Up To Date is a CD ROM based reference guide some attendings have. It
is a fabulous quick reference that can be easily used during a clinic
visit. Unfortunately, we cannot access most of healthlinks.washington.edu
and all the lovely resources that it has. You can, however, get individual
access to many useful sites such as MDConsult, NEJM, Lancet, by contacting
the UW library.
Various reference books are available in attending offices. They are
eager to share these resources. In addition, Beacon Hill has a resident
teaching file with primary care articles available for copying.
My favorite primary care reference books:
Ackerman. Clinical Atlas of 101 Common
Skin Diseases. A little different from Kirkpatrick –
gives you 10-20 pictures of each of the most common diseases,
so that you get more of an idea of the spectrum of the dermatology.
Goroll. Primary Care Medicine.
2000. Comprehensive text for primary care issues, organized by
symptoms (e.g. “Nausea.”)
Greene, Walter. Essentials of Musculoskeletal
Care. 2001. A nice concise synopsis of the exam and general
approach to common musculoskeletal ailments.
McGee, Steve. Evidenced based physical
diagnosis. 2001. Gives you the pearls of physical diagnosis
that every UW resident should know.
Fihn, Stephan and Dawn DeWitt. Outpatient
Medicine. 1998. More concise than Goroll; less complete
but perhaps a better introduction to primary care medicine. Written
by UW’s finest.
The Swedish Hospital reference librarian is Cheryl Goodwin (386-6469,
E-mail her with any questions particularly about references for e-cases.
Patient education literature is available for almost any problem and
is a good way to enhance patient care. MA’s can locate most sheets
but you should familiarize yourself with them too. PacMed has a number
of clinical quick reference sheets that help manage patient data for common
disorders such as diabetes, health care maintenance and depression.
Some books that attendings like
to recommend to patients:
Strong Women and Men Beat Arthritis
by Miriam Nelson, PhD. Putnam books. (Vickie Allen)
Feeling Good by David Burns.
(Vyn Reese) For the depressed patient who is motivated and relatively
analytical in nature.
Dr. Shapiro's picture perfect diet.
(Dena Kennedy) A visual approach to modifying your diet –
the visual punch often is a good motivator for change.
Some useful medical websites for residents:
The medicine residency website. PacMed ecases can be found here,
as can many primary care handouts.
The ultimate place to look for medical resources. Unfortunately,
most of it is inaccessible from the PacMed computers because of
a firewall restriction. However, you can access it from anywhere
else in the UW system or at home (once you’ve set up a proxy
(also found at the top of the healthlinks-care provider toolkit
A great initial place to look for answers and patient handouts.
From here you can search mdconsult, derm atlases, patient handouts,
immunization schedules, prevention guidelines, natural meds, traveler's
Resource for traveler's health
Practical guidelines on managemznt of basic gi/liver disorders,
organized by symptom (e.g. “diarrhea”).
A great resource for patient handouts on rheum and ortho ailments.
This is the single best resource for medical software for the palm. My
- ATPIII Cholesterol guidelines:
an interactive and informational tool for diagnosing and treating hyperlipidemia
- ePocrates – a great pharmaceutical
resource – a must have for any resident.
- Johns Hopkins Antibiotics Guide:
a good free alternative to a Sanford guide, if you have room.
- JournalToGo – when you
HotSync your PDA, it will download the latest abstracts on any journal
- mobileMICROMEDEX – has
the same pharmaceutical information as epocrates, but also has toxicology
and alternative medicine info. Medicine residents can download this
for free if you go instead through the healthlinks.washington.edu site
and click on ‘micromedex.’
- BreastCa: an interactive tool
for predicting breast cancer risk; good for reassuring patients.
- MedCalc and MedMath –
calculate most medical equations, including FENa, CrCl
- MedRules – evidence-based
prediction rules for various things, including suspicion for PE or pneumonia
- Skyscape’s 5-minute clinical
consult: one of the few things that I paid for. Provides bullets
of medical info for most common things.
AHA guidelines, including atrial fibrillation, valvular heart disease,
secondary prevention of CAD, CABG, chronic stable angina, CHF, pacemakers,
The Hi-Note software is a nested memo program; this is what I use to take
notes. They have a desktop program too. Well worth the investment if you
take a lot of notes on your palm.
J-File is a good database program, though it costs money. The databases
I have are CSF analysis, Pleural fluid analysis, Synovial fluid analysis,
Eponyms, Lab Values.
Multiple channels, mostly nonmedical (e.g. NY Times, seattle.citysearch.com)
but also includes a couple of medical journals (Lancet)
Interactive tool for calculating cardiac risk based on the Framingham
An interactive and informational tool about osteoporosis risk and treatment,
created by UW’s own Mary Laya and Mary Migeon.
A calculator for converting among pain medicines
A rough illustration of various rhythms. Good for teaching medical students.
Intro to the PacMed Computer
System (“IDX”) for Medicine Residents
- There are two interfaces: one is web-based (tends to be slower and
more cumbersome) and xterm. Call IS 621-4357 for more information on
getting the software.
- You will get two separate usernames:
- One is the LAN account (it will be a username like “melissac”
or “christophers”), which you use to log into the computers
at PacMed, and which you will enter every time your screensaver
locks you out.
- The other is your IDX account (which is something more cryptic,
like “MC13”), which you will use to access medical records.
To use the terminal-based interface:
double-click on the “IDX-TERM” icon on the desktop.
- Log in with your IDX account.
- At the menu, choose “MREC”
- The computer will prompt you with “Select Function:” Type
- Enter the patient’s name in the format LASTNAME,FIRSTNAME (you
can input just the first 3 letters and the computer will give you other
options), or put in the medical record with a period before it. When
you hit enter, a menu of options should appear.
|Note: IDX requires use of all capital letters.
To look up past notes:
- Hit F for Flowsheets
- Scroll till you find NOTES
- Hit V for VIEW
- Hit E for ENTER CELL
- Scroll until you have selected the note you wish to view.
- Hit D for DISPLAY DETAIL.
- Commands for scrolling are at bottom of screen – B for back,
F for forward.
- F10 kicks you back to the previous list of all notes.
- To look up labs/radiology: two ways.
- Hit F for FLOWSHEETS
- Scroll until you find the lab/radiology you want to look up.
- Hit V for VIEW.
- This gives you a better idea of the big picture, lab trends or all
radiology that has been done.
- Or: while at the main menu,
- Hit I for INQUIRY (general)
- Hit O for ONE SECTION
- Type in L and hit F10.
- This gives you all labs in reverse chronological order.
|F10 is like the ‘escape’ key –
use it to go back to the previous menu.
To add notes: while
at the main menu,
- Hit A for ADD DATA. This will put you into a screen that makes
you enter several fields before writing the notes. Use the Tab
key to go from one field to the next.
- For the date, type T for ‘today’.
- Enter your name (you can use your dictation/pacmed rx 5-digit
- Enter the attending name that staffed the patient with you (you
can use their number).
- Type PROG (note all caps).
- Then hit E to go into the entry field.
- Type your note.
- Hit F10 a couple of times when you are done.
You can edit notes within 30 days if you typed the original note
in, but not if you dictated it. Just hit E on the original menu
for EDIT DATA.
|Call IS (Information Services) for any computer-related questions,
including passwords: 621-4357
To check your schedule:
- hit F10 until you get kicked back to the original menu, where
you had originally selected “MREC.” Now select “SCH”.
- When it prompts “Select function,” press “4”.
- Type your IDX number in, and the date to peruse.
- When it prompts “Which session for detail?” type
PM for an afternoon clinic, AM for a morning one.
HOW TO USE PACMED VOICEMAIL (note: this is different
from the voice mail that is provided with your pager)
To leave a message for a voice mail user (indicated by an * in the directory),
dial the appropriate number:
|1101 Madison Clinic
|Beacon Hill Clinic
During the greeting, enter the desired mailbox number and press “#”.
Follow the instructions to leave a message.
To leave a message for a voice mail user who only has a phone mail box
(indicated by ** in the directory):
Dial 4191 (internally) or (206) 621-4191 (externally).
During the greeting, enter the mailbox number and press “#”.
Follow the instructions to leave a message.
KING COUNTY COMMUNITY
|Information and Referral
|Senior Information and Assistance
|Community Information Line
|Mayor's Office for Senior Citizens
|Adult Protective Services
(Van service of people with disabilities)
(Van service and taxi scripts for people age 65+ with limited
(Transportation to medical appointments for people age 60+)
Home and Community Services/COPES
King Co Respite
King Co Volunteer Chore Service
Meals on Wheels
24 Hour Crisis Line
Geriatric Regional Assessment Team
Evergreen Mental Health 3 day response
Mental Health Professionals
(Can assist with involuntary commitment)
Community Services Officer
(Through the police department)
Alcohol and Drug Helpline
Domestic Violence Info Line
Wa State Domestic Violence Hotline
Columbia Legal Services
Legal information on a variety of issues pertaining to seniors
Senior Rights Assistance
Information for clients ages 55+ with issues related to health
insurance, long term care, social security, end-of-life planning,
estate planning, landlord-tenant problems, consumer issues,
homeowner concerns, and legal topics. They have a Senior Legal
Social Security Admin and Medicare
Provides info on health insurance, long-term care ins, and
|Durable Medical Equipment
Bridge Ministries (Free equipment)
Wheel Chair Haven (Used equipment – discounted)
Fall Factors (Reduced grab bars)
King Co Housing Authority
Seattle Housing Authority
Housing and Urban Dev (HUD)
SHAG (Senior Housing Assistance Group provides affordable housing
for low and moderate income persons age 62+)
Home Sharing for Seniors
Minor Home Repair
WA Telephone Assistance Program
|Community Resource Information Online
Directions to PacMed
PacMed Clinics-Beacon Hill
1200 12th Avenue S, Seattle, WA 98144
From I-5 Northbound: Take the James Street
exit (164A) and turn right on James. Continue east on James Street up
and over the hill. (James becomes E. Cherry at Broadway.) Turn right onto
12th Avenue. Continue on 12th Avenue (through light at Yesler) to PacMed
Clinics-Beacon Hill (large orange brick building). Veer left at light
as the street divides around the PacMed campus. Turn right at the sign
to “Main Entrance Parking” and park in the garage.
From I-5 Southbound: Take the James Street
exit (165A) and turn left on James (the second light). Continue east on
James Street, up and over the hill (James becomes E Cherry at Broadway).
Turn right onto 12th Avenue. Continue on 12th (through light at Yesler)
to PacMed (large orange brick building). Veer left at the light as the
street divides around the PacMed campus. Turn right at the sign to “Main
Entrance Parking” and park in the garage.
From I-90 Westbound: Exit at Rainier Avenue
North. Continue north on Rainier Avenue (straight through the light at
Dearborn). Turn left onto Jackson Street. Turn left onto 12th Avenue South
and proceed to PacMed (large orange brick building). Veer left at the
light as the street divides around the PacMed campus. Turn right at the
sign to “Main Entrance Parking” and park in the garage.
From West Seattle: Head east over the West
Seattle Bridge/Spokane Street. Exit onto Columbian Way (East). Turn left
at the first light (Spokane Street). Turn left again at next light (one
small block) onto 15th Avenue South. Continue (north) to Beacon Avenue.
At Beacon Avenue, either continue straight on 15th or jog to the left
for one block. Travel north to PacMed.
Metro bus routes 36 and 60 also stop right at our door.
PacMed Clinics-1101 Madison
1101 Madison St, Suite 301, Seattle, 98104
From I-5 Northbound: Exit at the James-Madison
exit (Exit164A). Continue to Madison Street and turn right. Follow Madison
east to Boren Avenue. Turn right at Boren and left at Marion. The entrance
to the Marion-Minor garage is on you immediate left. The clinic is on
the third, fourth and seventh floors.
From I-5 Southbound: Exit at James Street exit
(Exit 165A). Turn left on James and proceed east to Boren Avenue. Turn
left on Boren and right at Marion. The entrance to the Marion-Minor garage
is on you immediate left. The clinic is on the third, fourth and seventh
601 South Carr Road, Suite 100, Renton, WA 98055
From I-5 Southbound & Northbound: Take
I-405 northbound (Renton) exit and follow I 405 northbound directions
From I-405 Northbound: Take the Kent/Auburn
(2A) exit and travel southbound on Highway 167. Take the S. 180th Street
exit. Turn left on East Valley Highway and then left on 43rd S.W./S. 180th.
Go up the hill to Smithers (third light) and turn right. Parking lot will
be on your right hand side.
From I-405 Southbound: Take the Kent/Auburn
exit for Highway 167 southbound. Travel south on Hwy 167 and take the
S 180th Street exit. Turn left at East Valley Hwy and left onto 43rd SW/S
180th. Go up the hill to Smithers (third light) and turn right. Parking
lot will be on your right hand side.
From Hwy 167 Northbound: Take S 180th Street
exit. Turn right at light. Go up the hill to Smithers (second light) and
turn right. Parking lot will be on your right hand side.
Dictating is an art which takes practice to master. It is an important
skill learned in residency yet it is not formally taught. It documents
patient care, communicates it to other physicians and is the primary determinant
of billing. The following is a suggested template for a non-yearly clinic
visit. It incorporates efficient communication of data and documents thought
process in a format that easily justifies billing. Remember that transcription
is a health care cost. Using simple sentences, abbreviations and references
to past notes helps keep these costs down.
|Medquist #: (206) 493-1311
Work type: (1= Stat, 2=H&P, 3=Progress Note, 4=Consultation, 5=Telephone
note, 6=Letterhead note)
Clinic location: (11=Beacon Hill, 14=Renton, 30-Madison)
Dictate your name, patient name (spelling both
first and last name), PacMed number, date of service, report type
and attending name.
Problem List: If one already exists,
refer to that dictated note (i.e. See note 5/2/01)
CC: Age, gender and reason for visit.
HPI: Briefly summarize interval if
this is a follow up. Include the “seven” components
of each complaint.
(character, location, duration, radiation, intensity, precipitating
factors, associated symptoms)
If FH and SH are relevant to the problem, document it.
PMH: if relevant.
ROS: Refer to HPI if included there.
Rx: Give name dose and schedule.
Make reference to prior note (i.e. see med list 5/2/01) if there
are no changes. Accuracy is essential.
PE: Use abbreviations.
Labs/Studies: Note briefly the labs
and studies reviewed that are relevant to this visit.
A/P: Active Problems
cc: Primary care provider and consultant
Problem List: See 5/2/03.
CC: 55yom with painful foot.
HPI: 2d acute onset swelling/pain/redness
in R big toe. Denies F/C/NS/other jt complaints/trauma. 1st occurrence.
Enjoyed a banquet of meat, fish, and asparagus 3d ago.
PMH: Htn, CAD, DM.
SH: Born in Phillipines, moved here 15
yrs ago. 2 beers/d.
PE BP 150/90, P 80, Wt 300. NAD. R 1st MTP swollen, tender, erythematous,
with decreased ROM.
Please see written note for full details of the benign remainder of exam.
A: First gout attack for this pt with
multiple risks – gender, ethnicity, etoh, dietary indiscretion,
hctz. Ddx includes infection, pseudogout, trauma. Also HTN – may
have pain component, but goal is 130/80 for a diabetic.
- Reviewed dietary precautions.
- Prednisone 20mgx5d, ibuprofen prn.
- No indication for allopurinol/probenecid yet – if he has recurrence,
will do 24hr urine collection for further workup.
- HCM – UTD on pneumovax,td,flu; colonoscopy neg 6/2002; declines
RTC 2wks for BP check and htn med review.
Coding, or billing, is an important part of medical training that is
often neglected. Residents often feel, appropriately so, that there is
so much to learn and focus on why spent time on something as trivial as
billing? However, billing is essential for any medical service, even non-profit,
to remain viable. This includes PacMed, Harborview and the University.
For these reasons, PacMed residents learn the basics of billing as part
of their training. All billing levels are derived from the dictated note
by a highschool or college graduate with no medical experience.
Coding reference chart
The following is a simplified version of the Evaluation and Management
coding used for all billing. Its overall organization and finer nuances
can be explained in due time by your attending. There is an algorithm
used by Beacon Hill attendings to determine what documentation is required
to bill for a level three verses a level four visit.
Abbreviated Coding Guide (minimum
|# of History elements
|# of systems (ROS)
||1 (3 if new pt)
||2 (3 if new pt)
|# of exam bullets