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
- Meaningful Use Requirements:
- 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.
