How To Use Cerner Charting: A Step-By-Step Guide

Cerner EMR is a widely used electronic health record (EMR) system that enables healthcare professionals to efficiently document patient care. Whether you're a student nurse, a clinician, or a new user, understanding the basics of Cerner charting is crucial for navigating patient records, documenting assessments, and managing medical data effectively. This guide provides a step-by-step walkthrough to help you get started with charting in Cerner.

1. Open ‘Cerner PowerChart’ and enter your user ID and password 
2. Click ‘PowerChart’ to access the system 
3. If prompted, enter your credentials again for verification 
4. Once logged in, the default screen may vary based on your role and permissions 

• Click on ‘List Maintenance’ (accessible via the wrench icon or a blue hyperlink on the main screen)
• Click ‘New’ and select your care area or unit 
• Expand the facility list using the plus (+) button to locate your assigned unit
• Select the entire unit census if you return to the same unit weekly 
• Click ‘Finish’ to save the selection 
• Move the unit from the ‘Available List’ to the ‘Active List’ using the blue arrow 
• Click ‘OK’ to confirm your selection 

• Select a patient from your list 
• Click ‘Establish Relationship’ 
• Choose your role (e.g., Student Nurse, Patient Care Tech, RN) 
• Confirm the relationship to enable access to charting functions 

The ‘Care Compass’ provides an overview of: 

1.Patient assignments 

• To-Do List (including medication schedules and assessments) 
• New orders or results (indicated by exclamation marks) 
• Alerts for overdue tasks 

To customize your view: 

• Click the ‘Arrow’ to expand the ‘To-Do List’ 
• Adjust the time frame (e.g., 2-hour vs. 12-hour view) to see scheduled tasks 
• Check off completed tasks (note: some actions may require verification from an instructor or RN) 

• Click on ‘Patient’s Name’ to open their chart 

2. The ‘Patient Summary’ displays: 

• Vital signs 
• Recent lab results 
• Medications (current and home meds) 
• Procedures and social history 
• Notes and assessments from previous shifts 

3. To review detailed notes: 

Navigate to the ‘Documents’ section to find progress notes, history, and physical assessments 

• Click on the ‘MAR’ tab to view the patient’s medication history 
• Identify scheduled and PRN (as-needed) medications 
• Use the Medication Administration Wizard (MAW) to: 
• Scan the patient’s wristband 
• Verify medication orders 
• Document administration time 
• Co-sign with an instructor or RN if required 

Most charting occurs in the ‘Interactive View’ (IView) section. Follow these steps: 

1. Entering Vital Signs 

• Locate ‘Adult Quick View’ 
• Adjust the time frame (e.g., every 2 hours instead of every 15 minutes) 
• Click ‘Insert Date’ and ‘Time’ to document in real-time 
• Input vital signs, pain assessment, and early warning scores (MEWS) 
• Save and sign the entry 

2. Completing System Assessments 

• Go to the ‘Systems Assessment’ tab 
• Select the relevant areas (e.g., neurological, respiratory, cardiovascular) 
• Open dynamic groups (e.g., wounds, IV sites) by clicking the expand (+) button 
• Document findings and sign the assessment 

3. Frequent Documentation (Hourly Rounding) 

• Use the ‘Frequent Documentation’ tab for hourly rounding 
• Chart patient positioning, toileting needs, and pain levels 
• Ensure all safety measures (e.g., bed alarms, fall precautions) are documented 

4. Intake And Output (I&Os) 

• Navigate to the I&O section 
• Record fluid intake (IV, oral, tube feeds) 
• Document urine/stool output and drain levels 
• Save and sign the entry at the end of the shift 

5. Restraints (if applicable) 

• Chart every 2 hours if a patient is in restraints 
• Include skin integrity checks and patient behavior 

• Go to the ‘Notes’ section 
• Select ‘Free Text Nursing Note’ 
• Document relevant observations, interventions, or communications 
• Keep notes concise and communicate with your nurse or instructor before adding extensive details 

• Student nurses must have their charting co-signed by an instructor or RN 
• Look for a red authentication checkmark indicating pending verification 
• Remind the responsible nurse to co-sign before the shift ends 

• Use ‘Results Review’ to find historical lab values and diagnostic reports 
• Double-click on chest X-rays, blood cultures, or microbiology reports for detailed analysis 

• Chart in real-time whenever possible 
• Use the reassessment tab to document updates without re-entering all data. 
• Verify co-signatures before logging out 
• Customize your display settings to streamline navigation 

Mastering Cerner charting enhances efficiency and ensures accurate patient documentation. By familiarizing yourself with ‘PowerChart’ navigation, patient assessments, medication administration, and frequent documentation, you can streamline workflows and improve patient care. For additional guidance, consult your instructor or assigned nurse during clinical practice.