Documentation of Medical Student Clinical Patient Encounters
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3/8/2016 Documentation of Medical Student Clinical Patient Encounters FSU College of Medicine CDCS System, Spring 2010 Student Responsibility: Document every patient you see while with your preceptor whether you lay hands on them or not. While seeing patients, use either your PDA CDCS System in MBusiness to enter the data, or write on paper so you can enter the patient data later on the CDCS system using the web interface. If you use the PDA, sync as soon as possible, preferably immediately after entering patients, with you laptop while it is connected to the internet either by modem or over the wireless LAN so that we can compile the data. This will help eliminate lost data from resetting the PDA or losing power. Karen Myers will check your entries on the Monday following your preceptor session. Documentation Instructions Go to the CDCS web-site and sign in using your FSU College of Medicine sign on, or open MBusiness on your PDA and select the CDCS system. Select Add New Encounter. You will see the following : On the PDA it is just a smaller version of this. Add New Encounter links you to a help prompt that answers most questions for you. Enter the required encounter information and then click Save. Click cancel to return to the previous page. Encounter Information This is all pretty straight-forward. Make sure the Date you enter is the date you actually saw the patient. Be sure to pick the correct Course Section and Course and your Preceptor. If your preceptor’s name does not show up, contact your regional campus clinical coordinator or Becky Shiveler immediately. Use your clerkship director until your preceptor shows up. Edit your encounters online after that. Use Site only if you are in a different community than your regional campus. Type in Other Location if site not on list. Select the appropriate Setting of Service. 1 3/8/2016 Type of Visit List Type of Visit records the primary reason that the patient has come to the doctor’s office or that the physician initiated the visit. See the list at right. For annual physicals use Periodic Preventive Care. Use Physical Exam NOS to record an encounter that occurs to perform physicals for sports, insurance or other physicals that require a form to be completed. Chronic Dx Management is for visits to manage diseases like Diabetes and Hypertension and refill prescriptions for these established conditions. Patient Information Select the patient Age, Gender and Race. If you have a Newborn, select the age of 0 weeks. Acute Care initial Acute followup Admission Chronic Dx Management/med refill Counseling Critical care Discharge Immunization Obstetrical care Periodic Preventive Care Physical Exam, NOS PostOp Prenatal Care PreOp Rounds Simulator Simulated Patient Surgery/Procedure Well Child Visit If this is not the first time you have seen this patient, select No under Patient is New to Me. Problems include any or all of the problems which were addressed at this visit or considered in the treatment for this visit. To make it easier to pick problems, they have been organized by category and alphabetically by letter. You can add as many problems as were addressed. Just click >> to add to the list. If the problem was not on the list, there are “Other xxx problems” for every category. Use these, but only if you cannot find something that “fits.” See Problems List by Category on page 6. Select the Visit Level of Care that indicates most accurately your interaction and involvement with the patient during this encounter based on the clerkship syllabus. General instructions are under the little green . Minimal: Min. Pt. contact - The student either observes only or has minimal contact with patient which amounts to less than doing an Hx or PE. An example might be that your faculty calls you into the exam room to listen to an interesting murmur. Moderate: Hx and/or PE - The student performs either a problem focused or complete Hx and/or PE but has no role in the diagnosis or treatment of the patient. Full: Hx and PE + (DDx and/or Tx) - The student performs a history and physical exam and is involved in the diagnosis and treatment of the patients under supervision of the resident or attending physician. This includes ongoing management of hospitalized patients. 2 3/8/2016 Procedures There is a long list of procedures to pick from. You can add none, or multiple procedures for any encounter. If you do not select a Procedure Category, all the available procedures will come up under Procedures. If you pick a category like Evaluation and Management, a much shorter list of procedures (just the ones in that category) will show up. You must pick both the procedure and the Level of Care (Observed, Assisted or Performed) you had with the procedure and add >> it to the box. You may add multiple procedures. See list of Procedures by Category on Page 4. Use Notes to remind yourself of some interesting aspect of the encounter or to specify a diagnosis when you had to select Other from the problem list because the real problem was not there. Click Save Save your encounter and make sure it tells you that it saved. If you are using the web interface, you should be able to go directly into Previous Patient Encounters and look at this patient encounter entry. If you are using the PDA interface, Save puts the patients entered into cache memory and holds them there until you sync. You can check to see if there are patients waiting to sync by looking under the Menu > Tools and selecting Forms Manager. You should sync your PDA to your laptop or wirelessly AS SOON AS POSSIBLE, preferably that evening, to download your new entries into the system. Once you sync your PDA while online, it connects with the server and copies all of the patients into the system. Look on the web site. If they did not all show up, sync again. They should then appear listed on the Patient Encounter section of the CDCS pages in your M-Business. If this does not happen after you sync, sync again. Let Becky Shiveler 645-1196, rebecca.shiveler@med.fsu.edu know immediately if you lose any patients. Leave a voice message or send an email. Editing Previous Patient Encounters Once you have synced your PDA to the server, you should see all encounters you have entered. You can edit any old patient encounter, but only using the web interface. Find the patient you need to edit and click the edit button next to the encounter. If you happen to duplicate a patient accidentally, you cannot delete encounters. Simply change the Preceptor to Preceptor Test on one of the entries. It will be purged. 3 3/8/2016 Procedures List by Category Category of Procedures Assessments Assessments Assessments Assessments Assessments Assessments Assessments Assessments Assessments Assessments Assessments Counseling Counseling Counseling Counseling Counseling Counseling Critical Care Critical Care Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Diagnostic/Screening Evaluation and Management Evaluation and Management Evaluation and Management Procedure D103 Requirements ADL Assessment APGAR Score Determination Bladder Diary Review Breast Cancer Risk Assessment Confusion Assessment Tool Get up and Go Test Home Safety Evaluation Incontinence Assessment Mini-Mental Status Exam Nutritional Assessment Comp. Osteoporosis Risk Assessment Abnormal PAP Smear Counseling Behavioral change plan Contraception Counseling Lactation Counseling Patient education plan Preconception Counseling CPR Intubation Arterial blood gas Breast Exam, Diagnostic Breast Exam, Screening Cardiac diagnostic procedure Colon/Sigmoidoscopy Creatinine Clearance Calculation Culture Cystoscopy Depression Screening Tool Domestic Violence Screening EKG (interpreted) Endoscopic upper GI examination Genetic Screening KOH/wet prep Lumbar puncture Mammogram Mental Status Evaluation, Full Mini-COG Pain Screening Pap Smear Pulmonary function testing Substance Abuse Screening Tobacco Use Screening Ultrasound X-ray interpretation Casting/splinting Cervical Exam in Labor Digital Rectal Exam 4 3/8/2016 Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Evaluation and Management Informatics Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Surgical Treatment, nonsurgical Treatment, nonsurgical Treatment, nonsurgical Treatment, nonsurgical Treatment, nonsurgical Presentation Presentation EKG (performed) Functional Hx Family Hx Foley Placement HPI IUD insertion IV placement Medication Review Comp. NG tube placement PE – Abdomen PE – Pulmonary PE –Musculoskeletal PE—Heart PE—HEENT Pelvic Exam PE—Neuro PE-Vital Signs PMH ROS SHx PDA Consultation Abnormal Pap Management Biopsy, Breast Biopsy, NOS Biopsy, Skin Circumcision Cryosurgery C-Section D&C Elliptical excision Endometrial ablation Incision and drainage Laparoscopic surgery Major Surgical Procedure Minor surgical procedure Thoracentesis Tubal Ligation Vaginal Delivery Vasectomy Venipuncture Wound Repair/Suturing ECT Injection NOS Intralesional injection Joint Aspiration/injection Joint Reduction Oral Presentation Documentation Items in red will not show up in 3rd year. 5 3/8/2016 Problems List by Category Problem Allergy Dermatology General Allergic rhinitis Skin infection, fungal Dizziness/vertigo Anaphylaxis Skin infection, viral Edema Other, Allergy problem Skin neoplasm, benign Failure to thrive, Geriatric Cardiovascular Skin Tags Failure to thrive, Pediatric Aortic aneurism Skin/hair infestation Fainting/syncope Arrhythmia/dysrhythmia Sunburn Fatigue/malaise Atrial Fib Urticaria/Angioedema Fever Cardiac Arrest Viral Exanthems Frailty Chest Pain Evaluation Warts Functional impairment Congenital heart disease Endocrine Gait Disturbance Congestive Heart Failure Adrenal disorder Genetic/congenital disorder Coronary Artery Disease Diabetes Type 1 Hernia, not hiatal Deep Vein Thrombosis (DVT) Diabetes Type 2 Hyper/hypothermia Heart Murmur Diabetic foot Hyperlipidemia Hypertension Goiter/thyroid nodule(s) Iatrogenesis/Medical Error Hypoplastic heart Hirsutism/virilization Immobility/Falls Myocardial Infarction Hyperthyroidism Lab Results, abnormal Other, Cardiovascular NOS Hypoglycemia Language not English Palpitations Hypothyroidism Multiple chronic diseases Pericardial disease Ketoacidosis Nutritional disorders Peripheral Vascular Disease Other, Endocrine problem Obesity Persistent fetal circulation Pituitary disorder Other, General problem NOS Shock/hypotension Short stature Pain, Chronic NOS Valvular disorder ENT Palliative/end of life care Varicosities Cold/URI Poverty Dermatology Ear wax Rehabilitation Abscess, skin Epistaxis/nose bleed Sarcoidosis Acne Hearing loss Sensory impairment Actinic Keratosis Hoarseness Sleep disorder Alopecia Laryngitis Sweats Birthmark Mouth disorder Teratogenic disorder Blisters/bullae Nasal congestion/rhinitis Weight Loss Bruising/petechiae Neck Mass Wound care/non-healing wound Contact Dermatitis Other, HEENT problem GI System Cyanosis Other, Pharyngitis Abdominal pain Dandruff Otitis externa Anal disease NOS Eczema/atopic dermatitis Otitis media Appendicitis Epidermal Cysts Pharyngitis, strep Ascites Insect Bite Sinusitis Biliary track disease/gallstones Itching/puritis General Cirrhosis/liver failure Other, Derm problem Adherence Colitis Pigmentation problem Altered Mental State Constipation Psoriasis Chills Diarrhea Rash NOS Cultural differences Diverticular disease Rosacea Dehydration Dysphagia/swallowing problem Seborrhea Dental problem Seborrheic Keratosis Developmental disorder Skin infection, bacterial 6 3/8/2016 GI System Infectious Disease Musculoskeletal Esophageal spasm Other, ID Other, Musculoskeletal Gall Bladder disease Peritonitis Overuse injury Gastritis PID Pain, joint Gastroenteritis/food poisoning RSV Pain, muscle/soft tissue GERD SARS Plantar fasciitis GI Bleed, Lower Sepsis Shoulder pain/injury GI bleed, Upper STD NOS Strain/sprain Guaiac (+) stool Syphilis Tendonitis Hemorrhoids Tuberculosis Tenosynovitis Hepatitis, Acute Medication Neonatal Hepatitis, Chronic (B/C) Drug allergy Breast feeding problem Hiatal Hernia Drug Interaction Intrauterine growth restriction Incontinence, fecal Drug Overdose/Toxicity Large for gestational age Inflammatory Bowel disease Drug Reactions Neonatal apnea Irritable Bowel Syndrome Drug Side Effect Neonatal asphyxia Jaundice Other, Medication problem Neonatal drug withdrawal Nausea/vomiting Men's Health Newborn distress Other, GI problem Benign prostatic hyperplasia BPH Other, Neonatal Problem Pancreatitis Genital warts, male Premature infant Peptic or gastric ulcer Infertility, male Transient tachypnea of newborn Polyps, GI Other, Men's Health Neurological Small bowel obstruction Penile Discharge (Urethritis) Bell’s palsy Splenomegaly Prostatitis Closed head injury Volvulus Scrotal/testicular problem Delirium Hematology Sexual Dysfunction, Men Dementia, Alzheimer’s Anemia Metabolic Dementia, other Bleeding Disorders/Coagulopathy Acid/base disorder Dementia, Vascular Bone marrow failure Calcium disorder Febrile seizures Isoimmune disorder Dyslipidemia Headache, migraine Leukemia/Lymphoma Fluid electrolyte disorder Headache, tension Lymphadenopathy Other, Metabolic problem Hydrocephalus Other, Hematology problem Vitamin deficiency Multiple sclerosis Platelet disorder Musculoskeletal Neuropathy Sickle Cell disease Ankle pain/injury Numbness Splenomegaly Back pain, w/wo sciatica Other, Headache Infectious Disease Bursitis Other, Neuro problem Abscess, NOS Carpal tunnel syndrome Pain Management AIDS Congenital musculoskeletal problem Parkinson's Bacteremia Costochondritis Seizure Disorders Cellulitis Fibromyalgia Stroke Chicken Pox Ganglion cyst TIA Chlamydia Gout Tinnitus Gonorrhea Joint, artificial Obstetrical HIV Positive Knee pain/injury Abortion/miscarriage HSV II congenital Osteoarthritis Ectopic pregnancy Influenza Osteomyelitis Gestational Diabetes Meningitis Osteoporosis Incompetent cervix Mononucleosis 7 3/8/2016 Obstetrical Prevention Pulmonary Urinary/Kidney Labor Alcohol Use/Abuse Asthma Hematuria Lactation Caffeine Use Bronchiolitis Incontinence, urinary Multi-fetal gestation FamHx of CA Bronchitis Kidney Stones OB emergency FamHx of CAD/MI Bronchopulmonary dysplasia Nephropathy, NOS Other, OB problem FamHx of depression COPD Other, Kidney problem Placenta praevia FamHx of DM Cough, acute Other, Urologic problem Placental abruption Health maintenance Cough, bloody Painful urination/dysuria Post term pregnancy Hx of Abuse Cough, chronic Proteinuria Postpartum care Immunizations Croup/Stridor Pyelonephritis Pre-eclampsia/eclampsia Occupational Exposure Cystic Fibrosis Renal Failure, Acute Pregnancy Dx Other, Prevention problem Emphysema Renal Failure, Chronic Premature labor Sexual Activity, Risky Epiglottitis Renal Insufficiency Premature rupture of membranes Tobacco Use/smoker Meconium aspiration Urinary frequency Prolapsed cord Violence Prevention Other, Pulmo problem Urinary obstruction Second Stage Labor Psych/Behavioral Pleural effusion Urinary retention Vaginal bleeding in pregnancy Abuse, sexual Pleuritis Urinary tract infection Oncology Abuse/neglect, Child Pneumonia Women's Health Benign neoplasm Abuse/neglect, elder Pneumothorax Abnormal vaginal bleeding CA, bladder ADHD Pulmonary embolus Amenorrhea CA, breast Adjustment Disorder Pulmonary nodules Breast disease, NOS CA, colon Anxiety disorder, generalized Shortness of breath Breast Lump CA, endometrial Autism Rheumatology Cervical disease CA, head & neck Bed wetting/enuresis Lupus Contraception CA, kidney Bipolar disorder Other, Rheumatology problem Dysmenorrhea CA, lung Depression Raynaud’s Phenomenon Endometriosis/adenomyosis CA, ovarian Domestic Violence Rheumatoid Arthritis Estrogen replacement/HRT CA, pancreatic Dysthymia Scleroderma Fibroids, uterine CA, prostate Eating disorder Trauma Genital Warts, female CA, skin NOS Family Problems Abrasion Hyperemesis Gravidarum CA, testicular Intoxication Animal Bite Infertility, female CA, thyroid Learning/School Problems Burn Menopause Melanoma Marital Problems Contusion Menstrual Disorders, NOS Other, CA OCD Drowning Other, Women’s Health Problem Ophthalmology Oppositional Defiant Disorder Fall Ovarian cyst Cataract Other, Psych/Behavioral problem Fracture Painful intercourse Conjunctivitis Panic Attacks Gunshot wound Pap Smear, abnormal Corneal abrasion Parent-Child Relations Laceration Pelvic pain Enucleated eye Personality disorder Other, Trauma Pelvic Relaxation Eye Injury Pervasive Developmental Disorder Poisoning Premenstrual Syndrome Eyelid disease/condition Phobia, any Sexual assault Sexual Dysfunction, Women Foreign Body in eye Psychotic disorder Trauma, blunt Vaginitis/vaginal discharge Glaucoma PTSD Trauma, multiple Vulvar/vaginal disease NOS Lacrimal disease/condition Schizoaffective disorders Trauma, sharp Macular degeneration Schizophrenia Other, Ophthalmology problem Somatoform Syndromes Red eye Stressful situation Retinopathy, NOS Substance abuse Vision Problem Suicide attempt/ideation 8
