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Documenting Patient Encounters
The CDCS and MedEdIQ System for Clerkships
Summer 2008
The CDCS and MedEdIQ System for Clerkships
Summer 2008
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Outline
• CDCS– Purpose– Student responsibility– How to document encounters– PDA issues
• MedEdIQ
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Purposes of CDCS
• Course/clerkship evaluation
• Clerkship faculty/site evaluation
• Program evaluation
• Student self-evaluation
• Student education
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Purposes of CDCS
• LCME requirement for accreditation:– Comparability of teaching sites– Comparable educational experience
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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
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CDCS Problems Ranked
• Example Report
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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.
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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.
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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
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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
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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.
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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
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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.
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Syncing PDA
• # encounters stored
• Check it
• Timed-out syncs
• Every other day – danger of crashing with too many patients
• Keep it charged
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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
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Very Important
• FSU CDCS
• Before you start entering patients … Sync – Restore all data checked, puts latest schedule into PDA
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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
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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
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Patient General Information
• Age in days, months or years
• Newborns = 0 wks• Gender• Race/ethnicity• New Patient?
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Problems List
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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
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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
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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”
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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
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Visit Level of Care… Read Each Clerkship Syllabus
• Minimal: Min. Pt. contact
• Moderate: Hx and/or PE
• Full: Hx, PE + (DDx and/or Tx)
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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
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Procedure Level of Care
• Observed
• Assisted
• Performed
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Notes
• For student’s benefit
• Ideas– Learning issues identified– Complications– Interesting aspects of case not otherwise noted
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SAVE
• Wait for it to save
• It should return to screen at right
• If not, notify your local campus IT person
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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
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Troubleshooting
• Forms Manager under View Menu
• Check Forms Manager– For pending records– Sync again until empty.
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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
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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
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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.
•
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MedEdIQ
Evaluation of all Clerkships
In CDCS system under Evaluations
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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.
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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.
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