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 examinations (CK & CS) 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. Documentation is an essential and important feature of patient care, and learning how and what to document is an important part of medical education. Keeping this log becomes a student training exercise in documentation. The seriousness and accuracy with which students maintain and update their patient log will be part of their evaluation during the core rotations.

Not only by the number of diagnoses they log, but also by how conscientious and honest they keep this log and document their patient encounters. All of these features of documentation — seriousness, accuracy, conscientiousness and honesty — are measures of professionalism.

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.
  • Site evaluation: Demonstrate suitability of a particular practice or site as a location for student education.
  • 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:

This is not an exercise in recreational data gathering. There is sound rationale for collecting data.

The clerkship directors are monitoring data on an ongoing basis to insure you are meeting clerkship objectives.

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

Annually, data is reviewed by Academic Affairs, the curriculum committee, and the phase 3 & 4 committees to insure the clinical experiences are meeting the objectives of the clerkship and to assess the comparability of experiences at various sites.



Clerkship Director Responsibility

  • Review students' patient encounters regularly, at a minimum for mid-rotation and end of rotation (If, for example, the OB-GYN clerkship director notices you are not experiencing enough vaginal deliveries, steps can be taken early in the clerkship to remedy the situation)
  • 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 meaningful patient encounters.
  • Document all procedures.
  • 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. Failure to do so is considered unprofessional behavior and will be noted by your clerkship director. Completion of encounter/procedure logs is a barrier requirement for all required clinical courses. 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.)
      • If your supervisor’s name does not show up, choose “other” and include supervisor name in the comments section.


Encounter Information

Make sure the date you enter is the date you actually saw the patient. Be sure to pick the correct clerkship/course and your supervisor. If your supervisor’s name does not show up, choose “other” and include supervisor name in the comments section. All categories are in drop down menu form except for specific location and notes. Students will use these areas to type in specific information.

Enter Patient information (see below) and up to six diagnoses from 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.

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. 

  • Minimal: Min. Pt. contact — The student has minimal contact with patient which amounts to less than doing an Hx or PE. An example might be 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.

Encounter Log Categories

Procedure Information

There is a long list of procedures to pick from. You must pick both the procedure and the level of care (observed, assisted or performed) you had with the procedure. You may add multiple procedures. As with the encounter logs, all categories are in drop down menu form except for specific location and notes. Students will use these areas to type in specific information.

Use the Notes section 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.

Procedure Log Categories