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
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
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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)

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 FAQs

Stepwise Approach:
Check your patients 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 patients name on clipboard up front before calling the patients 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
patients 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 patients 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 patients
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.

Revised 8-24-2013