Professional Documents
Culture Documents
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
patients 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 days x-rays.
Otherwise, record labs, previous x-ray review findings, MRIs 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 doesnt want anything in his box), place the old chart notes in the clinicians 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
attendings 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)
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
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.
Revised 8-24-2013