PASTStudentTrackingSystem

BLANKCASELOGWORKSHEET(PDFVersion)
2012TyphonGroupLLC
Case#:

DateofService:

=REQUIREDFIELD
StudentInformation

ICD9DiagnosisCodes

Period:_________________
Rotation: _________________
Preceptor:_________________
ClinicalSite: _________________
___RuralVisit
___UnderservedArea/Population
SettingType: OP/ER/IP/LTC/Other
SurgicalManagement: ___Preop___Intraop___Postop
___OperatingRoomexperience

#1___________
#2___________
#3___________
#4___________

CPTBillingCodes
#1___________
#2___________
#3___________
#4___________
#5___________
#6___________

PatientDemographics(ignoreifGroupEncounter)
Age:_ _____yrs/mos/wks/days
___PreTerm(Premie)Child?
GestationalAge(atbirth):_____weeks
___Prenatalvisit?Enterfetusage:_____wks
Gender:M/F/T
Race:_____________
Insurance:_____________
Referral:_____________
ClinicalInformation

Birth&Delivery

NewbornProcedures
___Deepsuctioning
___Endotrachealsuctioning
___Bagandmask
___Intubationforventilation
___FullCPR
___Other:___________________

Medications
#OTCDrugstakenregularly:_____
#R currentlyprescribed: _____

ChiefComplaint: ___________________
Encounter#: _____

SocialProblemsAddressed
___AbusedChild/Adult
___Caretaking/Parenting
___Education/Language
___Emotional
___Grief
___Growth&Development
___Housing/Residence
___Income/Economic
___InterpersonalRelationships
___Issuesw/Comm.Resources
___Legal
___NeglectedChild/Adult

___Nutrition/Exercise
___Palliative/EndofLifeCare
___Prevention
___RoleChange
___Safety
___Sanitation/Hygiene
___Sexuality
___SocialContact/Isolation
___SpiritualIssues
___SubstanceAbuse
___Other:

Procedures/SkillsGeneralCompetencies(Observed/Assisted/Performed)
Obs Asst Perf
___ ___ ___ ABGAdultBrachial
___ ___ ___ ABGAdultFemoral
___ ___ ___ ABGAdultRadial
___ ___ ___ ABI
___ ___ ___ AirwayManagement
___ ___ ___ ApplicationCastLE
___ ___ ___ ApplicationCastUE
___ ___ ___ AsepticTechnique(Scrub)
___ ___ ___ AuscultatingFetalHeart
___ ___ ___ BLS/ACLS/PALS/AssistinginCode
___ ___ ___ CerumenRemoval
___ ___ ___ ChesttubeInsertion/Removal

NewbornComplications
___Meconiumaspiration
___Congenitalanomalies
___Birthtrauma/injury
___NICUAdmit:_______________
___Clinicallyapparentseizures
___Other:________________

MaternalProblems<24hrsPostpartum
___Hemorrhage
___Temperature>100.4F
___Hypertension(onsetpostpartum)
___Hematoma
___Other:________________________

ReasonforVisit: ___________________

AxisV(GAFScale0100): _____

#7___________
#8___________
#9___________
#10___________
#11___________
#12___________

UseICDcodesforpregnancyhistory&complications.
UseCPTcodesforlabs,anesthesia&modeofdelivery.
InfantGender: M/F/O
BirthWeight: ________grams
ApgarScores: 1min:______5min:______

TimewithPatient:_____minutes
ConsultwithPreceptor:_____minutes
TypeofDecisionMaking: ___Straightforward
___Lowcomplexity
___Moderatecomplexity
___Highcomplexity
StudentParticipation: ___Observationonly
___Lessthanshared
___Shared(5050)
___Primary(>50%)

TypeofH&P: ___ProblemFocused
___ExpandedProb.Focused
___Detailed
___Comprehensive
AxisIV
____________________________
(Psychosocial/Environmental):

#5___________
#6___________
#7___________
#8___________

#New/RefilledRxThisVisit: _____
TypesofNew/Refilled
RxThisVisit

AdherenceIssues
withMedications

Analgesic&Antipyretic:
Cardiology:
Dermatology:
Endocrinology:
ENT:
GIAgents:
Gynecology:
Hematology/Oncology:
InfectiousDiseases:
Neurology:
Ophthalmology:
Psychiatric:
Pulmonary:
Rheumatology:
Urology:
Vaccines:
WoundManagement:
Miscellaneous:

___Caretakerfailure
___Complexity/demandsoftreatment
___Denialofneed
___Disappearanceofsymptoms
___Disbeliefinbenefits/efficacy
___Fearofaddiction
___Financialconcerns
___Forgetfulness
___Knowledgedeficit
___Physicaldisability
___Pregnancy
___Psychiatricdiagnosis
___Religiousreasons
___Other/sideeffects:
________________________

OtherQuestionsAboutThisCase

___PatientdoesnotspeakEnglish

ClinicalNotes:

___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___

___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___

___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___

CultureObtained(blood,throat,wound,vaginal)
DigitalBlock
DigitalRectalExam/Hemoccult
EKG
EndotrachealIntubations
EvaluatingFetalPosition
FingerStick/HeelStick(peds)
FirstAssistinSurgery
HistoryandPhysical
IncisionandDrainage
InsertionNGTube
InsertionofCentralLine
InsertionofTractionPin
IntramuscularInjection
JointInjections/Aspirations
LesionExcision/Biopsy
LumbarPuncture
NebulizerTreatment
PerformingBreastExam
PerformingDelivery
PerformingPapSmear
PerformingSpeculumExam
PerformingTesticularExam
PerformingWetMount
PlacementofPPD
PreOpEvaluationofPatients
PulmonaryFunctionTest
RemovalofTractionPin
SimpleSuture
Splinting
StartingIVInfusion
SubcutaneousInjection
SutureRemoval
Thoracocentesis
UrethralCatheterization
VenipunctureAdult
VenipunctureChild
WoundCareandDressing