Solution Training Guide - SurgiNetr

SurgiNet Solution Training Guide

Revision: 003 December 29, 2006

©2006 Cerner Corporation. All rights reserved. This document contains confidential information, which may not be reproduced or transmitted without the

express written consent of Cerner. Page 1 of 30

Owner: IC Strategist

Solution Training Guide SurgiNet




express written consent of Cerner.

Page 2 of 30 Owner: IC Strategist

© 2006 Cerner Corporation

All rights reserved. This material contains the valuable properties and trade secrets of Cerner Corporation of Kansas City, Missouri, United States of America (CERNER) embodying substantial creative efforts and confidential information, ideas and expressions, no part of which may be reproduced or transmitted in any form or by any means or retained in any storage or retrieval system without the express written permission of CERNER.

Cerner believes the information in this document is accurate as of its publication date. While Cerner has made a conscientious effort to avoid errors, some may still exist. The information in this document is subject to change without notice, and should not be construed as a commitment by Cerner Corporation.

Overview This reference guide was designed to supplement a hands-on, instructor led session. Pictures of various screens have been included in order to show general information placement. Please note that these are standard screens and may not match exactly to those at your site.

Learning Objectives At the end of this session, class participants will be able to:

• Set up user preferences

• Check-in Case in Surgical PowerChart

• Document Segments

• Finalize Case

• Add Items to Case Pick List

• Fill and Use Items in Case

• Charge for Case

Course Length The class is designed for one half day class.

Prerequisites All participants are expected to be competent in the following areas:

• Computer basics

• Microsoft Windows






Information Security and Confidentiality

When dealing with computerized health care records, specific confidentiality and security issues must be followed to protect the patient. There are increasing HIPAA and JCAHO regulations that dictate how these records are handled.

• When selecting a password, don’t choose anything obvious, such as your birth date, social security number, or spouse and children’s names.

• Do not tell anyone your password.

• Your system may require you to change your password at regular intervals.

• When you open a chart you will be asked to identify your relationship to the patient, for example primary RN, consulting physician, etc. The system keeps an audit trail, or record, of who enters each chart and when. It records who read the chart and who recorded each piece of information in the chart.

• Security should be designed so that employees can only perform functions within the system that are necessary for their position/role. Also, employees should only be able to view data that is necessary to perform their job. For example, a lab technician should have the ability/security to utilize all of the functions within the PathNet® solution, but an ED Nurse should not have that ability.

• Do not leave the computer while still signed on.

• Do not access any charts that do not apply to your current job and caseload.

• Each facility has its own specific confidentiality and information security policy. It describes the repercussions of not following these rules.

Tips and Tricks Cerner Application

• Press and release the secondary (usually right) mouse button and see if any of the menu items apply.

• Use your cursor to hover over the buttons to see if any of the button names jog your memory.

• If a single mouse click doesn’t work, try a double mouse click.






Getting Started Logging In

Follow this procedure to log into the system:

1. At the Main Menu window, double-click on the SurgiNet icon.

2. At the Cerner log-in window, type your user name in the User Name field.

3. Press the Tab key to move to the next field and type your password into the Password field.

4. Click on the OK button or press the ENTER key.






Logging Out When you have completed your activities, remember to log out of the application you are working on for security purposes. Logging out can be done in one of the following three ways:

1. If you are exiting the application temporarily, but planning on returning to that computer shortly, click on the suspend user icon on the toolbar. This will return the screen to the log on window and place the cursor in the password field.

2. If you choose the icon displayed below, you will enter the Exit Application window. This first option available allows you to prepare the application for the next user. This will return the screen to the log on window and place the cursor in the user name field. The second option will completely shut down the application and the third option will allow you to suspend the application.






Scheduling a Case Using Surgical Case Manager

1. Open Surgical Case Manager by clicking the dropdown arrow on the tool bar and

selecting surgical case manager. .

2. Click the New Case button (on the upper left corner of the screen and looks like a white paper with a star behind it). The Person Search dialog box appears.






3. Type in the patient’s MRN number, last name with first name on the next line or social security number and click SEARCH or <Enter>.

4. Click OK.






Scheduling Information 1. The SurgiNet®: Surgical Case Manager window reappears with the patient’s name filled in.

2. In the Surgeon field, start typing in the surgeon’s name. The computer will automatically try to finish the name as you type.

3. If there are multiple physicians with the same last name, click the FIND icon behind the Surgeon field (binoculars). A Provider Selection window will appear with a list of physicians with that last name. Select the correct physician. Click OK.

4. Priority field: type in E twice to select Emergency, or click on the arrow and select Emergency. Elective, Urgent or Emergency are the only choices to use for the OR. Emergency is imminent loss of life or limb, Urgent is an add on that can’t wait, Elective will be scheduled by the OR scheduler.

5. OR field: click the drop down arrow and select the add on room.

6. Start Date field: type in t for today.

7. Start Time field: type in n for now.

8. Encounter Type field. Select routine. These choices are used by admitting and routine is the one we are to use.

• Click the drop down arrow.

• Highlight the correct type of encounter at the bottom of the list.

9. Add On Case field: click in the box

Adding Procedure 1. Click the Add box under the Scheduled Procedures field.

2. A Surgical Procedure box will appear. Remember this is choosing the pick list. Pick something as close as possible so you have the supplies you need.

3. In the Procedure field, begin to type in the name of the surgical procedure. The computer will complete the name for you. Then use the drop down box to highlight a more specific procedure. Remember the verb is first. (ie:Carpel tunnel release is under release Carpel tunnel.

4. Press TAB.

5. Choose the Anesthesia type if you know it (can be changed later) Specialty, and Duration will default in.

6. Click Primary procedure if more than one procedure needs to be chosen.

7. Add Procedure Modifiers if appropriate.

8. Click OK.






9. Click APPLY on the bottom of the screen. A box saying Successful Case Creation will

appear. It contains a Case Number. A pick list will print automatically to sterile hall.

10. Click OK.

11. Click on the X (close window button) in the upper right corner to exit Surgical Case Manager.

12. Click retrieve on the main screen to pull up the case just scheduled.

Surgical PowerChart Selecting a patient in Surgical PowerChart

1. Click the SNSurgiNet® icon (unless the application is already open, in which case, click on icon at bottom of screen). The Surgical PowerChart screen will appear.

2. The first time you use Surgical PowerChart, you will be prompted to select a Surgical Area. Each subsequent time you enter the application; the most recent Surgical Area used will default in. (Note: If you need to change surgical areas, click on the location tab at the top of the screen.) A “Case Selection” window then appears and shows all of the procedures that are scheduled for that day. To view other dates, refer to #4 below.






• The patients are listed in alphabetical order.

• You can also change the order of the case list by sorting according to surgeon or operating room. You do this by first scrolling to the right of the window, then clicking on the appropriate column heading. You can also sort the operating rooms in ascending or descending order by clicking on the OR column heading again.

• Changing the date:

• To change the date one day at a time, click the small double button to the immediate right of the date field. The top button is to move forward and the bottom button moves back in time.

• To change to a distant date, click the upside down triangle to view the calendar. From there, click the correct date or use the < or > to change the months.

Note: The upper < and > change the year and the lower change the month. Make sure that you have the correct year.

• Now click RETRIEVE and a list of patients will appear.

3. Click on the Check In box to the left of the patient’s name. If the patient has not been

Checked In (which is the process of associating a patient with a financial number), the next screen that appears will vary, depending on whether the patient was booked through






Scheduling Appointment Book or Surgical Case Manager. If the patient has already been Checked In to Surgical PowerChart a black check will already be in the check in box,

4. If the patient was booked through Schedule Appointment Book (by the surgery schedulers), a Check In” box appears.

• Make sure you are on the General tab.

• Verify that you have the correct patient.

• Click the SET ENC (set encounter) button towards the bottom right of the screen.

• When the Encounter Selection box appears, click to highlight and choose the correct patient encounter. (Compare the FIN number with the one on the chart and the one on the patient to verify that you have chosen the correct encounter.

Note: It is very important that you choose the correct encounter at this point. If you choose the wrong encounter, the patient’s documentation and bill will not be correct.

• Click OK.

• The Check In screen reappears. Click OK.






5. If the patient was booked through Surgical Case Mgr, an Associate Encounter box will appear.

• Confirm that the admit date, encounter type, and FIN number are correct and click ACCEPT.

• If it is not the correct patient encounter, click RE-SELECT. An Encounter Search window will appear.

• Click and highlight the correct FIN number/encounter and then click OK.

6. Open a previously checked in case by double clicking on patient’s name in the Case Selection Window.

• Your patient’s name and basic information will display in the patient banner highlighted in yellow. The overview banner will display. Hover over the menu tab on the left and all of the bands of the patient chart will display. Choose perioperative docs for surgical documentation. Immediately under the perioperative documentation tab is a field that contains all document types associated with this case. Click the down arrow to view the choices of preop nursing assessment, Main OR Intraop Record, and PACU Nursing assessment . Click to highlight the correct choice.

Note: Click on Task at the top left corner of the screen and choose Document Type Prompt. This setting will prompt you for a document type prior to starting the case.






Changing Document Types 1. Select the Document Type Drop down and choose a new record type such as Pre Op

Nursing assessment.

2. The new record will display with all segments pertaining to that record. This gives you the ability to view or document between surgical areas like PreOp and IntraOp. The same functions listed below for the IntraOperative record pertain to all records.






Surgical Documentation Layout

1. Choose the Main OR Intraop Record. Documentation can be customized for different

surgeons and procedures, so you may not always see the same segments listed. Additional available segments can be viewed by clicking on the Add Segment icon (explained further below).

2. A red exclamation mark to the left of the segment indicates required fields are present. These are indicated by a box above the field that will fill with a black check mark when documented .

3. Under the list of segments is a set of numbers that indicate the number of pages that make up the segment that is currently being viewed. The yellowed-in number indicates which page is currently being displayed.

4. On the bottom right is a long blank white box. It is the comment field. Each segment has its own comment field, which will print out with that segment on the hard copy.

5. The Pre Care Activity and Post Care Activity are PNDS diagnosis and expected outcome fields related to the specific segment you are in. Click to view the associated nursing diagnosis.






Anatomy of a segment

1. To move from one segment to the next, click on NEXT or PREV on the bottom right of the screen. This should take you in the normal progression of the case. Some segments must be visited twice before you can finalize the case. The segments listed on the left are in alphabetical order. You can move from one segment to another by clicking on the left side display if you prefer.

2. Each segment consists of fields. Types of fields include:

• Check box: click small box to select entry. A check mark will appear.

• Drop down box: click on small arrow to view options, then highlight and click to select correct entry.

• Multiple entries: click on small downward arrow as described above. When the correct option is selected, click on double right arrow to move the entry to response box. Repeat to select additional responses. To remove entry from response box, highlight and click on double left arrow.






• Free text: type in value using letters, numbers, or both.

• Numeric: type in value using only numbers.

• Date/Time: type in date (T = today) and time (N = now), or click on prompt to enter current date/time. Can adjust, as needed using up or down arrows.

• Provider field (Staff): begin typing the last name of the staff person. The computer will try to complete it for you. If there are multiple matches, click on the binoculars icon, highlight the correct choice, and click OK.






3. To move from one field to field, click in the desired field. The TAB key will advance the cursor to the next field for you, within the current page selected.

4. Some segments contain List Boxes. A list box is used for repeating forms where you can add more than one entry into that segment.






5. Completing a List Box:

• When all fields of a segment are filled in including multiple pages of the same segment, click on the ADD button toward the bottom of the screen. This will transfer your entries into the list box.

6. Modifying a List Box Entry After It’s Been Added:

• Click to highlight the entry in the top list box.

• Change the appropriate field(s).

• Click MODIFY on the bottom of the segment screen and the new information will transfer up to the appropriate line in the list box. When the top entry has not been highlighted and you add information the illistration below shows what the error looks like. It must be removed and modified correctly.

7. Deleting a List Box Entry After It’s Been Added:

• Click to highlight the unwanted entry in the list box on the top of the screen.

• Click REMOVE on the bottom of the segment screen.

• Click YES when asked if you want to delete the current entry, and the unwanted entry.






Adding an additional segment

8. Click on a segment on the left of the screen. Right click on it and the add segment box will

appear. Click on the segment on the left that you want to add Then click the > button and the segment will move to the Selected list. Click OK. The segment will now be available on the left to document on. OR…

1. Click the icon on the top left of the screen that looks like a file with a star behind it. An Add Segment window will appear (see above).

2. The list on the left contains segments that have not been used for this patient. The list on the right contains segments that have already been opened for this patient’s record.

3. On the Available list, click and highlight/choose the appropriate segment. Then click the > button and the segment will move to the Selected list. Click OK.

4. Back on the SurgiNet® Document Manager screen, the Documentation tab list on the far-left side of the screen will now show the new segment in bold print. It will not have a check mark in front of it.

5. Click and highlight/choose the new segment then complete the documentation.






Discontinuing a segment

5. If you have nothing to document in a segment, discontinue it. These segments were added to make documentation complete for that individual procedure. Think carefully before discontinuing a segment.

6. Highlight segment on the display list, right click, and click Discontinue.

7. If you are prompted to give a reason, select an appropriate reason, then click OK. (none can not be left as an appropriate reason) Note: If you need to activate a discontinued segment, highlight it, right click, and click Activate.






Finalizing the Surgical Documentation record 1. Click the green flag icon under the perioperative doc banner.

2. If all listed segments and required fields have been completed and all have a green check, a Document Verified message will appear. Click YES to finalize the document.

3. If all segments/fields have not been completed, a Documentation Deficits screen will appear listing the missing entries.

4. To access each segment, double click on the entry, complete the appropriate fields, and click

OK in the segment. Repeat for each segment requiring documentation.

5. Discontinue segments as needed.

6. When all segments are completed and/or discontinued, click the green flag again

7. The system will do another deficit check and then display a message that there are no deficits. Click OK to finalize the case. You will then be prompted to print the document, click no.

Entering Pick List Documentation 1. Once documentation is complete click on the Pick List tab.

2. Set view options. (this only has to be set up once)

3. Right click anywhere in Pick List, and click on Options.






• Display Options screen, General tab appears.

• Make sure only the following boxes have check marks in them, and are arranged in this order: Item Image, Description, Used Qty, Item Number, Duplicate Indicator, Open Qty, Hold Qty. To deselect an entry, click on the check mark. It will disappear. To move an entry up or down, highlight it, and then use the arrows on the right to reposition it appropriately.

• Click on the Advanced tab.

• Make sure the following are set up as shown:

• Set Open Qty to 1 times the base issue factor of the item






• Default Used Qty = Fill Qty checked

• Click OK.

Anatomy of the Pick List The case number appears at the top of the Pick List. Below it are the item classes, in the same order as on the preference card. Note that when the case number is highlighted, all pick list items are listed alphabetically, regardless of class. When an item class is highlighted, only the items in that class are listed.

Note the columns listed on the right side:

• Open – These are the items that are pulled for the case that will be opened prior to case starting. (this is reference information)

• Hold – These items are pulled for the case, but are not opened. (this is reference information)

• Used – This is the qty that was actually used. This qty will default from the Open qty. It will feed into the charge quantity.

Edit Pick List Items 1. You should always click and update Use on the case pick list before modifying the Used

quantities individually. Follow these steps to update the Use on the case pick list.

• Left click on the case number on the left side of the screen.






• Right click the case number, left click on Use.

• Chart by exception to modify item Used quantities for the case.

Add items not on Pick List 1. Click on Ellipses (looks like three dots) to the left of the Add button.

2. Find All Items appears. You can search by description or manufacturer item number as the

easiest ways.

3. To search by description, In the field to the right of Search For, type the name of the item, the begins with or includes will help refine your search. Then click Find Now. To search by manufacturer item, change search on box to item number and type in what you can. Any possible matches will show up below. Try various ways, first few numbers, first letters. Sometimes the items have spaces, dashes, periods etc in the item number.

4. If unable to locate item, click New Search, and type a different description or search criteria.

5. When found, highlight item, and double click. Item is moved to the Pick List.

6. Note: it you get a message saying that the quantity is zero, or that none are available, click OK. This is for inventory purposes not used at BRMC.

7. Continue pulling in additional items.

8. When finished, click OK.

9. Confirm that all items have been moved to the Pick List, and edit quantities as needed.

10. If you need to delete an item, highlight it, right click, and click, delete.






11. If you are unable to find an item, the item will need to be entered as a free text item. Go back to the item add box and type in as much information as you can enter. Click add and a box will pop up that asks if you want to add as a free text item. Click yes. Update the quantity used. This will be entered on the pick list as a free text item and will be handled by other people for charges.

Document Inventory Items When documenting inventory in the OR record (for instance, when documenting implants) the system can automatically feed those updates into the case pick list as well, thereby reducing the documentation process.

1. Click on Documentation tab and go to the appropriate segment. If the item is already listed on the Pick List , click on the down arrow on the inventory field and select the implant. If it does not exist on the picklist, click on Ellipses (looks like three dots) and search for the item.

2. Fill out the rest of the documentation on the segment and add the item to the list box (see

steps for completing a List Box under the Documentation steps above)

3. Repeat process for each item.

4. Once you have added at all the implants to documentation and click next it will pop up with a

Picklist Update Confirmation Window. If for example you are documenting the heart room foley in the catheter segment, that foley tray is included in the pack and you would not want to add it to the picklist.

5. Review the updates that will be made to the pick list

6. Click OK to accept these changes






7. Once those changes are accepted, they will feed into the case pick list. Double check quantity on the pick list and make sure it is accurate.






Printing Print Surgery Schedule 1. Click on the SurgiNet® Report Builder icon in the toolbar.

2. Reports that you have privileges to will display.

3. Highlight the report you want to print.

4. Click on Printer Icon.

5. Enter the beginning and end dates for the report.

6. Click Print






7. You should get a printing confirmation message. Click OK.

8. Repeat the above steps for additional reports.

9. When finished, click the X in the upper right corner of the screen to exit the application.

Print Case Pick List This can be accomplished via the Case Select screen via Surgical PowerChart, or by accessing the standalone version of the Case Select screen, which is called the SurgiNet Case Checkin application.

1. Click on the Surgical Case Check In icon on the Appbar.

2. To print a pick list for an individual patient, highlight that patient.

3. To print pick lists for more than one patient, highlight the first patient, then press the control key while highlighting additional patients.






4. Click Print at the top of the screen, and then click Pick List.

5. The Print Set Up screen appears.






6. Highlight the correct printer. Front desk is SURGY sterile hall is SURGSH.

7. Change the number of copies as needed.

8. Document Types tab:

9. Make sure Intra Op Record is checked.

10. Pick List Parameters tab:

11. Format: click on Reporting Classes.

12. Sequences Other: Make sure Comments are listed first. If not, highlight the entry and click the up arrow on the right side of the screen.

13. Click Save Setup in the bottom left corner. You will not have to reenter these settings in the future.

14. Click OK.

15. You should see a printing confirmation. Click OK.

16. Click on the X in the upper right hand corner of the screen to exit the application.

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