Transcript Documenting Patient Encounters

The Clinical Data Collection System
(CDCS)
Doctoring 103
Spring 2011
7/18/2015
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Objectives
Clarify student responsibility
 Enter patients into the CDCS system on
the web and PDA
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 Identify problems and procedures in the
system
 Select appropriate Level of Care
Edit encounters and get reports online
 Use new PDA medical software
effectively
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Handouts
Under Preceptorship in D103
Blackboard site
 CDCS Instructions M1 2011
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 Includes list of problems, list of procedures
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Student Responsibility
Document all patient encounters
 Document required procedures
 Keep PDA synced
 By Monday following preceptor week
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 Karen Myers checks
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5% of Doctoring grade
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Purposes of CDCS
Course evaluation
 Preceptor/site evaluation
 Program evaluation
 Student self-evaluation
 Student education
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Purposes of CDCS
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LCME requirement:
 Equivalence of teaching sites
 Comparable educational experience
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Entering Patients
No iPod/iPhone app yet. Plans to get
one by Summer Clinical Practicum
 With wireless, can enter in website using
Safari
 Use CDCS website to
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Enter patients [4 per session minimum]
Edit patients
Add notes
Look at cumulative reports
Evaluate faculty, clerkship, etc.
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CDCS Website
My Resources
 Click CDCS
 Sign on: Med account Username and PW
 Click on
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Encounter General Information
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Exceptions
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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
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If seeing patients with preceptor’s partner
 Document using your preceptor’s name
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For testing purposes only: use Preceptor Test
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Exceptions
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Service Learning Experiences like
Neighborhood Health Night Clinic
 Use Course / Preceptor: FSU Cares
 Also record in your ePortfolio
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Type of Visit
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Reason for patient
making appointment
Or Dr initiating visit
Use Periodic Preventive
Care for annual
physicals
Use Physical Exam,
NOS for insurance,
sports…that require a
form
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Type of Visit List
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
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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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Problem Categories
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Allergy
Cardiovascular
Dermatology
Endocrine
ENT
General
GI System
Hematology
Infectious Disease
Medication
Men’s Health
Metabolic
Musculoskeletal
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Neonatal
Neurological
Obstetrical
Oncology
Ophthalmology
Prevention
Psych/Behavioral
Pulmonary
Rheumatology
Trauma
Urinary/Kidney
Women’s Health
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Problems List
By category or Alphabetical listing
 Multiple entries allowed
 NOS = not otherwise specified
 Familiarize problems on list
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http://www.med.fsu.edu/informatics/Problem List
Card.pdf
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Use “Other …” sparingly
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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
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Visit Level of Care
 Minimal:
Min. Pt. contact
 Moderate: Hx and/or PE
 Full: Hx, PE + (DDx and/or Tx)
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Procedures
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Procedure Categories
Not necessary to pick
 Use shortens procedures list
 All D103 procedures under Evaluation and
Management category and Informatics
 Read Requirements for procedures:
minimums
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 1 PDA consultation per visit
 5 total history items
 5 total physical exam items
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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
 Should return to screen with words
Encounter Saved
 Back to Encounter to add a problem
or procedure
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Edit Existing Patient Encounters
Students can edit
encounters
 Select Previous Patient
Encounters
 Fill out form or leave blank
to see all patients
 Click Edit button by
encounter
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Accessing Reports of Student Encounters
From FSU COM
website
 Log onto CDCS
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 Med userID and
Password
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Select Aggregated
Patient Encounters
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Pick Parameters
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Reports
Click Printer Friendly Version to print
 Problems, call IT Help Desk, Nancy Clark or
Margaret Stephens
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Try It Out
Enter test patients
 Use Preceptor Test
 Review Handout
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 Problems List
 Procedures
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Discuss expectations with preceptor
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Case 0
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?
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Case 0 Codes
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Type of Visit:
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Problems:
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Visit Level of Care:
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Procedures:
Case 1
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58 yr old male patient came in with a cough for 3
weeks. You did a HPI. His problems list includes
HTN, DM 2, and obesity. You check in Epocrates
to see if any of his current meds could cause a
cough. He is diagnosed with bronchitis and given
an antibiotic. It also noted that his blood
pressure is out of control (he failed to take his
meds that morning), his last follow-up for
diabetes was many months ago and it was poorly
controlled as well. Your preceptor advises the
patient that he needed lab work and a follow-up
within one month to adjust his meds for HTN and
DM.
 How to code?
Case 1 Codes
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Type of Visit:
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Problems:
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Visit Level of Care:
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Procedures:
Case 2
Several members of the girls soccer
team at one of the local high schools
show up for Sports/team Physicals. You
get to do 5 PMH and complete
physicals, all on 16-18 year olds. All
have histories of sprains and other
sports related trauma but no current
pathology.
 How do you code?
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Case 2 Codes
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Type of Visit:
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Problems:
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Visit Level of Care:
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Procedures:
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How many encounters?
Case 3
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A 12 year old boy comes in with a painful
rash on his genitalia only that started last
night. He has mild asthma. You do an
HPI. Yesterday, he was playing in a
wooded area, went to the bathroom, then
washed his hands. He has a history of
allergy to poison ivy. Your physician
discusses this case with you and the both
of you decide that this is contact dermatitis
(poison ivy) and treat accordingly.
Case 3 Codes
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Type of Visit:
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Problems:
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Visit Level of Care:
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Procedures:
Case 4
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62 year old man comes in to get his pain
medications refilled. He has arthritis of the
shoulders and lower back pain. The pain
medicine is for the arthritis for which you
review with him his symptoms. While he is
there you also discuss his smoking habit,
and he complains of pain in his mouth.
Upon examination (HEENT), you notice an
abscessed tooth. Your preceptor refers the
patient to a dentist.
Case 4 Codes
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Type of Visit:
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Problems:
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Visit Level of Care:
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Procedures: