Documenting Patient Encounters
The CDCS and MedEdIQ
System for Clerkships
Summer 2008
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Outline
• CDCS
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Purpose
Student responsibility
How to document encounters
PDA issues
• MedEdIQ
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Purposes of CDCS
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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
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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
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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 MBusiness 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
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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
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Edit patients
Add notes
Look at cumulative reports
Evaluate faculty, clerkship, etc.
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Syncing PDA
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# 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
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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.
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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
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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
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Changes for 2008-09
• Add to Procedures: KOH/wet prep
• New Problems (type of visits):
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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
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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
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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.
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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:
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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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