Documenting Patient Encounters

1. Documenting Patient Encounters The Clinical Data Collection System (CDCS) Doctoring 103 Spring 2010

2. Objectives • 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

3. Student Responsibility • Document all patient encounters • Document required procedures • Keep PDA synced • By Monday following preceptor week • Karen Myers checks • 5% of Doctoring grade

4. Purposes of CDCS • Course evaluation • Preceptor/site evaluation • Program evaluation • Student self-evaluation • Student education

5. Purposes of CDCS • LCME requirement: • Equivalence of teaching sites • Comparable educational experience

6. Entering Patients • Enter patients on PDA most efficient • Use CDCS website to • Edit patients • Add notes • Look at cumulative reports • Evaluate faculty, clerkship, etc.

7. Navigation bar Click CDCS Sign on: Med account Username and PW Click on CDCS Website

8. Encounter General Information

9. Exceptions • 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

10. Exceptions • Service Learning Experiences like Neighborhood Health Night Clinic • Use Course / Preceptor: FSU Cares

11. Patient General Information • Age in days, months or years • Newborns = 0 wks • Gender • Race/ethnicity • New Patient?

12. Problems List

13. Problem Categories • 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

14. Problems List • By category or Alphabetical listing • Multiple entries allowed • NOS = not otherwise specified • Familiarize problems on list • http://www.med.fsu.edu/informatics/Problem List Card.pdf • Use “Other …” sparingly

15. Problems List • Document: • Only problems addressed at visit • NOT all patient active problems list • Problems considered in treatment • Signs and symptoms undiagnosed • Pertinent Risk Factors

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

17. Procedures

18. Procedure Categories • Not necessary to pick • Use shortens procedures list • All D103 procedures under Evaluation and Managementcategory

19. Procedure Level of Care • Observed • Assisted • Performed

20. Notes • For student’s benefit • Ideas • Learning issues identified • Complications • Interesting aspects of case not otherwise noted

21. SAVE • Wait for it to save • Should return to screen with Create a New Encounter button • If not, get help

22. Entering Patients on PDA • 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.

23. Very Important When you get back to campus • Sync M-Business while on FSUMED wireless: Menu > Sync All • Check Menu > Tools > Forms Manager all encounters transferred

24. Forms Manager

25. Sync PDA • 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

26. Troubleshooting PDAs • 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

27. More Troubleshooting • Too many programs running • Use Memory > Running Programs to close programs • Reinstall: http://sync.med.fsu.edu:8091, download client software

28. 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 Edit Existing Patient Encounters

29. From FSU COM website Log onto CDCS Med userID and Password Select Aggregated Patient Encounters Accessing Reports of Student Encounters

30. Pick Parameters

31. Reports • Click Printer Friendly Version to print • Problems, call IT Help Desk, Nancy Clark or Margaret Stephens

32. Try It Out • Enter test patients • Use Preceptor Test • Review Handouts • Problems List • Procedures • Discuss expectations with preceptor

33. Patient for Practice • 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?

34. New Medical Reference Software • 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

35. Install Software 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