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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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