The Clinical Data Collection System (CDCS)Doctoring 103

Spring 2010

The Clinical Data Collection System (CDCS)Doctoring 103

Spring 2010

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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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