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Cerner Charting systems

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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 I came from a facility that had Meditech (outdated I know!)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?
Author: alice  3-06-2015, 18:48   Views: 773   
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