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WRITE Course Requirements,
Evaluations, & Grading
Patient Visit Log
PURPOSE/GOAL
The log record serves several important purposes:
- Maintains a personal record of your clinical learning experiences so that you may:
- build on experiences in independent learning
- fill in gaps in your clinical experiences by requesting appropriate patient assignments
- have a guide and stimulus to patient follow-up care
- identify challenging cases to study in depth
- choose cases to discuss during case presentations, faculty visits, or residency interviews
- Provides an evaluation of the WRITE Program.
OVERVIEW OF THE WEB-BASED PROGRAM
This section includes directions for use of the web-based data collection system for capturing information about your encounters with patients. If you have further questions about the use of the WRITE Patient Visit Log system, please contact Dr. Jan Carline at carlinej@u.washington.edu, or (206) 685-2135. This system meets the basic requirements for insuring privacy of patient information under HIPAA regulations.
The WRITE Student's Patient Visit Form uses a web-based data collection form for the entry of patient information. The student enters information about patient encounters directly into a secured browser form by typing in responses and making choices from radio buttons or pull-down menus. Data is stored in a secure database as it is entered on a Department of Medical Education and Biomedical Informatics server in Seattle.
At the end of every month (around the 25th), Dr. Carline copies all of the data currently in the system for processing. Please have all your entries up to date on or before the 25th of each month. He will then produce reports for use by the student, the WWAMI Regional Offices, and other WRITE faculty members, including UWSOM Clerkship Directors. Copies of the report will be emailed to the WWAMI Regional Deans and the students. Students should in turn share their monthly report with their preceptor. The student may also request a copy of their entries in a database file as well; additionally, reports can be prepared specifically for Faculty Visits. Students are encouraged to enter log reports daily.
STUDENT DATA ENTRY INSTRUCTIONS
To reach the WRITE Student's Patient Visit Form login page, either type or paste the following URL into your browser: https://www.mebi.washington.edu/writeproject/login.html
Type in your UW Net ID for the user name, and the password that was provided and click on the submit button.
Once you have logged into the system, and have been accepted, you will be taken to the encounter form itself.
On the top portion of the form, you will enter basic information about the patient encounter. PLEASE NOTE: The WRITE Patient Visit Log program is implemented currently on hand-held computers. The information listed below attempts to display the type of information collected for each patient encounter, but does not do so in terms of the visual display that the user would encounter.
WRITE Patient Visit Log Data Elements
1. Date of each session (DDYY)
2. Patient’s age (choose appropriate age group):
- Infant < 2 years
- Child 2 thgough 12
- Adolescent 13 through 18
- Adult 19 through 65
- Senior > 66
3. Indicate gender: M, F
4. Type of visit:
- I = Initial visit - this is the first time you have seen the patient
- R = Return visit - you have seen the patient previously
5. Location of the visit:
- C = Physician office or clinic
- H = Hospital
- ER = Emergency Room
- O = Other location, i.e. nursing home, home visit
6. Your Level of participation in the procedure is coded:
- 0 = Observation with minimal activity (i.e. Second Assistant)
- 1 = Partial involvement (First Assistant, up to 50% activity)
- 2 = Full involvement (Start to Finish Care, more than 50% activity
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On the second portion of the form you will use the Problems & Procedures Table, which lists the data categories that you will use to document each patient encounter. PLEASE NOTE that the specific data included in these lists were chosen by WRITE faculty to help them identify if you have had sufficient experience with basic types of problems and procedures. It is not a complete list of all the things you might encounter.
Choose a problem area on the left hand side of the screen (such as Cardiovascular or Allergies).
Indicate a specific problem associated with that area (at the right side of the screen).
You may enter up to three problems for each encounter. If a patient presents with more than three problems, indicate either the specific problems that you dealt with during the encounter, or the three most important problems. You must enter at least ONE problem. If there is no secondary or tertiary problem, you must choose “No other problem” from the problem lists. Once you have chosen “No other problem” you do not need to make a choice for the specific problem area.
Choose the procedure type on the left;
Indicate the specific procedure on the right side of the screen; you may choose two procedures for each encounter. If no procedure was done, you must choose “No procedure” or “No other Procedure.”
You may make notes for your own use, e.g., specific information about the patient problem or procedure. This information will be saved but not analyzed. It will be returned to you if you request a copy of the database file.
Enter your initials before you submit the encounter - this is essential to indicate your data, and not have it confused with other users of the system.
You may edit any entry before you leave the case. You may restart the entry totally by clicking on reset.
When you are satisfied with your entry, click on the submit button. Once you have submitted the form, you will not be able to make any changes to the data.
The next screen gives you the choice of entering another encounter or logging off from the system.
If you have taken a long time to enter a case, or have been interrupted and delayed in completing a case, you will be asked to log in again. Data submitted before the request to log in again will be saved. Data from the last case you attempted to submit will not be saved, and you will need to reenter the case.
When you have completed entering all data, log off the system and close your browser. No information will be left on your desktop computer. If you have any difficulty using this system, please contact Deven Hamilton at dht2@u.washington.edu.
Remember, log data should reflect your daily activity as you see patients. If you see the same patient more than once in a day, you do not need to log that patient more than once, but then the next day, if you see that patient again, go ahead and add that visit to your log data.
Click Here for PDF file of Problems/Reasons For Visit
Click Here for PDF file of Procedures
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