ER Documentation and Depart
From Guide to YKHC Medical Practices
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:
- 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
- Diagnosis
- Patient Education/Follow up
- Prescriptions (if any)
- Medication Reconciliation – this MUST be completed on every patient
- Charges
- Under “Charges” click on discharge order
- Remember to complete E&M charges at this time.