Outpatient RAVEN Charting
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.
