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Patient Encounter and Procedure Logs

Rationale

During the clinical years students need to develop the clinical competencies required for graduation and post-graduate training. These competencies are evaluated in many different ways: by faculty observation during rotations; by oral examinations; by written examinations; and by the USMLE Step 2 CK examinations or the school's final examinations. In order to develop many of these competencies and meet the objectives required for graduation, the school needs to ensure that each student sees enough patients and an appropriate mix of patients during their clinical terms. For these reasons, as well as others discussed below and to meet accreditation standards, the school has developed this patient encounter and procedure log policy.

One of the competencies students must develop during their clinical training involves documentation. The seriousness and accuracy with which students maintain and update their patient logs are measures of professionalism and will be part of their evaluation during the core rotations.

Purpose

Evaluation of:

  • Course/clerkship evaluation: Demonstrate student exposure to patients with medical problems that support course objectives.
  • Clerkship faculty/site evaluation: Demonstrate level of student involvement in the care of patients.
  • Student evaluation: Demonstrate student exposure to, and participation in, targeted clinical procedures.
  • Program evaluation: Demonstrate student exposure to patient populations in both inpatient and outpatient settings.
  • Student self-evaluation: Quantify for students the nature and scope of their clinical education and highlight educational needs for self-directed learning.
  • Student education: Conversation with clerkship directors about the experience can be used as a point of discussion about the students accomplishment of educational objectives that are illustrated by the review of clinical data from their experiences.

Data Reviewed at the end of each year:

The clerkship directors monitor data on an ongoing basis to ensure that students meet clerkship objectives.

The curriculum committee, regional campus deans, and clerkship directors review data to ensure comparability between sites.

Annually, data is reviewed by Academic Affairs, the curriculum committee, and the Core Clinical Subcommittees to ensure the clinical experiences meet the objectives of the clerkship and to assess the comparability of experiences at various sites.

Responsibility

Clerkship Director Responsibility

  • Monitor and review students' patient logs regularly, at a minimum for mid-rotation and end of rotation
  • Discuss encounters with the students
    • Identify if students are meeting course objectives
    • Identify areas needing supplementation
    • Identify learning needs
    • Address difficulties in meeting clerkship objectives

Student Responsibility

  • Document all required patient type/clinical conditions and procedures/skills
  • Document information in a timely manner. You are strongly encouraged to enter data on a daily basis and are required to do so on a weekly basis by 7 a.m. each Monday. Completion of logs is a barrier requirement for all required clinical courses.  Failure to do so is considered unprofessional behavior and will be noted by your clerkship director. Failure to complete logs will result in a 69/F for the course.

What to Document

  • Patients ≠ Encounters
  • Record only clinically relevant interactions (If you talk to the patient or touch the patient, you should log the encounter)
  • History (full or partial)
  • Physical exam (full or partial)
  • Procedures (observed, assisted, or performed) - Elicitation of information from the patient about his/her illness and/or treatment (taking a history); performance of one or more physical examination maneuvers (doing a physical exam); and/or performance of a medical/surgical procedure.

Outpatient Guidelines

  • You must talk to or lay hands on the patient to record the encounter
  • Don't record observed H&Ps
  • Exception:observation of a procedure

Inpatient Guidelines

  • A student will only enter additional encounters on the same patient during their hospital stay if the patient's condition/circumstances change sufficiently to warrant a new examination, procedure, or reassessment or a new diagnosis arises
  • Note: Same patient but change of setting (nursing home to hospital) even same day = new encounter (If you see a patient in the morning at the clinic, they are admitted to the hospital and you round on them that night, that is two encounters. Document both.)

Encounter Information

 

Select the Level of Care that indicates most accurately your interaction and involvement with the patient during this encounter based on the clerkship syllabus.

  • Minimal: Min.Pt. contact -The student has minimal contact with patient which amounts to less than doing an Hx or PE.
  • 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.

Procedure Information

There is a long list of procedures to pick from. You must pick both the procedure and the level of care you had with the procedure (Be present and observe, Act with direct supervision, Act with indirect supervision, Act without supervision, Provide supervision).

  1. Be present and OBSERVE - At early stages it is the privilege of the trainee to be present and observe what he or she will be expected to do at the next stage. Gradually the trainee can start doing parts of the activity.
  2. Act with DIRECT SUPERVISION - At this stage the trainee may carry out the full activity independently. The supervisor is in the room watching and can intervene or take over at any time deemed This has been called “proactive supervision” or “routine oversight.” Part of this level can include coactivity—that is, the activity is done collaboratively with a senior individual.
  3. Act with INDIRECT SUPERVISION - At this stage the trainee may carry out the full activity independently with a supervisor not present in the room but available within minutes. This has been called “reactive supervision” or “responsive oversight.” It includes the availability of supervision by telephone for advice. Reactive supervision may develop from checking all findings related to the trainee’s performance, through checking key findings.
  4. Act WITHOUT SUPERVISION - At this stage the trainee may carry out the full activity with no supervisor available on short notice. The trainee reports post hoc the same or the next day. This stage gradually extends into fully and mature unsupervised practice, but as long as the trainee is in training, he or she acts under “clinical oversight” or “backstage supervision.” This stage marks the grounded trust that should allow for certification to take full responsibility for an entrustable professional activity. At the UME level, this may only include foundational skills such as vital signs, taking a history, performing a physical exam.
  5. PROVIDE SUPERVISION - This level is awarded when a senior trainee may act in a supervisory role for more junior The trainee must have shown the ability to provide supervision.

You may add multiple procedures. As with the encounter logs, all categories are in drop down menu form.