04/22/23 1

Documenting Patient Encounters

The CDCS and MedEdIQ System for Clerkships

Summer 2008

04/22/23 2

Outline

• CDCS– Purpose– Student responsibility– How to document encounters– PDA issues

• MedEdIQ

04/22/23 3

Purposes of CDCS

• Course/clerkship evaluation• Clerkship faculty/site evaluation• Program evaluation• Student self-evaluation• Student education

04/22/23 4

Purposes of CDCS

• LCME requirement for accreditation:– Comparability of teaching sites– Comparable educational experience

04/22/23 5

Data Reviewed at End of Each Clerkship

• Average number of patients per student• Level of participation• Setting of service (inpatient, outpatient, ED…)• Average age (% over age 65)• Gender of patients• Ethnicity• Top 10 diagnoses and Patient Presentations

04/22/23 6

CDCS Problems Ranked

• Example Report

04/22/23 7

Student Responsibility

• Document specified patient encounters• Document all procedures• Timely manner- at POC or same day• Keep PDAs synced – every other day• When e-mail from Margaret Stephens,

Becky or Nancy says update your M-Business on your PDA, DO IT.

04/22/23 8

What Encounters to Document

• Patients ≠ Encounters!• Basic Rule: Record clinically relevant

interactions, for example– History (full or partial)– Physical exam (full or partial)– Procedures (observe, assist or perform)

• Change of setting (nursing home to hospital) even same day.

04/22/23 9

Outpatient

• New Rules beginning with the 3rd year:– You must talk to or lay hands on the patient to

record as an encounter– Don’t record observed encounters of H&P– Exception: observation of a procedure

04/22/23 10

Inpatient

• Multiple encounters on same day:– Enter initial encounter, e.g. admit workup– Enter additional encounter on same patient on

same day only if:• Patient’s condition changes enough to warrant a

new workup; or• A new diagnosis arises; or• You perform a procedure on the patient; or• Patient requires reassessment

04/22/23 11

Inpatient

• Next/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.

04/22/23 12

Clerkship Directors Responsibility

• Review students patient encounters weekly/biweekly

• Discuss encounters with students– Identify if students are meeting course objectives– Identify areas of needed supplementation– Identify learning needs– Address difficulties in meeting clerkship objectives

04/22/23 13

Entering Patients on Web

• Use as last resort to enter patients• Use CDCS Website to

– Edit patients– Add notes– Look at cumulative reports– Evaluate faculty, clerkship, etc.

04/22/23 14

Syncing PDA

• # encounters stored• Check it • Timed-out syncs• Every other day – danger of crashing with

too many patients• Keep it charged

04/22/23 15

Entering Patients on PDA

• Open M-Business• Select the FSU Avantgo Server

– ▲on taskbar• Select FSU CDCS• Select Patient Encounters• Select Create a New Encounter

04/22/23 16

Very Important

• FSU CDCS• Before you start

entering patients … Sync – Restore all data checked, puts latest schedule into PDA

04/22/23 17

Encounter General Information

• Course section explained– OB stands for clerkship– Number stands for regional campus– A-F stands for the rotation block– Dates are beginning and end of rotation block

• Pick Correct Course Section first

04/22/23 18

Encounter General Information

Use 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 List

• Sync your PDA. Still not there?• Call Clinical Coordinator or Becky Shiveler• Use Clerkship Dir until faculty added, then

edit encounters to select correct faculty• Sync PDA after notified faculty has been

added• If see pts with partner, use faculty name

04/22/23 19

04/22/23 20

Patient General Information

• Age in days, months or years

• Newborns = 0 wks• Gender• Race/ethnicity• New Patient?

04/22/23 21

Problems List

04/22/23 22

Problems List

• By category or Alphabetical listing• Multiple entries allowed• NOS = not otherwise specified• Familiarize yourself problems on list

(handout)• http://www.med.fsu.edu/informatics/ProblemList.pdf • Use “Other… problem” sparingly

04/22/23 23

Problems List

• Document:– Only problems addressed at visit

• NOT all active patient problems– Problems considered in treatment– Signs and symptoms undiagnosed– Pertinent Risk Factors

Changes for 2008-09

• Add to Procedures: KOH/wet prep • New Problems (type of visits):

– Preventive Care Visit, adult female – Preventive Care Visit, adult male– Preventive Care Visit, adolescent – Chronic Disease Mgmt Visit

•  Changed Well Child Care to Well Child Care Visit

04/22/23 24

More Changes

• Changed Physical Exam, Routine to Physical Exam, NOS (Not Otherwise Specified)– Use for sports, insurance, occupational, and other

administrative type physicals only– Use Preventive Care Visit codes for everything

that might be called “routine physical exam,” “annual physical exam,” “annual GYN exam” or “check-up”

04/22/23 25

More Changes

• Changed Med Refill, Chronic Disease Mgmt to Med Refill

• Use 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

04/22/23 26

04/22/23 27

Visit Level of Care… Read Each Clerkship Syllabus

• Minimal:  Min. Pt. contact• Moderate: Hx and/or PE• Full: Hx, PE + (DDx and/or Tx)

04/22/23 28

Procedures

• List expanded• Review specific clerkship requirements

Required Procedures

• In ALL CAPs and Starred*

• Certain # required for graduation

• Review report: Required Procedure Tracking in CDCS

04/22/23 29

04/22/23 30

Procedure Level of Care

• Observed• Assisted• Performed

04/22/23 31

Notes

• For student’s benefit• Ideas

– Learning issues identified– Complications– Interesting aspects of case not otherwise noted

04/22/23 32

SAVE

• Wait for it to save• It should return to

screen at right• If not, notify your local

campus IT person

04/22/23 33

Troubleshooting PDAs• Make sure you are on the internet when syncing• Check M-Business Connect Settings

– Hostname: sync2.med.fsu.edu– Port: 8092– Username: firstname.lastname– Set Password: med password– Connect Options

Refresh all content Use Secure Connection

• Never interrupt Epocrates or M-Business during sync

04/22/23 34

Troubleshooting

• Forms Manager under View Menu

• Check Forms Manager– For pending records– Sync again until empty.

04/22/23 35

More Troubleshooting

• Too many programs running – Use switcher to close programs

• Reinstall: http://sync2.med.fsu.edu, download latest client software

• New version out? Upgrade promptly when told in e-mail.

• Avoid soft resetting

04/22/23 36

Edit Existing Patient Encounters

• Students can edit on web• Select Previous Patient

Encounters• Fill out form or leave blank to

see all patients• Click Edit button by

encounter

04/22/23 37

Summary Reports

• Request a summary report of all your patients, all years, to OME prior to 4th year interviews.

• Give us 30 days notice.

Major Points to Remember

• When e-mail from Margaret Stephens, Becky or Nancy says update your M-Business on your PDA, DO IT.

• Entering Encounters– Record all clinically relevant Encounters– Pick 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.•

04/22/23 38

MedEdIQEvaluation of all Clerkships

In CDCS system under Evaluations

04/22/23 39

MedEd IQ

• MedEd IQ used for: – Evaluation of clinical experience– Evaluation of clerkship faculty– Quality improvement– Comparability between campuses and sites– LCME accreditation reports– Faculty development needs

MedEd IQ

• No automatic e-mails for clerkships. • Clinical Coordinators usually send e-mail

announcing ready to complete, • Student’s 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.

Comments

• Constructive and positive comments are extremely helpful. for making change

• Suggest ways faculty/experience could be improved.

• Unprofessional comments help no one. • Serious faculty issues should always be

brought to your Campus Dean.

04/22/23 42

MedEd IQ

• One for each clinical faculty, NOT one per clerkship

• Generated by encounters entered under that doctor’s name

• Feedback to faculty is intentionally delayed in order preserve anonymity

• Be professional and respectful• Due the last day of clinical rotation

Points to Remember

• No automatic e-mails for end of clerkship evaluations.

• Student’s responsibility: check and ensure all are done by last day of rotation.

• Unprofessional comments help no one.

04/22/23 44