Documenting Patient Encounters

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Documenting Patient Encounters. The CDCS and MedEdIQ System for Clerkships Summer 2008. Outline. CDCS Purpose Student responsibility How to document encounters PDA issues MedEdIQ. Purposes of CDCS. Course/clerkship evaluation Clerkship faculty/site evaluation Program evaluation - PowerPoint PPT Presentation


  • **Documenting Patient EncountersThe CDCS and MedEdIQ System for ClerkshipsSummer 2008

  • **OutlineCDCSPurposeStudent responsibilityHow to document encountersPDA issuesMedEdIQ

  • **Purposes of CDCSCourse/clerkship evaluationClerkship faculty/site evaluationProgram evaluationStudent self-evaluationStudent education

  • **Purposes of CDCSLCME requirement for accreditation:Comparability of teaching sitesComparable educational experience

  • **Data Reviewed at End of Each ClerkshipAverage number of patients per studentLevel of participationSetting of service (inpatient, outpatient, ED)Average age (% over age 65)Gender of patientsEthnicityTop 10 diagnoses and Patient Presentations

  • **CDCS Problems RankedExample Report

  • **Student ResponsibilityDocument specified patient encountersDocument all proceduresTimely manner- at POC or same dayKeep PDAs synced every other dayWhen e-mail from Margaret Stephens, Becky or Nancy says update your M-Business on your PDA, DO IT.

  • **What Encounters to DocumentPatients Encounters!Basic Rule: Record clinically relevant interactions, for exampleHistory (full or partial)Physical exam (full or partial)Procedures (observe, assist or perform)Change of setting (nursing home to hospital) even same day.

  • **OutpatientNew Rules beginning with the 3rd year:You must talk to or lay hands on the patient to record as an encounterDont record observed encounters of H&PException: observation of a procedure

  • **InpatientMultiple encounters on same day:Enter initial encounter, e.g. admit workupEnter additional encounter on same patient on same day only if:Patients condition changes enough to warrant a new workup; orA new diagnosis arises; orYou perform a procedure on the patient; orPatient requires reassessment

  • **InpatientNext/subsequent day encounters:Check specific clerkship syllabus to determine if next/subsequent day monitoring of patients being cared for in inpatient setting is to be documented.

  • **Clerkship Directors ResponsibilityReview students patient encounters weekly/biweeklyDiscuss encounters with studentsIdentify if students are meeting course objectivesIdentify areas of needed supplementationIdentify learning needsAddress difficulties in meeting clerkship objectives

  • **Entering Patients on WebUse as last resort to enter patientsUse CDCS Website to Edit patientsAdd notesLook at cumulative reportsEvaluate faculty, clerkship, etc.

  • **Syncing PDA# encounters storedCheck it Timed-out syncsEvery other day danger of crashing with too many patientsKeep it charged

  • **Entering Patients on PDAOpen M-BusinessSelect the FSU Avantgo Server on taskbarSelect FSU CDCSSelect Patient EncountersSelect Create a New Encounter

  • **Very ImportantFSU CDCSBefore you start entering patients Sync Restore all data checked, puts latest schedule into PDA

  • **Encounter General InformationCourse section explainedOB stands for clerkshipNumber stands for regional campusA-F stands for the rotation blockDates are beginning and end of rotation blockPick Correct Course Section first

  • **Encounter General InformationUse Site if you are in a different community than your regional campus. Type in Other Location if site not on list.

  • If Faculty Member not on ListSync your PDA. Still not there?Call Clinical Coordinator or Becky ShivelerUse Clerkship Dir until faculty added, then edit encounters to select correct facultySync PDA after notified faculty has been addedIf see pts with partner, use faculty name


  • **Patient General InformationAge in days, months or yearsNewborns = 0 wksGenderRace/ethnicityNew Patient?

  • **Problems List

  • **Problems ListBy category or Alphabetical listingMultiple entries allowedNOS = not otherwise specifiedFamiliarize yourself problems on list (handout) Use Other problem sparingly

  • **Problems ListDocument:Only problems addressed at visitNOT all active patient problemsProblems considered in treatmentSigns and symptoms undiagnosedPertinent Risk Factors

  • Changes for 2008-09Add to Procedures: KOH/wet prep New Problems (type of visits):Preventive Care Visit, adult female Preventive Care Visit, adult malePreventive Care Visit, adolescent Chronic Disease Mgmt VisitChanged Well Child Care to Well Child Care Visit**

  • More ChangesChanged Physical Exam, Routine to Physical Exam, NOS (Not Otherwise Specified)Use for sports, insurance, occupational, and other administrative type physicals onlyUse Preventive Care Visit codes for everything that might be called routine physical exam, annual physical exam, annual GYN exam or check-up


  • More ChangesChanged Med Refill, Chronic Disease Mgmt to Med RefillUse Health Maintenance when you deal with a health maintenance issue during an acute care visit for an illness.Check with clerkship directors for guidance on using visit codes**

  • **Visit Level of Care Read Each Clerkship SyllabusMinimal: Min. Pt. contactModerate: Hx and/or PEFull:Hx, PE + (DDx and/or Tx)

  • **ProceduresList expandedReview specific clerkship requirements

  • Required ProceduresIn ALL CAPs and Starred*Certain # required for graduationReview report: Required Procedure Tracking in CDCS


  • **Procedure Level of CareObservedAssistedPerformed

  • **NotesFor students benefitIdeasLearning issues identifiedComplicationsInteresting aspects of case not otherwise noted

  • **SAVEWait for it to saveIt should return to screen at rightIf not, notify your local campus IT person

  • **Troubleshooting PDAsMake sure you are on the internet when syncingCheck M-Business Connect SettingsHostname: 8092Username: firstname.lastnameSet Password: med passwordConnect OptionsRefresh all content Use Secure Connection Never interrupt Epocrates or M-Business during sync

  • **TroubleshootingForms Manager under View MenuCheck Forms ManagerFor pending recordsSync again until empty.

  • **More TroubleshootingToo many programs running Use switcher to close programsReinstall:, download latest client softwareNew version out? Upgrade promptly when told in e-mail. Avoid soft resetting

  • **Edit Existing Patient EncountersStudents can edit on webSelect Previous Patient EncountersFill out form or leave blank to see all patientsClick Edit button by encounter

  • **Summary ReportsRequest a summary report of all your patients, all years, to OME prior to 4th year interviews. Give us 30 days notice.

  • Major Points to RememberWhen e-mail from Margaret Stephens, Becky or Nancy says update your M-Business on your PDA, DO IT.Entering EncountersRecord all clinically relevant EncountersPick Correct Course Section first Use Site if you are in a different community than your regional campus. Type in Other Location if site not on list. **

  • MedEdIQEvaluation of all ClerkshipsIn CDCS system under Evaluations**

  • MedEd IQMedEd IQ used for: Evaluation of clinical experienceEvaluation of clerkship facultyQuality improvementComparability between campuses and sitesLCME accreditation reportsFaculty development needs

  • MedEd IQNo automatic e-mails for clerkships. Clinical Coordinators usually send e-mail announcing ready to complete, Students responsibility: check and ensure all are done by last day of rotation.These are not anonymous, but only a few COM faculty and staff may see them.

  • CommentsConstructive and positive comments are extremely helpful. for making changeSuggest ways faculty/experience could be improved.Unprofessional comments help no one. Serious faculty issues should always be brought to your Campus Dean.


  • MedEd IQOne for each clinical faculty, NOT one per clerkshipGenerated by encounters entered under that doctors name Feedback to faculty is intentionally delayed in order preserve anonymityBe professional and respectfulDue the last day of clinical rotation

  • Points to RememberNo automatic e-mails for end of clerkship evaluations. Students responsibility: check and ensure all are done by last day of rotation.Unprofessional comments help no one.**

    *Print out the Note Pages. The talk is in the Notes section.

    Students, while you have been using the CDCS for the last two years, there are differences in the instructions for documentation of patient encounters for the 3rd and 4th year encounters. Please follow this closely.*This presentation will cover these very important topics.*Course/clerkship evaluation: Demonstrate student exposure to patients with medical problems that support course objectives.Clerkship faculty/site evaluation: Demonstrate level of student involvement in the care of patients.Student evaluation: Demonstrate student exposure to and participation in targeted clinical procedures.Program evaluation: Demonstrate student exposure to patient populations specifically mentioned in the COM mission.Site evaluation: Demonstrate suitability of a particular practice or site as a location for student education.Student self-evaluation: Quantify for students, the nature and scope of their clinical education highlighting educational needs.Student education: To use in conversation with clerkship directors about the experience, can be used as a point of discussion about the students accomplishment of educational objectives that are illustrated by the review of clinical data from their experiences.

    *Comparability of campuses is an important concept for us to understand. For accreditation of a medical school, the LCME requires that