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Documenting Patient Encounters. The Clinical Data Collection System (CDCS) Doctoring 103 Spring 2010. Objectives. Clarify student responsibility Enter patients into the CDCS system on the web and PDA Identify problems and procedures in the system Select appropriate Level of Care - PowerPoint PPT Presentation
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The Clinical Data Collection System (CDCS)Doctoring 103
Spring 2010
The Clinical Data Collection System (CDCS)Doctoring 103
Spring 2010
04/21/23 1
Clarify student responsibility Enter patients into the CDCS system
on the web and PDA• Identify problems and procedures in the
system• Select appropriate Level of Care
Edit encounters and get reports online Use new PDA medical software
effectively
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Document all patient encounters Document required procedures Keep PDA synced By Monday following preceptor week
• Karen Myers checks 5% of Doctoring grade
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Course evaluation Preceptor/site evaluation Program evaluation Student self-evaluation Student education
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LCME requirement:• Equivalence of teaching sites• Comparable educational experience
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Enter patients on PDA most efficient Use CDCS website to
• Edit patients• Add notes• Look at cumulative reports• Evaluate faculty, clerkship, etc.
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Navigation bar Click CDCS Sign on: Med account Username
and PW Click on
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If your preceptor isn’t on the list• Tell Karen Myers and Becky Shiveler ASAP
• Use Karen Myers as Preceptor until yours shows
up
Edit and switch back to preceptor when there If seeing patients with preceptor’s partner
• Document using your preceptor’s name For testing purposes only: use Preceptor
Test
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Service Learning Experiences like Neighborhood Health Night Clinic • Use Course / Preceptor: FSU Cares
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Age in days, months or years
Newborns = 0 wks
Gender Race/ethnicity New Patient?
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Allergy Cardiovascular Dermatology Endocrine ENT General GI System Hematology Infectious Disease Medication Men’s Health Metabolic Musculoskeletal
Neonatal Neurological Obstetrical Oncology Ophthalmology Prevention Psych/Behavioral Pulmonary Rheumatology Trauma Urinary/Kidney Women’s Health
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By category or Alphabetical listing Multiple entries allowed NOS = not otherwise specified Familiarize problems on list http://www.med.fsu.edu/informatics/Problem List C
ard.pdf
Use “Other …” sparingly
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Document:•Only problems addressed at visitNOT all patient active problems list
•Problems considered in treatment•Signs and symptoms undiagnosed•Pertinent Risk Factors
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Minimal: Min. Pt. contact Moderate: Hx and/or PE Full: Hx, PE + (DDx and/or
Tx)
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Not necessary to pick Use shortens procedures list All D103 procedures under Evaluation
and Management category
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Observed Assisted Performed
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For student’s benefit Ideas
•Learning issues identified•Complications• Interesting aspects of case not otherwise
noted
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Wait for it to save Should return to screen with
Create a New Encounter button If not, get help
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Open M-Business Select CDCS V7 Select Patient Encounters Select Create a New Encounter
Note: on iPhone, enter encounters into CDCS web site using Safari. Caution: once you sign in, no one else can use your iPhone to enter their patients.
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When you get back to campus
Sync M-Business while on FSUMED wireless: Menu > Sync All
Check Menu > Tools > Forms Manager all encounters transferred
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Patients won’t show up on PDA or web until you sync
Make sure you see it sync After sync, check to see if all
encounters show up Any error messages like Invalid ID,
contact Nancy, Kenneth, DL, Andy Z. and get fixed
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Make sure you are on FSUMED when syncing
Check M-Business Connect Settings• Hostname: sync2.med.fsu.edu• Port: 8092• Username: med ID• Set Password: med password• Connect Options
Refresh all content Use Secure Connection
Never interrupt Epocrates during sync
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Too many programs running • Use Memory > Running Programs to close
programs Reinstall: http://sync.med.fsu.edu:8091,
download client software
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Students can edit encounters on web or PDA
Select Previous Patient Encounters
Fill out form or leave blank to see all patients
Click Edit button by encounter
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From FSU COM website
Log onto CDCS• Med userID and
Password Select Aggregated
Patient Encounters
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Click Printer Friendly Version to print Problems, call IT Help Desk, Nancy
Clark or Margaret Stephens
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Enter test patients Use Preceptor Test Review Handouts
• Problems List• Procedures
Discuss expectations with preceptor
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78 yr old white female who has fallen. You take a HPI and SHx. She says she has been dizzy. You observe that she is very frail. You do the musculoskeletal PE. Examination finds no fractures. In addition to physical exams, you perform an ADL assessment and a Get Up and Go test and notice a gait disturbance.
How do you code this?
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DynaMed – disease quick reference
Essential Evidence – guidelines, POEMs, evidence based decision support calculators
PEPID – Drugs, interactions, disease, labs, calculators, images, clinical rotations
Clinical Evidence – treatment evidence
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Before you leave: Enter patient in CDCS on PDA and
sync Check to see if went to online CDCS Run each program as you install it
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