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

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documenting patient encounters

Documenting Patient Encounters

The Clinical Data Collection System (CDCS)

Doctoring 103

Spring 2010

objectives
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
student responsibility
Student Responsibility
  • Document all patient encounters
  • Document required procedures
  • Keep PDA synced
  • By Monday following preceptor week
    • Karen Myers checks
  • 5% of Doctoring grade
purposes of cdcs
Purposes of CDCS
  • Course evaluation
  • Preceptor/site evaluation
  • Program evaluation
  • Student self-evaluation
  • Student education
purposes of cdcs1
Purposes of CDCS
  • LCME requirement:
    • Equivalence of teaching sites
    • Comparable educational experience
entering patients
Entering Patients
  • Enter patients on PDA most efficient
  • Use CDCS website to
    • Edit patients
    • Add notes
    • Look at cumulative reports
    • Evaluate faculty, clerkship, etc.
cdcs website
Navigation bar

Click CDCS

Sign on: Med account Username and PW

Click on

CDCS Website
exceptions
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
exceptions1
Exceptions
  • Service Learning Experiences like Neighborhood Health Night Clinic
    • Use Course / Preceptor: FSU Cares
patient general information
Patient General Information
  • Age in days, months or years
  • Newborns = 0 wks
  • Gender
  • Race/ethnicity
  • New Patient?
problem categories
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
problems list1
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
problems list2
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
visit level of care
Visit Level of Care
  • Minimal:  Min. Pt. contact
  • Moderate: Hx and/or PE
  • Full: Hx, PE + (DDx and/or Tx)
procedure categories
Procedure Categories
  • Not necessary to pick
  • Use shortens procedures list
  • All D103 procedures under Evaluation and Managementcategory
procedure level of care
Procedure Level of Care
  • Observed
  • Assisted
  • Performed
notes
Notes
  • For student’s benefit
  • Ideas
    • Learning issues identified
    • Complications
    • Interesting aspects of case not otherwise noted
slide21
SAVE
  • Wait for it to save
  • Should return to screen with Create a New Encounter button
  • If not, get help
entering patients on pda
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.
very important
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
sync pda
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
troubleshooting pdas
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
more troubleshooting
More Troubleshooting
  • Too many programs running
    • Use Memory > Running Programs to close programs
  • Reinstall: http://sync.med.fsu.edu:8091, download client software
edit existing patient encounters
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
accessing reports of student encounters
From FSU COM website

Log onto CDCS

Med userID and Password

Select Aggregated Patient Encounters

Accessing Reports of Student Encounters
reports
Reports
  • Click Printer Friendly Version to print
  • Problems, call IT Help Desk, Nancy Clark or Margaret Stephens
try it out
Try It Out
  • Enter test patients
  • Use Preceptor Test
  • Review Handouts
    • Problems List
    • Procedures
  • Discuss expectations with preceptor
patient for practice
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?
new medical reference software
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
install software
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