Documenting Patient Encounters

1
Documenting Patient Encounters

• The CDCS and MedEdIQ System for Clerkships
• Summer 2008

2
Outline

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

3
Purposes of CDCS

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

4
Purposes of CDCS

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

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

6
CDCS Problems Ranked

• Example Report

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.

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.

9
Outpatient

• New Rules beginning with the 3rd year
• You must talk to or lay hands on the patient to
  record as an encounter
• Dont record observed encounters of HP
• Exception observation of a procedure

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
• Patients 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

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.

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

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.

14
Syncing PDA

• encounters stored
• Check it
• Timed-out syncs
• Every other day danger of crashing with too
  many patients
• Keep it charged

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

16
Very Important

• FSU CDCS
• Before you start entering patients Sync
  Restore all data checked, puts latest schedule
  into PDA

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

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.
19
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

20
Patient General Information

• Age in days, months or years
• Newborns 0 wks
• Gender
• Race/ethnicity
• New Patient?

21
Problems List
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

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

24
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

25
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

26
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

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)

28
Procedures

• List expanded
• Review specific clerkship requirements

29
Required Procedures

• In ALL CAPs and Starred
• Certain required for graduation
• Review report Required Procedure Tracking in
  CDCS

30
Procedure Level of Care

• Observed
• Assisted
• Performed

31
Notes

• For students benefit
• Ideas
• Learning issues identified
• Complications
• Interesting aspects of case not otherwise noted

32
SAVE

• Wait for it to save
• It should return to screen at right
• If not, notify your local campus IT person

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

34
Troubleshooting

• Forms Manager under View Menu
• Check Forms Manager
• For pending records
• Sync again until empty.

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

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

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.

38
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.

39
MedEdIQ

• Evaluation of all Clerkships
• In CDCS system under Evaluations

40
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

41
MedEd IQ

• No 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.

42
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.

43
MedEd IQ

• One for each clinical faculty, NOT one per
  clerkship
• Generated by encounters entered under that
  doctors name
• Feedback to faculty is intentionally delayed in
  order preserve anonymity
• Be professional and respectful
• Due the last day of clinical rotation

44
Points to Remember

• No 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.