Documenting Clinical Encounters My Evaluations

Student Standards

PATIENT INFO

Patient Initials

Gender

Age range

Ethnicity

VISIT INFO

Minutes

Record the number of minutes that the encounter took including reviewing chart, history, physical exam, presentation to preceptor, development of plan, communicating plan to patient and any documentation that you do in the patient’s chart. *Note the number of patients you should be seeing per hour in each course clinical grading rubric in week 8.

*Note that you cannot chart one patient an hour and count that as clinical time. For example, if you chart 12 patients for one day, but were only in clinic 8 hours, the12 patients do not count as 12 hours.

Client Complexity

· Comfort Assessment-will rarely use; actually not sure when this would be appropriate other than in a hospice setting or if managing a patient that is dying

· Episodic (acute condition)-common for sick visits or acute problems; usually not scheduled in advance

· Single/controlled/chronic disease-one chronic disease that is well-managed, such as providing a refill for anti-HTN meds when BP is well controlled

· Single/uncontrolled/chronic disease-management of one chronic disease that is not well controlled, such as intervention (labs, medication adjustment, etc.) for poorly controlled HTN.

· Multiple/controlled/chronic diseases-management of more than one chronic condition that is well controlled (asthma, COPD, DM, HTN, allergies, etc.)

· Multiple/uncontrolled/chronic diseases-management of more than one chronic condition that is not well controlled (same examples but require more the conditions require more work-up or intervention than if they were controlled)

· Wellness screening/HPDP-annual adult physicals, well-baby checks, well woman exams

· Immunizations-this would be for the rare occasion when you only provide an immunization without the other components of a wellness exam or visit. For instance, flu shots. Rarely should use since the majority of the time you will be incorporating a visit to give the immunization (as part of a wellness visit or acute visit). Although this may be quite frequent in certain settings i.e.: retail clinics.

Student Level of Function

Record your estimated percentage of your level of independence. Your level of independence should progress as you progress through the program. For example, in NR 511 little to no patient encounters should be 100% student, whereas by NR 661 most of the encounters should be 75 to 100% student.

CODING

Diagnosis Information

Record ALL appropriate diagnoses that apply; diagnoses should correlate with what was assessed and what was done at the visit. You can search by keyword or by ICD-10 code in the search section.

For wellness visits, diagnosis codes are typically one of the codes listed below. You can add additional diagnoses to the list if they apply.

COMPETENCIES

Skills & Procedures

*Note that any test/procedure, etc. should correspond correctly with the diagnoses charted or chosen. For example, the patient cannot come in for conjunctivitis and mark that a pelvic examination was done without a diagnosis to support the need for a pelvic exam.

** Be sure to record your competencies on the “Clinical Competency Checklist” that is located in Course Resources. This is a log of competencies that you keep throughout all 5 clinical courses and check off with the date when it was completed. Your goal is to complete as many of these competencies by completion of your clinical rotations. You can also use this tool to show preceptors what experiences that you are lacking and hope to complete on appropriate patients.

Notes

Always record the following:

· Chief complaint

· CPT, visit billing codes (See chart below)

CATEGORY

SUBCATEGORY

CPT (E&M) CODES

Outpatient Office Services

New Patient

99201-99205

Established Patient

99211-99215

Preventative Medicine Visits

New Patient

99381-99387 (codes vary by age group)

Established Patient

99391-99397 (codes vary by age group)

You might also wish to add more information regarding the patient’s visit but it is not necessary. DO record the following in the notes section: (if applicable):

· Specific type of anticipatory guidance (I.e. when to eat solid foods, how to do an SBE)

· Specific type of immunization (i.e. Quadravalent pneumococcal, TdaP)

· All specific diagnosis, if not chosen in the dropdown menu