glass icon to open search screen
Click on time on words – My Plan Favorites to open and the Favorite folder opens
Click one time on desired orderset
Orders for signature tray indicates order with green number, click on tray icon

Orders for signature box pops up, click on Sign button

Ordering Physician box pops up, enter Physician name, ensure that Cosign Required is highlighted and click the OK button

Order Phases with details screen opens

Most physicians have already completed their ordersets so this is just a matter of double checking to make sure the correct labs and antibiotics are ordered.
Ordersets are divided into the different phases of care for the patient. (Think of each phase as a different piece of paper). The best view (and least confusing), is to click on the name of each phase to see only those orders
Office schedulers / MA's will usually only enter the PAT phase for Pre Admission Testing labs and/or the PreOp phase for antibiotics or other Day of Surgery orders that need to be completed before patient goes to the OR.
Small down arrows next to order details indicate that a different detail is available in a drop down list
If just a few items need to be changed then right click on the words of the detail to see the Modify button
If items are missing then click Add to Phase to add additional orders
NEVER initiate orders, they will always be placed in a planned status. Orders are only initiated when the patient is in that area of the hospital.
To make sure that you have all of the orders in the orderset, then click on the Orderset Name in the gray View column, this changes the buttons on the bottom right corner to Orders for Signature (this button automatically puts orders in a Planned state).

After clicking the Orders for Signature button, the screen changes. Simply click the Sign button to drop the orders. NEVER click Initiate Now buttons.

Orders have now been placed on the patient’s chart. If you do not need to add a History and Physical, then click the red X in the top right corner of PowerChart to go back to Scheduling Appointment book.

Adding History and Physical’s to the patient’s chart

Follow the steps on page 1 and page 2 to find patient if just adding H&P. There are 2 ways to enter H&P’s: import a PDF OR copy and paste into a note.

One time document type set up:

Click Note| Scan| Import in the Dark menu of the left side of the chart
Click on word Documents on gray row at top to open drop down list
Click options to open Clinical Note Options screen

Click Default Document Type drop down arrow and select History and Physical
Go to All Available Document Types, click on time on words to select History and Physical. (Other requested options include Cardiology Consultation for cardiac clearances or History and Physical update)
Click on grey single arrow button (under double arrow button) to move the selection to the Personal Document Type List column. Note: don’t click the double arrow button or you move EVERY document type.
Click OK

OPTION 1: Import a PDF into the patient’s chart

Click Note| Scan| Import in the Dark menu of the left side of the chart
Click Scan | Import icon to open the Add Document pop up
If default Type is not History and Physical, click drop down to select
Change Author to surgeon
Click Import button and the Network folder opens up. This will vary depending on how your office is set up.
We recommend that you have a folder set up on your network specifically for H&Ps that you can open to import the document into Cerner.

See next page for screenshot.

Open Network folder
Change drop down to all files
Click one time on desired document
Click on the open button
Verify information then click Sign button to complete importing the document.

OPTION 2: Copy and paste note into the patient’s chart

Click Note| Scan| Import in the Dark menu of the left side of the chart
Click Add icon to open the Add Document pop up
If default Type is not History and Physical, click drop down to select
Change Author to surgeon
Click in white space. On keyboard, select Ctrl V keys together to paste previous copied item. Text can be edited and formatted.
Click Submit button to save into the chart. Never click the Save button or Save and Close button because no one will be able to see it but YOU.
Follow steps on next page to make sure you haven’t accidently saved instead of signed/submitted documents

Checking to make sure documents are Signed or Submitted.

Click on Message Center located in 2^nd grey bar on top of screen
Towards the bottom of the Inbox Summary grey column, you will see “Saved Documents” If there is a number next to those words then you need to sign any documents in there so that other users such as nursing and HIM can see them. Click on words to open Saved Document screen.
Double click on patient’s name to open the sign screen
The sign button is defaulted
Click Ok to sign or OK & Next to sign and go to next document.