Medicine is 10% patient encounter 90% documentation
This is a breakdown of all things EMR for CSMC
Soarian: The Basics
Main screen overview
Searching for patients
Soarian Setup / Settings
Writing notes
Setting up templates
Note Overview
Reviewing records
HIM-EMR: old records
Transcribed: specialists, consult H&Ps
Documentation: Social work, CIWA, PT evals
Orders
Favorites
OBGYN: CPOE Admission
NSVD Admit
C/S Admit
- NPO
- Ancef 2 gm x1 prior to C-section
- GBS treatment (if positive): Ampicillin 2gm IV (loading dose), then 1gm IV Q4 until delivery
Post Delivery Orders | NSVD(postpartum) & C/S(post op)
OBGYN: Favorites
- NST: Place in observation, Non stress test
- Obs: Place in observatioin, fetal monitoring
- Routine labs: CBC, Type and Screen, UA, UCx, Amniosure, spot urine Cr, spot urine protein, LDH, uric acid
OB Workflow
Induction of Labor / Scheduled C section
Prior to mother coming in
[ ] H&P
[ ] Admission orders
[ ] Admission Med Reconciliation
[ ] Update Signout sheet
[ ] Send Group Message to make aware of continuities and upcoming delivery
– ex. 21yo G1P0 @ 39 weeks. IOL on 7/14/19 @ 8am. Continuity of Dr Chu and Wall.
Once mother presents to L&D
[ ] Physical exam, addendum to H&P or free text
[ ] Updates/Free Text SVE exams q2-3 hours
Delivery
[ ] Delivery Note
After Delivery
[ ] Post partum orders
Discharge / Day of discharge
[ ] Progress / Discharge Summary template
[ ] Discharge med reconciliation
[ ] Written Rx for pain meds if needed