PowerChart Physician Reference: Using PowerNote
provider in scrubs
Using PowerNote

PowerNote is an application within PowerChart in which providers can create documents directly into the electronic medical record using an interactive template system. PowerNote templates are built and customized on-site by ITS staff in conjunction with departmental faculty and staff. PowerNote eliminates the cost and time lag associated with traditional dictation and transcription, and puts the provider in direct control of the documentation process.

NOTE: Items listed in bold below indicate an area of your PowerChart window that you can click on.
To view a larger version of any image, click on the image.

PowerNote is accessed via the PowerNote Icon in the toolbar of the Clinical Notes tab. Prior to accessing PowerNote, it is CRITICAL to open the patient chart to the correct visit, in order to ensure that your PowerNote is charted on the correct visit. To access PowerNote:

  1. Open the desired patient's chart in PowerChart
  2. VERIFY the correct FIN (Financial Number, AKA Visit Number) on the yellow demographic banner. (Click the Location link to change to a different visit if needed.)
  3. Click on the Clinical Notes tab.
  4. Click on the PowerNote icon in the toolbar.

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Access PowerNote from Clinical Notes

PowerTip: Here is the Accessing Powernote tip.

Upon launching PowerNote, the Open Note window is displayed. The tabs listed in this window allow you to open PowerNote templates in many ways:

  • New: A listing of all available templates. Click search to view all templates alphabetically.
  • Existing: Lists all active (saved) and signed PowerNotes for the selected patient. Here you can finish notes that were saved, or copy a signed note to a new one.
  • Precompleted: If you create your patient notes using a consistent style or format, you can save a note as a precompleted note and use this note format from one patient to the next. Remember to edit the information in the note as needed before signing.
  • Catalog: Sets of notes that go together for a specific unit, department, procedure or diagnosis.
  • Recent: Lists notes that you have accessed, the last note accessed is listed first.
  • Favorites: Anytime you add an encounter pathway or precompleted note to Favorites, it is saved on this tab.

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PowerTip: The Open Note window will always return you to the location of the last PowerNote template used.

PowerNote templates are interactive. Once accessed, creating a PowerNote is a combination of point-and-click and free text entry. When creating a PowerNote, follow these guidelines:

  1. Select the content of the note from the left and upper right panels. The lower right panel contains a preview of the note.
  2. To clear sentences and terms, right-click on the selected term and then select Clear.
  3. Clicking on WHAT will allow free text entry.
  4. When including Results in your note, depress the SHIFT key as you click to select groups of results, or depress the CTRL key to randomly select results.
  5. Your mouse pointer may change from [+] to [-] as you move it from left to right across the selected text. Clicking on the text when the [+] is displayed will add or display that text in the note. Clicking when the [-] is displayed will remove the text from the note.

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PowerNote Window

PowerTip: When the mouse pointer displays as [X], clicking the item underneath will chart that item in the negative aspect (clicking Chest Pain would display as Denies Chest Pain).

To Save a PowerNote for later completion:

  1. Click on the Save button on the toolbar.
  2. You may exit from PowerNote.

You note will not appear in the patient's chart until it has been signed. Saved notes will appear as Active notes on the Existing tab when you return to PowerNote.

To Sign a PowerNote:

  1. Click on the Sign button on the toolbar.
  2. Select the appropriate document type.
  3. The document title will display automatically. Do not change.
  4. Set the Document Date and Time to reflect when the note was written or then the patient service was delivered. This will be the date and time that the note will be displayed in the Flowsheet and on the Clinical Notes tab.
  5. If you need to forward the note to another provider for review, check Request Endorsement, then click under each column heading to complete the information. Remember to select either Review or Sign under the Type column.
  6. Click the OK button.

You will be returned to the Clinical Notes tab and asked if you would like to view your new document.

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PowerNote Sign Window

PowerTip: Saved notes may be accessed, viewed, and altered by other PowerNote users. Unneeded copies of Saved notes may be deleted by the author.

Once a PowerNote is signed into the electronic medical record, all modifications must be made directly from the Clinical Notes tab in the patient chart. To modify a PowerNote:

  1. Open the desired note from the Clinical Notes tab.
  2. Click on the Modify Document icon in the toolbar.
  3. Modifying a document may include:
    • Strikethrough: select a portion of the existing text you wish to strike out, then click the S button on the toolbar. The text will appear in red text with a line through it. You MUST include an addendum when you strikethrough text.
    • Addendum: you MUST add an addendum to explain any strikethrough, or you may add an addendum to include any additional information in your note.
  4. Click the Sign button when complete.

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PowerTip: Maximize the Modify document window to easily view the text in the document. Once a modification is signed, it cannot be removed and is considered a FINAL portion of the document.

If you create your patient notes using a consistent style or format, you can save a note as a precompleted note and use this note format from one patient to the next. Remember to edit the information in the note as needed before signing. To create a Precompleted Note:

  1. Complete all sections of the note that you wish to be precompleted.
  2. Click on File in the upper left corner of the screen.
  3. Click on Save as Precompleted Note.
  4. Insert your Cerner username into the beginning of the note title.
  5. Click Save as New.

Your Precompleted note will now be available for you to use on future patients. Simply access your Precompleted note from the Precompleted tab when opening PowerNote.

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Precompleted Save Window

PowerTip: It is not recommended to share precompleted notes, as other users will not only be able to use your note, but the can also CHANGE it.

If you discover that your PowerNote has accidentally been written on the wrong visit:

  1. Open the patient's chart to the correct visit (FIN).
  2. Open the incorrect note on the Clinical Notes tab.
  3. Click the In Error (red X) button on the toolbar.
  4. Enter a reason for the error in the window provided and click OK.
  5. Click the PowerNote icon on the toolbar to open PowerNote
  6. Click on the Existing tab and select All Encounters.
  7. Check the Copy to New Note box.
  8. Double-click on your original note from the list to open it as a copy.
  9. Sign the new note. (Be sure to check the DATE and correct if needed.)

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PowerTip: The AUTHOR of the PowerNote is the only person that may mark the note In Error. Remember to forward any corrected notes back to the appropriate individuals as needed.

If you discover that your PowerNote has accidentally been signed with the wrong document type:

  1. Open the patient's chart to the correct visit (FIN).
  2. Open the incorrect note on the Clinical Notes tab.
  3. Click the In Error (red X) button on the toolbar.
  4. Enter a reason for the error in the window provided and click OK.
  5. Click the PowerNote icon on the toolbar to open PowerNote
  6. Click on the Existing tab and select All Encounters.
  7. Check the Copy to New Note box.
  8. Double-click on your original note from the list to open it as a copy.
  9. Sign the new note with the CORRECT NOTE TYPE included. (Be sure to check the DATE and correct if needed.)

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PowerTip: The Note Type field will always default the last note type used on the most recently signed document. Always remember to check this field before signing any PowerNote.