Use Powerscribe for procedure notes, IR office visits, and IR ultrasound (including in-clinic ultrasound). Use Powerchart for all other documentation, including vascular anomalies clinic note.
PowerChart Accounts and Notes.
All MDs, including fellows, should have these PowerChart Note Types relevant to IR:
a. Interventional Radiology Communication - Document all phone calls with parents/patients.
b. Interventional Radiology Consultation - Document all in-patient and outpatient consults.
c. Interventional Radiology Inpatient MD - Daily review on weekends and holidays should be documented here.
d. Vascular Access Note: All types of vascular access should be documented here,
e. Interventional Radiology Uncategorized
f. Brief Operative - All procedures with the exception of GJs and vascular access should be accompanied by a brief op note.
g. Vascular Anomalies Visit.
h. Same Day Surgical Assessment - required for all outpatient procedures.
- How to add these PowerChart Note Types to Your Personal Document List:
- Use a test patient (Test, test)
- Select "Documents" and then "Options"
- Scroll down to the relevant documents and add to personal list.
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Daily Progress Note
- Daily progress notes are listed under Interventional Radiology Inpatient MD
- Subject: Daily Progress Note
- Brief note including Plans as shown below.
- The attending is notified for endorsement (Review option only).
Interventional Radiology Consultation
This is an example of the documentation for “Interventional Radiology Consultation” for an inpatient with appendicitis and an outside CT scan.
After reviewing the case with an IR MD, the NP entered the encounter under a template that collects meds, labs, etc and followed a standard format. The subject is standardized as “Interventional Radiology Consultation” and listed under Consultation section in Powerchart.
The attending MD on call or who reviewed the consult is notified to endorse or verify (to be determined based on further discussions) then endorses/verifies these notes at the end of the document.
These encounters are not currently billed for. All notes on daily followup on inpatients should be listed under Inpatient only.
This is an example of the documentation for “Interventional Radiology Consultation” for an inpatient with appendicitis and an outside CT scan.
After reviewing the case with an IR MD, the NP entered the encounter under a template that collects meds, labs, etc and followed a standard format. The subject is standardized as “Interventional Radiology Consultation” and listed under Consultation section in Powerchart.
The attending MD on call or who reviewed the consult is notified to endorse or verify (to be determined based on further discussions) then endorses/verifies these notes at the end of the document.
These encounters are not currently billed for. All notes on daily followup on inpatients should be listed under Inpatient only.
