Outpatient RAVEN Charting

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!
• Problem List - i.e., PMHx, chronic problems. Should be updated at each visit.
• Medications - Medication reconciliation at EVERY visit.
• Allergies - Review and update as necessary.
• Procedure Hx - Review and update as necessary.
• Social Hx - Review and update as necessary. Tobacco, ETOH, and drugs should be updated by screener at intake.
• Family Hx - Review and update as necessary.
• ROS - At least three systems, at least two pertinent negatives each.
• Vital Signs - Address any abnormally.
• PE - General or problem focused.
• Labs, diagnostics, EKG - Order and review.
• Impression/Plan - Should ALWAYS be free text!
• Visit Diagnoses - Any diagnosis addressed at visit along with a plan for each.
• Follow-up plans - RTC, phone call, transfer, etc.
• Patient Education - Pertinent to visit diagnoses.
• Patient Summary - Print and provide before patient leaves clinic.
• Patient signature - Required if patient gets medication, copy and upload to Multimedia.

How to Create and Do an Ambulatory Encounter

category:outpatient