The Clinical Encounters Database aids in documentation of data collection, one of the six major components of the Family Medicine Clerkship. The purpose of the database is twofold:

• To collect accurate information on student clinical experience thus promoting better evaluation of the curriculum, and
• To act as a clinical tool for the student=s own use and future reference.

Clinical encounters that lead to learning should be entered into the database. Sufficient time should be allowed between patients to permit this. Entries that are extremely useful for the "Problem" database for the DF&CM include "Age, Gender, Problem List, Involvement, and Attending Faculty".  Default entries for this clerkship include your base Campus, discipline of Family Medicine, and the Date & Time.  For the "Procedure" entries include "Procedure List" in place of "Problem List".  Only by logging all pertinent material can the full scope of the student=s experience be evaluated.  Providing this data allows the Department to respond to the rare instance where the clerkship site lacks the necessary scope of practice or where the student=s role needs to be addressed.

Scheduling time for necessary housekeeping, including accessing needed resources and data collection during patient care, is simply a good habit that is acquired by practice and will be respected by your preceptor.  Hot-synch frequently - perferably at lest weekly.  Check remaining battery power frequently.  If batteries discharge, your data will be lost.  If you do not submit electronic data you will be required to submit paper documentation of the scope of your experience.

The Health Insurance Portability and Accountability Act (HIPAA) is directing the implementation of specific requirements to protect privacy of individuals.  THe privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information (PHI) to the minimum necessary to accomplish the intended purpose.  For example, because the "old" elderly might be more easily identified by problem and age in this population, "Patient Age" for those over 90 years old should simply be entered as "90".  You have already successfully completed the HIPAA orientation exam.  If you have additional questions or need clarification about HIPAA issues that are not adequately addressed at http://www.ncvhs.hhs.gov/ , please contact DFCM faculty.