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Cerner EHR Tips

Distributed by the Information Services Training Team | © Carondelet Health Network. All Rights Reserved

Progress Note Quick Reference Guide

This guide provides information for providers rounding in hospitals and covers how to create, sign, and copy

electronically signed progress notes. For assistance beyond what is covered in this guide, please contact the

Carondelet Service Desk at 520-872-2500.

Creating a Progress Note

Follow the steps below to create a progress note for a patient.

1. Open the patient’s chart in Cerner for the correct visit

(encounter).

2. Click on the PowerNotes tab.

3. Click the Add+ button in the upper-right corner to create a

new note.

4. Select the Progress Note note type and click the OK button.

NOTE: The first time you create a note, you may need to

click the Catalog tab to find the Progress Note type.

5. When prompted to auto-populate patient results in your

note, click the Ok button. NOTE: You can

uncheck any results you do not want to include.

6. Document your progress note results. To use

structured documentation and quickly select

results—click the <Show Structure> link.

Otherwise, click the <Use Free Text> link to free

-text results and observations.

7. Please see the rest of this reference guide for

specifics on how to document certain types of

results.

8. When you are finished, click the Sign/Submit

button to sign your progress note.

9. Click the Sign button.

Continued on Next Page

Audience: Hospitalists

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Best Practice Documentation

As you document your progress note, consider the following best practice suggestions:

Hospital Course: It is recommended that you document this paragraph using Free Text as the available

structure may not meet your needs.

Physical Examination: It is recommend that you document this paragraph using Structured document. We also

strongly recommend creating a macro for typical patient types/conditions to save time with documentation.

Health Status: It is recommended that you modify the list of medications to exclude PRN medications.

Review and Management: It is recommended that you copy/paste the results of microbiology and radiology

reports as comments if you would like the details to be included in your notes.

Impression Plan: It is recommended that you use the Dx Code Search term document and select patient

diagnoses. It is also recommended that you use Free Text to document your plan for each of the patient’s

diagnoses.

Viewing and/or Copying Reports into your Note

Follow the steps below to view radiology and microbiology

reports from with your progress note.

1. Click the Review and Management paragraph link in the

Note Navigator.

2. Within the Results Review sentence, click the Micro

Results term. For radiology results, click the Launch

Rad Interp (flowsheet) term in the Radiology Results

sentence.

3. Double-click the See Report text beside the test name.

4. Review the result. If you would like to include the text of these results in your note, you

will need to select the text and copy (Ctrl+C).

5. Click the Close button.

6. To include a reference to the reports in your note, click the Include Selected button.

7. If you copied the micro results earlier, you can add them into your note as a

comment. Right-click the Micro Results term and select Comment.

8. Paste the text of the result into the Comment window and click the OK

button.

Continued on Next Page

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CERNER EHR JOB AID

Copy an Existing Progress Note into a New Note

If you are rounding on a patient for whom you have already documented a progress note, you can save time by

copying your previous progress note. Follow the steps below to copy a progress note into a new note.

1. Open the patient’s chart in Cerner for the correct visit (encounter).

2. Click on the PowerNotes tab.

3. Click the Add+ button in the upper-right corner to create a new note.

4. Click the Existing tab.

5. Click the Copy to new note checkbox.

6. Highlight the note to be copied in the list of existing notes. NOTE: You can only copy notes you created.

7. Click the OK button.

8. When prompted, select which paragraphs you want to copy into your new note and click the OK button.

9. Click the OK button to update the auto-populated results.

10. Update, complete, and sign the new note (click the Sign/Submit button).