Revised 8-24-2013

ALL STUDENTS INVOLVED IN PATIENT

CARE IN CFAC: Very important:

Write your first and last name in the note with your class year (such as MS4 or ’15). List all

students involved in treating the patient (including your supervisory 4th year student) and

writing the note.

Attention: Doors to be open at all times when there is not a patient in the room.

FALL PRECAUTION: return height of the exam chair to the ground before leaving the patient !

THE BIG THREE: You must have The Big 3 in every note if the patient was brought back to the exam

room:

1) PMH-list all conditions, not just “reviewed”

2) MEDS-make sure all meds updated and listed. If not available, have a release form signed for

patient’s pharmacy to obtain a list. Please see “EMR: Friend or Foe” for the slide on “Before

Presenting: Complete Meds and Allergies” for further details on this multi-step process of using

the Meds Module appropriately.

3) Allergies-record in med module as noted in medications module instructions. Update each visit.

Tobacco status, basic vitals, and appropriate physical exam findings related to the chief complaint are

also expected to be in each chart note, regardless of the chief complaint. Temperature is required for

all patients with wounds. Please note the charting deficiency template to see common reasons that

students are given automatic charting deficiencies.

When doing X-rays, make sure the radiographic findings box is checked (see established or new patient

form to click this button) and record your x-ray findings here. Only mark this box if x-rays are taken that

day. You can also record other imaging studies in this box if it is already selected for that day’s x-rays.

Otherwise, record labs, previous x-ray review findings, MRI’s in the objective section after the physical

exam. Be very careful not to uncheck boxes that have text written in them, or those written notes will

disappear!

Please note: Use the documentation tool from the patient chart to avoid duplicated encounters

unlinked to a billing encounter. If you have any problems starting an encounter, check with the front

desk and let your attending know there was a problem starting the encounter. Any notes with

improper importing/copy-pasting are subject to deletion if they cause a non-billable encounter to be

generated. The student will then need to restart their entire note once this is discovered. (Exceptions

to importing: Selective Importing from Meds/Allergies that were entered properly using the meds

Revised 8-24-2013

module and importing select items for PMH/Social Hx/Family Hx is acceptable. Please carefully follow

the Medications Module instructions to properly reconcile and import meds and allergies.

Flag your note only after it is complete and you have checked over the whole note in the Medcin

module view (looks like the printed chart notes). Unless otherwise directed by the attending (Dr.

Canales, for instance doesn’t want anything in his box), place the old chart notes in the clinician’s inbox.

All other patient documents should be put in the” to be scanned box” or given to/discussed with the

resident if there are action items to do for the patient.

Every patient needs a scheduling slip to check out-attached to the demographics sheet. If a surgically

minded patient, write SX in the blank line. See the bulletin board for examples of how to use “SX”. Ask

the front desk for a scheduling slip if one is not attached to the demographics sheet.

New Patients= A New patient also includes any established patient not seen in 3 years.

Have clinician meet the patient before doing the H & P. If the clinician is backed up, let the resident

know, who will provide direction, or leave a post-it note with “New Patient, room___” on the

attending’s computer. The attending must approve all procedures being done to their patient. If the

clinician is backed up, ask the resident before performing a nail or callus debridement. While waiting, fill

out any appropriate Medicare toenail sheet/ABN form and look up when their last nail procedure was

billed to determine the criteria that they meet for medically necessary nail/callus care. (eg. High risk foot

vs painfully mycotic toenails)

A DPM must be present for all radiographs.

Do not fill out anything on the assessment portion of the form or medcin note unless directed to for

that specific patient by your attending clinician. Do not delete anything in the assessment portion of the

note, as it will affect the billing and subject your attending physician to disciplinary action in an audit.

Please let your attending know if there is a concern with the assessment portion of the note.

Do not put any extra spaces before your text in the text field boxes (ie. objective/plan). This makes it

more difficult and time-consuming for your attending to add to these sections from the medcin module.

In the Plan, use hyphens(-), not numbers(1,2,3) for the different components.

Surgery students: If the front desk is not calling out surgery patients, please remind them to look at

the surgery list so that you will be seeing the appropriate type of patients.

You are part of the team that is fully responsible for the care of the patients at CFAC.

Use your common sense and develop your patient management and physical diagnosis skills, and when

in doubt, ask for assistance from your supervising 4th year, resident, or attending physician.

Revised 8-24-2013

More Details on Midtown Clinic Initial Workflow-A Response to FAQ’s

Stepwise Approach:

Check your patient’s papers to be sure that a scheduling slip is stapled to the demographics sheet.

Browse through plan of the last note.

Write Room number next to patient’s name on clipboard up front before calling the patient’s name and

bringing them back. While bringing them back, can check the past note for more details on an

established patient, and establish rapport with a new patient.

Take Vitals. Always take temperature for any postop patient or patient with a wound. Pay attention to

the BP number. If high, retake the BP and pulse manually once patient relaxed and seated in the exam

room. If significantly high, take the pulse and ask them about other relevant symptoms right away and

immediately inform attending/resident/4th year for further direction.

Seat patient in room and have them remove socks and shoes on both feet.

New patients: New Patients= A New patient also includes any established patient not seen in 3 years.

Clarify the basic chief complaint “Heel pain or ingrown nail, etc”, then go seek your attending so they

can welcome the patient to the practice and help guide your questioning of the patient and direct the

patient’s visit. If you cannot find the attending, leave a post-it note at their workstation with “New

Patient, Room #__” . You can also inform the 4th year/resident as available. You will then proceed with

the full H&P using the new patient form and computer.

Enter medications, allergies and vitals into the chart before presenting the patient back to the attending.

If they come in with a medication list, you will also be copying this list to be scanned into the chart so

that dosages will be available. Make sure the patient’s name and chart number are on this list before

placing in the “to be scanned” box. It is usually easier with a new patient to clarify their

medical/family/social history and medication/allergy history with them before focusing fully on their HPI

and exam. Enter the medications/allergies directly into the computer and check that the patient’s

pharmacy information is entered. Using the new patient form to quickly checkmark positive ROS and

PMH items before entering these in the computer will typically be most efficient for a new patient.

Established patients: Check carefully in the plan and ask them about changes to their condition,

including how well they are following the treatment plan. Perform a focused H&P. Recheck and update

their medical history, medications/pharmacy information, allergies and tobacco status using the

computer chart before presenting. If the same attending is seeing the patient, present pertinent

medical history (ie. Diabetic, kidney disease, last vascular screening) with any new updates (recent

hospitalization, surgery, or new diagnosis; medication change). If a different attending is seeing the

patient, present a more complete picture of their medical history and highlight the updates in your

presentation.

Revised 8-24-2013

Note: If patient is casted, and the plan does not indicate whether a cast change/dressing change is

needed, inform the attending (or a 4th year/resident) before continuing with your focused H&P. If the

cast room is occupied, the cast can be removed in the room if the floor is properly draped. Surgical

patients with dressings: inform the attending/resident before removing the dressing.

Important: Recheck your Medcin module chart view for all required note components, and for note

completeness, including transfer of all pertinent hand-written information into the note. Fix any

discrepancies before flagging the note to the attending clinician.

Note: Established patients who are here for basic orthotic pick-ups, etc, should still have

PMH/MEDS/ALLERGIES/Personal history/Vitals in their note.

Note: If the patient refuses to cooperate with the H&P components, inform the resident/attending who

will provide further direction. If not all information was obtained, work with the attending to document

appropriately.