Outpatient RAVEN Charting: Difference between revisions

Revision as of 01:41, 14 February 2019

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.

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.

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

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 - Should ALWAYS be free text!
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.

How to Create and Do an Ambulatory Encounter

category:outpatient

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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===
 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
 * Surgical Hx- PLEASE UPDATE IF YOU CAN.