Cerner Charting systems

Nurses General Nursing

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Help! I've moved and am at a facility that has Cerner as the charting system. I came from a facility that had Meditech (outdated I know!) which I felt was so simple and easy to chart on because you go down the list, check the screens you need to chart on, and enter data though your space for notes was limited. I'm used to charting on EVERYTHING- WDL or not.

Cerner I feel is so disorganized. In the assessment screen I can select whether or not things are WDL at the very top of the assessment form which is fine and dandy. But an issue I came up across was a male patient who had a leg wound. Obviously I can't say that his skin is WDL, he has a wound. But on the skin section I don't have an option to select that he was a wound therefore leading them to go look at the wound assessment form. I can select options like red, ashen, bruised, etc but nothing to flag them to look at the wound section and leaving them wondering why the top section is not marked as WDL when nothing abnormal is charted in the lower section. Obviously I'm going to show and tell them of any areas of wounds in my shift report but I just feel like it could be charted better.

I'm really not a fan of charting by exception (especially since the concept is essentially "new" to me as I've used Meditech for 3 years). Any tips or tricks on getting over feeling like i'm not charting enough or any Cerner tips/tricks you can offer?

I wish this had some replies! This is a big problem for me, too. With Cerner, it's so hard for me to find the patient education that has been done by other staff so I can coordinate efforts. With charting by exception, I feel like there is no log of all of the work I have done.

I wish this had some replies! This is a big problem for me, too. With Cerner, it's so hard for me to find the patient education that has been done by other staff so I can coordinate efforts. With charting by exception, I feel like there is no log of all of the work I have done.

Education is just in the "Forms" on the left side of the screen. I always check that at the beginning of the shift so that I know whether or not I need to chart education for the day.

Specializes in Pediatrics, Emergency, Trauma.

Our corner has a place for Incision/Wound in the assessment; check to see if there is a category for that under Physical Assessment

Our corner has a place for Incision/Wound in the assessment; check to see if there is a category for that under Physical Assessment

I chart "not intact" or "intact with abnormalities" and then chart in the wound section as appropriate :up:

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I agree that Cerner charting systems are not the most intuitive or user-friendly, but I have nothing else to compare it to since this is the only brand of computer charting I've ever used.

If you feel the need to chart additional information, click on 'Progress Notes,' then 'Nurses Progress Notes,' and type a narrative note.

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