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, DOIT.

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 • Don’t record observed encounters of H&P • 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: • 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

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

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. Minimal:  Min. Pt. contact Moderate: Hx and/or PE Full: Hx, PE + (DDx and/or Tx) Visit Level of Care… Read Each Clerkship Syllabus

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 student’s 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, DOIT. • 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, • 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.

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 doctor’s 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. • Student’s responsibility: check and ensure all are done by last day of rotation. • Unprofessional comments help no one.