Outpatient RAVEN Charting - Revision history

JenniferH: /* How to Create and Do an Ambulatory Encounter */

2020-11-20T14:53:41Z

How to Create and Do an Ambulatory Encounter

← Older revision		Revision as of 14:53, 20 November 2020
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	===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===


			[[:Category:Outpatient\|Outpatient Main Page]]

JenniferH: /* How to Create and Do an Ambulatory Encounter */

2020-10-30T12:07:20Z

How to Create and Do an Ambulatory Encounter

← Older revision		Revision as of 12:07, 30 October 2020
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	===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===

	~~[[Category:Outpatient]]~~

JenniferH at 17:09, 12 June 2019

2019-06-12T17:09:00Z

← Older revision		Revision as of 17:09, 12 June 2019
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	===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===

	[[:~~category:outpatient~~]]		[[Category:Outpatient]]

JenniferH at 18:47, 14 February 2019

2019-02-14T18:47:29Z

@@ Line 16: / Line 16: @@
 ===Required Documentation On A Patient Note===
 It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.
 ===[[media:Ambulatoryencounter-howto.pdf|How to Create and Do an Ambulatory Encounter]]===
 [[:category:outpatient]]

JenniferH at 01:41, 14 February 2019

2019-02-14T01:41:54Z

← Older revision		Revision as of 01:41, 14 February 2019
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	~~We are now charting in~~ our ~~new EMR~~ RAVEN~~. it~~ is a Cerner based system. You will receive ~~one-on-one~~ training ~~from one~~ of ~~our existing providers~~.		Clinic documentation is done through our Electronic Health Record (EHR), RAVEN which is a Cerner-based system. You will receive extensive EHR training prior to seeing patients. In addition, there is a dedicated EHR Medical Staff Trainer and there are extensive job aides available for you to reference as you become acclimated to the system. The providers with whom you will work for the first several months in clinic will also be of great assistance with ongoing training.

	~~You can use RAVEN pre-completed notes;~~ you ~~can modify templates to suit your needs and~~ documentation ~~styles; or~~ you can adopt good-shared pre-completed clinic notes with minor or no changes. Writing a good free text HPI and Assessment and Plan on an encounter is strongly suggested… ie Create a document where any follow up provider can quickly look at the beginning and end of your ~~note and understand the history, diagnoses and follow up~~ plan ~~with therapeutic goals if appropriate.~~		It is very important that you have good documentation so that the providers coming after you can see your plan for the patient. Your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.

	~~Please remember to select a document with the correct note type before you walk in the room. You may wish to document during the encounter with~~ the patient~~, depending on what they are being seen for~~. ~~At the end of the visit please do the DEPART /Visit Summary – and select education/follow up choices/ and medical reconciliation – as those are Meaningful Use requirements.~~

	~~Any time you do an action on a patient — follow up meds or analyze labs — please document what~~ your ~~plan is in a free text note or message saved to the chart~~. ~~You may~~ also ~~wish to modify the note from the original encounter. Then someone seeing the patient after you can see what~~ your ~~plan may have been~~ and ~~why you ordered certain things. A letter to the patient is also saved under~~ documentation ~~and can be used to explain to later providers what happened~~.

			'''Some important points to remember:'''
			*Choose the correct note type.
			*Type as much as you can during the visit.
			*Always do the Depart/Discharge Summary
			**Meaningful Use Requirements:
			***Patient education
			***Follow up
			***Medicine Reconciliation
			*Any time you perform an action for a patient, e.g., follow up on a medication, review labs, etc., please document what your plan is in an addendum, a free text note, or a general message saved to the chart. This way subsequent providers can see your action and plan.
			*Letters sent to the patient via PowerChart/FirstNet are also saved under ‘Documentation’ and can be used to explain to later providers what happened.

	===Required Documentation On A Patient Note===		===Required Documentation On A Patient Note===
	It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.		It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.
	* HPI		* HPI - Should ALWAYS be free text!
	* PMHx – update the active problem list and add/delete when necessary		* PMHx – update the active problem list and add/delete when necessary
	* Surgical Hx- PLEASE UPDATE IF YOU CAN.		* Surgical Hx- PLEASE UPDATE IF YOU CAN.

Mfaubion at 22:11, 21 August 2015

2015-08-21T22:11:31Z

← Older revision		Revision as of 22:11, 21 August 2015
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	===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===

			[[:category:outpatient]]

Mfaubion: /* How to Create and Do an Ambulatory Encounter */

2015-08-21T22:10:41Z

How to Create and Do an Ambulatory Encounter

← Older revision		Revision as of 22:10, 21 August 2015
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	===[[media:~~ambulatoryencounter~~-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:Ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===

Mfaubion: /* Required Documentation On A Patient Note */

2015-08-21T22:07:28Z

Required Documentation On A Patient Note

← Older revision		Revision as of 22:07, 21 August 2015
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	===Required Documentation On A Patient Note===		===Required Documentation On A Patient Note===
	It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.		It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.
	• HPI		* HPI
	• PMHx – update the active problem list and add/delete when necessary		* PMHx – update the active problem list and add/delete when necessary
	• Surgical Hx- PLEASE UPDATE IF YOU CAN.		* Surgical Hx- PLEASE UPDATE IF YOU CAN.
	• Soc Hx- Please put in who they live with.		* Soc Hx- Please put in who they live with.
	• Tobacco/Alcohol/Drugs Screening- should be done by your screener.		* Tobacco/Alcohol/Drugs Screening- should be done by your screener.
	• ROS – at least 3systems.- two pertinent negatives		* ROS – at least 3systems.- two pertinent negatives
	• Problem List –put any chronic issues on here or select no chronic problems. It should never be blank.		* Problem List –put any chronic issues on here or select no chronic problems. It should never be blank.
	• Exam		* Exam
	• Labs results if possible		* Labs results if possible
	• X-rays results if possible		* X-rays results if possible
	• EKG interpretation – found in the Results		* EKG interpretation – found in the Results
	• Diagnosis – select each one you addressed		* Diagnosis – select each one you addressed
	• Plan /Follow up for each diagnosis		* Plan /Follow up for each diagnosis
	• Patient Education – pick from note or depart		* Patient Education – pick from note or depart
	• Do Med Reconciliation- please eliminate duplicates from past visits if possible.		* Do Med Reconciliation- please eliminate duplicates from past visits if possible.
	• Patient understands education button.		* Patient understands education button.
	• Publish and Print the Visit Summary		* Publish and Print the Visit Summary
	• Have patient sign the page of the visit summary if they get medications and make a copy for putting in Multi media.		* Have patient sign the page of the visit summary if they get medications and make a copy for putting in Multi media.


	===[[media:ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===		===[[media:ambulatoryencounter-howto.pdf\|How to Create and Do an Ambulatory Encounter]]===

Mfaubion: Created page with "We are now charting in our new EMR RAVEN. it is a Cerner based system. You will receive one-on-one training from one of our existing providers. You can use RAVEN pre-complet..."

2015-08-21T22:06:04Z

Created page with "We are now charting in our new EMR RAVEN. it is a Cerner based system. You will receive one-on-one training from one of our existing providers. You can use RAVEN pre-complet..."

New page

We are now charting in our new EMR RAVEN. it is a Cerner based system. You will receive one-on-one training from one of our existing providers.

You can use RAVEN pre-completed notes; you can modify templates to suit your needs and documentation styles; or you can adopt good-shared pre-completed clinic notes with minor or no changes. Writing a good free text HPI and Assessment and Plan on an encounter is strongly suggested… ie Create a document where any follow up provider can quickly look at the beginning and end of your note and understand the history, diagnoses and follow up plan with therapeutic goals if appropriate.

Please remember to select a document with the correct note type before you walk in the room. You may wish to document during the encounter with the patient, depending on what they are being seen for. At the end of the visit please do the DEPART /Visit Summary – and select education/follow up choices/ and medical reconciliation – as those are Meaningful Use requirements.

Any time you do an action on a patient — follow up meds or analyze labs — please document what your plan is in a free text note or message saved to the chart. You may also wish to modify the note from the original encounter. Then someone seeing the patient after you can see what your plan may have been and why you ordered certain things. A letter to the patient is also saved under documentation and can be used to explain to later providers what happened.

===Required Documentation On A Patient Note===
It is very important that you have good documentation so that the providers coming after you can see what the plan is for your patient. The SRC Unit Director who will be your clinical supervisor will review your records quarterly. Each SRCs coder will also be reviewing your charts and asking for more documentation if necessary.
• HPI
• PMHx – update the active problem list and add/delete when necessary
• Surgical Hx- PLEASE UPDATE IF YOU CAN.
• Soc Hx- Please put in who they live with.
• Tobacco/Alcohol/Drugs Screening- should be done by your screener.
• ROS – at least 3systems.- two pertinent negatives
• Problem List –put any chronic issues on here or select no chronic problems. It should never be blank.
• Exam
• Labs results if possible
• X-rays results if possible
• EKG interpretation – found in the Results
• Diagnosis – select each one you addressed
• Plan /Follow up for each diagnosis
• Patient Education – pick from note or depart
• Do Med Reconciliation- please eliminate duplicates from past visits if possible.
• Patient understands education button.
• Publish and Print the Visit Summary
• Have patient sign the page of the visit summary if they get medications and make a copy for putting in Multi media.

===[[media:ambulatoryencounter-howto.pdf|How to Create and Do an Ambulatory Encounter]]===