ER Documentation and Depart
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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:
- Chief complaint – can be pulled in from the nursing chief complaint
- HPI- this should be free-texted in narrative format
- Review of Systems – can be from pre-completed notes, auto-text or macros
- Past Medical History – can be pulled in from the record
- Past Surgical History – can be pulled in from the record, if completed
- Social History – use the SH smart template for this by entering ..ykSocialHistoryMostRecent
- Allergies – can pull in from record
- Medication list – make sure the list is accurate if you are pulling in from record, may need to compete the meds rec first.
- Physical Exam – including pertinent vital signs
- Summary of diagnostic studies (lab, imaging, EKGs, etc)
- Description of any procedures – can use precompleted templates in RAVEN or free-text
- Emergency Department course/Medical Decision Making – make sure this includes differential diagnosis if appropriate.
- Impression and Plan – this should be free-texted
- Follow up – include from your depart summary
To discharge a patient:
- Click on the Depart button in the grey section at the top of the screen
- Complete the top 5 sections
- Patient Education/Follow up
- Prescriptions (if any)
- Medication Reconciliation – this MUST be completed on every patient
- Under “Charges” click on discharge order
- Remember to complete E&M charges at this time.
ED follow up appointments
- The ED is allotted a certain number of appointments for patients who need follow up in the ambulatory clinic the next day.
- To obtain one of these appointments, our current work flow is to ask the med tech to make the actual appointment for the patient in the computer. The patient is then given a letter with the appointment time on it. You also need to indicate this in your discharge paperwork under the follow up tab.