ER Documentation and Depart

ER Documentation

All patient encounters must be documented in RAVEN, our electronic medical record. There are standard pre-completed notes to choose from and modify for your own use.

All notes should include the following elements:

1. Chief complaint – can be pulled in from the nursing chief complaint
2. HPI- this should be free-texted in narrative format
3. Review of Systems – can be from pre-completed notes, auto-text or macros
4. Past Medical History – can be pulled in from the record
5. Past Surgical History – can be pulled in from the record, if completed
6. Social History – use the SH smart template for this by entering ..ykSocialHistoryMostRecent
7. Allergies – can pull in from record
8. Medication list – make sure the list is accurate if you are pulling in from record, may need to compete the meds rec first.
9. Physical Exam – including pertinent vital signs
10. Summary of diagnostic studies (lab, imaging, EKGs, etc)
11. Description of any procedures – can use precompleted templates in RAVEN or free-text
12. Emergency Department course/Medical Decision Making – make sure this includes differential diagnosis if appropriate.
13. Impression and Plan – this should be free-texted
14. Follow up – include from your depart summary

To discharge a patient:

1. Click on the Depart button in the grey section at the top of the screen
2. Complete the top 5 sections
   • Diagnosis
   • Patient Education/Follow up
   • Prescriptions (if any)
   • Medication Reconciliation – this MUST be completed on every patient
   • Charges
3. Under “Charges” click on discharge order
4. Remember to complete E&M charges at this time.