College of Podiatric Medicine and Surgery

DPM 2012 Third-Year Clinic Manual

July 19, 2010 to May 20, 2011
Course #CLPD*3217
Kevin Smith, DPM, MS, FACFAS Associate Dean for Clinical Affairs
JoAnn Williams Clerkship Coordinator for Clinical Affairs (515) 271-1489
DPMDPMDPMDPM 2011 Third-Year Clinic Manual 1

Table of Contents
Introduction................................................................................................................................................. 1 Immunization .............................................................................................................................................. 1 Clinical Curriculum ..................................................................................................................................... 1 General Objectives ..................................................................................................................................... 1 Podiatric Medicine Basic and Clinical Sciences Objectives ....................................................................... 1 Rotation Competencies Podiatric Medicine Competencies ....................................................................................................... 2 Podiatric Radiology Competencies ...................................................................................................... 3 Podiatric Surgery Competencies ......................................................................................................... 4 Podiatric Orthopaedics/Biomechanics Competencies ......................................................................... 4 Orthotics/Prosthetics Competencies ................................................................................................... 4 Internal Medicine Competencies ......................................................................................................... 4 Vascular Clinical Competencies .......................................................................................................... 4 Simulation Lab Competencies ............................................................................................................. 4 Podiatric Clinical Skills ............................................................................................................................... 6 Clinic Requirements Hours ................................................................................................................................................... 8 Attendance ........................................................................................................................................... 8 Supervision .......................................................................................................................................... 8 Student Conduct .................................................................................................................................. 8 Cleanliness/Precautions Protocol ........................................................................................................ 9 Infection Control/Body Substance Isolation ....................................................................................... 10 Blood and Body Fluid Exposure Prevention ...................................................................................... 11 Patient Protocol.................................................................................................................................. 11 Patient Care ....................................................................................................................................... 11 Radiology ........................................................................................................................................... 11 Instruments ........................................................................................................................................ 12 Medical Supplies ................................................................................................................................ 12 Electronic Medical Records ............................................................................................................... 12 Student Evaluation and Grades ............................................................................................................... 13 Patient Encounter System (PxDx) ............................................................................................................ 14 Campus Office Numbers .......................................................................................................................... 16 EMR Patient Flow-Chart in Clinic Operation ............................................................................................ 17

DPM 2012 THIRD-YEAR CLINIC MANUAL

INTRODUCTION
The third-year clinical experience is designed to develop basic hands-on patient evaluation and management skills for the podiatric medical student. The clinical education allows practical application of concepts presented during the pre-clinical years and further developed by the problem-based learning curriculum presented during the third year.

IMMUNIZATION RECORD
Before any student is allowed in clinic, a current immunization record must be on file in the Student Health Department. This policy will be adhered to strictly.

CLINICAL CURRICULUM
The third-year clinical curriculum requires the student to complete a series of assigned rotations with CPMS clinical faculty. Each rotation with a CPMS clinical faculty member is considered a separate rotation. The clinical experience is determined by the attendings clinic and clinic sites may vary. Upon completion of this clinical course, the third-year podiatric medical student will have demonstrated proficiency in the clinical skills and knowledge defined by the outlined competencies.

GENERAL OBJECTIVES
The student will demonstrate actions and attitudes consistent with the guidelines of clinical professionalism and skills as outlined throughout this manual, and as advised by the clinical faculty and medical staff with whom they interact.

PODIATRIC MEDICINE BASIC AND CLINICAL SCIENCES OBJECTIVES

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Increase vocabulary for describing the sciences basic to all medicine. Apply fundamental principles of medicine to podiatric practice situations. Formulate a fund of knowledge describing the structure and function of the human body. Recognize the structural and functional elements on which disease processes and therapeutic intervention are founded. Use and apply computer technology in achieving educational objectives. Recognize and evaluate areas of scientific promise for innovations in therapeutic modalities (i.e., gene therapy, molecular biology, interventional pharmacology, immunotherapy, and nutrition). Develop an understanding of cultural competency and the influence culture has on the patient/doctor relationship. Develop problem solving skills for integration of basic and clinical sciences. Recall a fund of knowledge about the structure and function of the lower extremity. Apply basic science (biochemistry, histology, anatomy, microbiology, pathology, physiology and pharmacology) principles to the treatment of disease processes of the body, particularly those that adversely affect the lower extremity. Perform a complete history and physical examination to establish a differential diagnosis. Order and interpret appropriate diagnostic tests related to findings of the history and physical examination. Propose a reasonable management plan for podiatric medical conditions. Demonstrate proficiency in performing basic podiatric skills.

11. 12. 13. 14.

DPM 2012 Third-Year Clinic Manual

ROTATION COMPETENCIES
The third-year clinical rotation competencies have been developed to provide basic podiatric medicine, podiatric radiology, podiatric surgery and podiatric orthopedic/biomechanic clinical experiences. The competencies encompass a range of clinical activities determined to be vital to the education of the thirdyear podiatric medical student.

Podiatric Medicine Competencies

1. Record a patient history: a. new patient All components of podiatric history completed. Student is aware of patients age, chief complaint; HPI questions are relevant to the chief complaint and relevant past medical history. Student has an adequate differential diagnosis. b. established patient Student has read chart prior to entering room and asked questions pertinent to the follow-up visit. Student assesses the trend of previously administered treatment. Student knows whether or not to continue treatment or change current treatment plan. 2. Perform and record a podiatric physical examination: a. vitals Student counts respirations during pulse taking. Student obtains blood pressure efficiently and pulse in less than 10 seconds. Student can explain some etiologies of fast pulse (tachycardia), slow pulse (bradycardia), or irregular pulse (arrhythmia) and is aware of blood pressure readings that require follow-up. b. vascular examination Student obtains and grades pulses. Student checks for and grades edema if present. Student checks for varicosities and assesses capillary fill time. Student can explain what they would do if they cant initially feel the pulses to possibly obtain readings and explain some reasons for absent pulses. c. neurological examination Student correctly assesses sharp/dull, proprioception, vibratory sensation and deep tendon reflexes. Student correctly assesses protective sensation via Semmes-Weinstein technique and has patients eyes closed during the proprioception, vibratory and protective sensation exam and can describe the pathway for vibratory and proprioceptive sensation. Student can describe the nerve roots responsible for both the Achilles tendon and patellar tendon reflexes. d. dermatological examination Student inspects the skin fully including between the toes and describes the findings of lesions properly in the chart. Student can list three primary skin lesions and three secondary skin lesions and can differentiate and define the terms IPK, HM, HD and tyloma. e. musculoskeletal examination Student properly grades the strength of all tested compartments. Student can list common findings with compartment syndrome. 3. Perform proper aseptic technique in preparation for clinical injection. Student obtains the correct local anesthetic, swabs the top of vial, draws with a 23 gauge or greater bore needle and properly discards the drawing needle. Student changes to a 27 or 25 gauge long needle; removes any residual bubbles and caps correctly. Student can describe location of local anesthetic metabolism; can determine the milligrams of local anesthetic drawn up and the toxic dose of anesthetics 4. Perform a local anesthetic block of the foot or ankle. Student swabs the skin, and is in proper location to perform the given nerve block. Student does not appear to inflict undue discomfort and actually uses the appropriate amount of local anesthetic. Student can describe how they would perform a posterior tibial nerve block and how local anesthetics work on a cellular level.

DPM 2012 Third-Year Clinic Manual

5. Perform a corticosteroid injection or joint aspiration on the foot or ankle. Student properly fills syringe with medication, prepares injection site (alcohol or antiseptic) and administers with minimal guidance/assistance of attending. 6. Prescribe oral medications for management of infection, pain, inflammation, etc. Student writes prescription with minimal assistance or guidance. 7. Prescribe topical medications for management of infection, inflammation, pain, etc. Student writes prescription with minimal assistance or guidance. 8. Identify indications and interpret appropriate lab tests (pre-op, rheumatologic, infection, systemic disease, etc.). Student identifies and interprets appropriate labs with minimal guidance from attending. 9. Perform the following skin and nail procedures: a. debridement of pathologic nails Student debrides nails without causing unnecessary pain or hemorrhage without clinician assistance. Student accurately describes the appearance and location of nail pathology, explain the pathology of nails and suggest alternative treatment to the clinician. b. debridement of hyperkeratotic lesions (IPK, tyloma, plantar verrucae, etc.) Student debrides all forms of hyperkeratotic lesions without causing unnecessary pain or hemorrhage without clinician assistance. Student accurately describes the appearance and location of lesions and explains the etiology and pathology of the lesions, and suggests alternative treatments to the clinician. Student applies appropriate padding to the foot and toes to accommodate the debrided lesions.

Podiatric Radiology Competencies

10. Order and interpret appropriate series of radiographs to visualize foot pathology. Student orders and interprets the x-ray, specifically in the area of the suspected pathology as it relates to the patients history and physical examination. Student suggests additional imaging studies as indicated based on the x-ray interpretation. 11. Order and interpret appropriate series of radiographs to visualize ankle pathology. Student orders and interprets the x-ray, specifically in the area of the suspected pathology as it relates to the patients history and physical examination. Student suggests additional imaging studies as indicated based on the x-ray interpretation. 12. Order and interpret appropriate special diagnostic studies (CT, bone scans, MRI, leukocyte scan, etc.). Student describes the indications for each special imaging study and the technique of administering each study, including the basic science behind its utilization. Student identifies the majority of normal anatomical structures as seen on CT and MRI. Student interprets a bone scan. 13. Apply principles of x-ray protection and radiation safety. Student knows to shield patients abdomen and his/herself during x-ray exposure. Student asks female patients date of last menstrual period to assess pregnancy risk and documents on x-ray order form. 14. Prepare film cassette for standard radiographs. Student opens cassette; loads correct film type and size into extremity cassette without assistance. 15. Properly position patients for the following x-ray projections: Student positions patient and selects exposure technique without assistance. Student knows angles and correct patient position and can operate exposure switch, technique panel and camera. a. dorsoplantar foot b. lateral foot c. oblique foot
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d. e. f. g.

AP ankle mortise ankle lateral ankle specialized projections (calcaneal axial, forefoot axial, oblique ankle)

16. Develop a quality radiograph using automatic processor or tank method. Student uses film ID flasher; opens cassette, removes film and places film into processor without assistance.

Podiatric Surgery Competencies

17. Demonstrate proper surgical aseptic technique. Student knows proper sterile field set-up, proper gloving technique and appropriate handling of instruments with minimal guidance/assistance of the attending. 18. Complete a surgical consent form. Student instructs patient to read consent, review possible complications and obtain patient signature with minimal guidance/assistance of the attending. 19. Redress a surgical wound or other open lesion including the application of wound vac. Student selects appropriate supplies, proper wound preparation and apply dressing with minimal assistance/guidance of the attending. 20. Remove sutures. Student selects proper instrumentation, appropriate preparation of procedure field and removal of sutures without need for assistance/guidance of attending. 21. Perform a partial or total nail avulsion with or without matricectomy. Student knows the steps, instrumentation and indications required to perform a partial or total nail avulsion with or without matricectomy. 22. Perform wound debridement or incision/drainage procedure. Student assesses wound for depth, size, drainage, presence or absence of granulation tissue and for local signs of infection. Student describes the indications for and performs wound debridement or incision/drainage procedure.

Podiatric Orthopaedics/Biomechanics Competencies

23. Apply foot/ankle strapping (low-dye, J-strap, basket weave). Student applies foot/ankle strapping (low-dye, J-strap, basket weave) without clinician assistance. 24. Justify the design fabricate and apply the correct padding (metatarsal. pad, heel pad, dancers pad, aperture pads, medical longitudinal arch pad, etc.). Student designs, fabricates and explains the indications for padding (metatarsal pad, heel pad, dancers pad, aperture pad, medical longitudinal arch pad, etc.). 25. Perform a non-weight bearing biomechanical examination (limb length discrepancy, STJ, MTJ, first ray, ankle) and interpret the data collected. a. patient prone b. leg in frontal plane c. STJ in neutral d. MTJ locked (if appropriate) 26. Perform a weight bearing biomechanical examination (RCSP, NCSP, tibial influence) and interpret the data collected. a. patient standing b. patient in angle and base of gait
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c. patients hips and knees extended with arms at sides d. STJ in neutral (if appropriate) 27. Assess gait patterns for pathology. a. observes gait systematically b. correlates gait patterns to normal standard c. observes and records common gait abnormalities 28. Orthotic management: a. casting (1) appropriately applies splints (2) positions patient appropriately b. writing a prescription (1) chooses materials appropriately (2) decides orthosis posting appropriately c. dispensing (1) evaluates orthosis non weight bearing (2) evaluates orthosis weight bearing

29. Modify and/or adjust an orthotic device. a. demonstrates an appropriate selection of materials b. demonstrates appropriate use of equipment 30. Apply lower leg splint or cast (Jones compression, BK cast, Unna boot, posterior splint, etc.). Student applies and explains the indications for a lower leg splint or cast (Jones compression, BK cast, Unna boot, posterior splint, etc.).

Orthotics/Prosthetics Competencies uses Podiatry evaluation. Internal Medicine Competencies

1. Functioned as a member of an interdisciplinary healthcare team by contributing knowledge and skills that could be utilized by team members. 2. Completed all components of a thorough history and performed a comprehensive physical examination and developed a diagnosis and suggested a treatment plan 3. Developed a differential diagnosis and management plan for a patient with lower extremity edema. 4. Described the methods to diagnose and manage a patient with a deep venous thrombosis. 5. Described the correlation between systemic diseases and their lower extremity manifestation. 6. Diagnosed and medically managed a diabetic patient. 7. Demonstrated positive attitude towards learning Internal medicine.

Vascular Clinical Competencies

1. 2. 3. 4. 5. 6. Performed and recorded a history and physical examination of a vascular patient. Performed post-operative management of a vascular patient. Assisted surgery using proper aseptic techniques. Performed wound debridement or incision/drainage procedures. Interpreted non-invasive vascular studies (ABI, TCOM, venous duplex, etc.). Demonstrated positive attitude towards learning heart & vascular care.

Simulation Lab Competencies

1. Perform a targeted history and physical examination and interpret abnormal history and physical examination findings. Perform a targeted history and physical examination and interpret abnormal history and physical examination findings. 2. Demonstrate knowledge of the most frequent clinical, laboratory, imaging, and pathological manifestations of common illness: Interpret pertinent laboratory data, ECG, checks x-ray, & noninvasive vascular studies.
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3. Develop management plans based on history and physical examination findings that include diagnostic modalities and appropriate referrals. 4. Recognize patients with life threatening emergencies related to cardiovascular and infectious diseases and institute initial therapy. 5. Describe the pathogenesis of cardiovascular and infectious diseases. 6. Describe the pre-operative care of a critical patient. 7. Demonstrate basic CPR skills, IV, intubation and defibrillation skills. 8. Describe the potential correlation between systemic diseases and their lower extremity manifestation in patients with cardiovascular and infectious diseases. 9. Presents cases in a concise, clear and organized manner. 10. Demonstrate ethical and empathetic interactions with the patient. 11. Communicates effectively with attending, team members, and other healthcare professionals. 12. Demonstrates appropriate attitude, cooperative, receptive to feedback. 13. Demonstrated positive attitude towards learning in the team environment of the simulation lab.

PODIATRIC CLINICAL SKILLS

During each clinical rotation of the first semester specific diagnostic and therapeutic clinical skills will be reviewed. Upon completion of the third year the student will acquire the skills and knowledge for the following clinical tasks: 1. Strappings: a. Plantar rest strap b. Low dye strapping c. Ankle strapping d. J-strap 2. Padding techniques: a. Longitudinal arch pads b. Metatarsal pad c. Mortons extension pad d. Dancers pad e. Toe crest pad 3. Pharmacological properties: a. Lidocaine b. Marcaine c. Procaine d. Long-acting corticosteroids e. Short-acting corticosteroids 4. Injections: a. Digital b. Hallux c. Posterior tibial d. Mayo e. Ankle f. Neuroma g. Plantar heel spur h. Joint aspiration for synovial analysis 5. Lower extremity arterial Doppler examination 6. Radiographic projections and positioning: a. AP (foot) b. Lateral (foot) c. Medial oblique (foot) d. Lateral oblique (foot) e. Forefoot axial f. Calcaneal axial g. AP (ankle) h. Mortise (ankle)
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i. j. k. l. m.

Lateral (ankle) Medial oblique (ankle) Lateral oblique (ankle) Charger view Harris-Beath

7. Foot radiograph interpretation: a. Metatarsus adductus angle b. Metatarsus primus adductus angle c. Hallux abductus angle d. PASA e. DASA f. Alignment of the first MTPJ g. Tibial sesamoid position h. Hallux interphalangeal angle i. Metatarsal protrusion distance j. Boehlers angle k. Forefoot abductus angle l. Kites angle m. Cuboid abductions n. Calcaneal inclination o. Talar declination p. Cyma line q. Kagers triangle 8. Describe the indications for and interpret an MRI for normal as well as pathologic findings. 9. Describe the radiobiologic characteristics, indication for and interpretation of bone scans. 10. Describe the indication for and interpretation of a CT scan. 11. Post-op dressing technique: a. b. c. d. Hallux valgus correction Hammertoe repair Tailors bunion correction Neuroma surgery

12. Instrumentation: a. Partial nail avulsion with and without matricectomy b. Total nail avulsion with and without matricectomy c. Surgical and topical treatment of a plantar wart 13. Neutral position casting. 14. Biomechanical measurements: a. b. c. d. e. f. Subtalar joint motion Neutral subtalar joint position Forefoot to rearfoot Ankle joint ROM First ray ROM Malleolar position

15. Normal and abnormal gait patterns and lower extremity joint motions occurring during gait. 16. Write a prescription for an oral antibiotic, anti-inflammatory, analgesic and topical corticosteroid. 17. Casting techniques: a. b. c. d. Jones compression BK cast Unna boot Posterior splint

DPM 2012 Third-Year Clinic Manual

CLINIC REQUIREMENTS
Hours
Morning clinic appointments may begin as early as 8:00 a.m. but most begin at 9:00 a.m. The last morning appointment may be scheduled as late as 11:30 a.m. Afternoon clinic begins at 1:00 p.m. and appointments may be scheduled as late as 5:00 p.m. Students should be in the clinic 15 minutes prior to the start of the clinic session. Students are required to remain in clinic (including external rotations) until the last patient is seen unless otherwise instructed by the attending clinician.

Attendance
1. Attendance at all assigned clinic sessions is mandatory. Students may not attend and receive credit in any other clinic except for which they are assigned. 2. If a student should miss a clinic session it will be determined by the Associate Dean for Clinical Affairs as to whether its considered excused or unexcused, not by the attending clinician. 3. Students who miss a clinic session will be expected to make it up per the following: a. Excused absence: illness; medical procedure; unforeseen family emergency; other university assignment; or circumstances beyond students control. Students will need to make up one clinic session for each excused absence. b. Unexcused absence: any absence other than the above reasons. If a student is dismissed from clinic for inappropriate behavior it will count as an unexcused absence. Students will need to make up FIVE clinic sessions for each unexcused absence from clinic. Students may appeal unexcused absences to the Associate Dean for Clinical Affairs. Three unexcused absences will result in the student being reported to the Vice President of Student Services for unprofessional behavior. It is at the discretion of the Vice President of Student Services to agree with the Associate Deans decision of unprofessional behavior or continue further with an investigation that may ultimately be referred to the College's Student Promotion and Evaluation Committee (SPEC) for review and recommendation. The recommendation of SPEC will be submitted to the CPMS Office of the Dean for final consideration. 4. Make-up sessions must be completed on days a clinician does not have other students with them during clinic. These are usually during winter break and/or at the end of the third year. Volunteering at a University-Wide Health Clinic seminar/function, volunteering at La Clinica or attending hospital rounds with a Foot & Ankle clinician would all be considered for make-up time. All make-up days MUST be pre-approved by the Office for Clinical Affairs. Make-up sessions may NOT be banked in advance except in cases of known extenuating circumstances and must be pre-approved by the OCA. 5. If a student has a medical procedure and is impaired due to pain or taking medication and is unable to participate in providing patient care, they will be excused from clinic until they are able to resume their clinical duties and their absence will be counted as a missed clinic session. 6. Absence from Clinic and Make-up Clinic forms are available in the Office for Clinical Affairs or on the OCA portal page. 7. A passing grade will not be given for the rotation until all missed clinic make-up time is completed.

Supervision
1. The attending clinician is responsible for all medical care provided to patients and for all medical care given by students. 2. Students are responsible for following the directions of the assigned clinician for the medical care of a patient. Students who perform any patient care without the authorization of the clinician does so without the protection of the University liability insurance and will be subject to University disciplinary action. 3. Students are responsible for following the directions of the practice manager (Diane Marshall) and/or the CMAs in following protocols and in helping medical staff give maximum comfort and care to patients.

Student Conduct
1. Students are not allowed to use clinic phones without permission, and are not permitted to make long distance calls on clinic phones. Absolutely no cell phones allowed. 2. If a student does not have patient observation or care duties, they should be in student workroom.

DPM 2012 Third-Year Clinic Manual

3. Loud talking, jostling or uproarious behavior is considered inappropriate behavior in the clinic. An atmosphere of dignity, respect and discipline should prevail in the clinic. 4. It is inappropriate for children of students to be in the clinic unless as a scheduled patient. 5. Students who are not dressed to see patients in the clinic or who do not have clinic assignments will not be allowed in the clinical areas and will be asked to leave. 6. If a student has an unresolved conflict with a clinician or staff member, he/she should make an appointment with the Associate Dean for Clinical Affairs to resolve the issue. 7. A break in confidentiality regarding patient care will be treated with appropriate disciplinary action. 8. Students are expected to help clinic staff with tasks such as cleaning rooms, stocking supplies and packaging instruments. 9. Laptops are to be used only for logging patient encounters or Electronic Medical Records (EMR) while in student workrooms. If a student is found to be using a laptop for any other reason, they will be dismissed from clinic and their absence will be considered unexcused.

Cleanliness/Precautions Protocol
1. Students are expected to be clean and neat in their appearance in clinic. Men must wear shirts and ties and women a skirt or dress pants and blouse. Avoid wearing clothing which may call undue attention to the physical body and could distract the patient or members of the medical team from the care being delivered. As a safety precaution, all students must wear closed-toe shoes and hosiery/socks. Hair should be clean, combed and neat. Long hair should be pulled back from the face and/or eyes. Beards and mustaches should be well groomed. Nails should be clean and well trimmed. Hand and wrist jewelry can interfere with treatment being given, therefore, should be kept to a minimum. No facial or tongue piercings. No visible tattoos. Because the student is representing the clinician, the clinician reserves the right to restrict the apparel or jewelry the student is wearing. All students must wear clean and pressed white clinical jackets. Students who are not appropriately dressed or groomed will be asked to leave clinic to correct the situation. 2. All clinic rooms must be clean before bringing patients into them for evaluation and treatment. The exam chair should be clean and the floor devoid of any debris. The top of the cabinet should be clean and well organized. CMAs are directly responsible for cleanliness, but students are expected to make sure the room is appropriately cleaned and ready for the next patient. 3. Clinic doors should be closed for confidentiality. The flags on the wall outside each clinic room should be used per the following guidelines: RED = Patient is in room BLUE = Patient is at X-ray BLACK = Room needs to be cleaned WHITE = CMA is in room GREEN = Student is in room YELLOW = Doctor is in room

4. Students should always wash their hands and don gloves before touching patients. The foot should not be touched without wearing gloves. 5. Gloves are to be removed using proper glove-removal technique before leaving the examination room. Gloves are to be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured or when they no longer provide a barrier. Gloves are not to be reused. New gloves must be donned each time a different patient is seen. 6. Face masks are to be worn when grinding/dremeling toenails. Face masks, goggles and/or gowns are to be worn whenever splashes, sprays, splatters or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated. 7. All debris should be caught by a towel on the debris tray which is pulled out from the footrest of the chair. After performing debridement procedures, debris is folded into the towel and discarded into the regular garbage can. Any gauze or materials saturated with blood should be discarded in the RED biohazard garbage can. The tray is then cleaned with a disinfectant provided by the CMA. During debridement, instruments should NEVER be laid on the debris table. Instruments should be placed on paper drape cabinet or mayo stand tray. 8. Students are responsible for handling all sharps appropriately. All used needles and blades should be appropriately discarded in the sharps containers without recapping the needles. If a student is stuck with a needle or in any way cuts him/herself during a patient visit, he/she is to contact the practice manager and their attending clinician immediately. 9. Food and drink (i.e. snacks) are allowed only in student workrooms, however it is not to be used as a lunchroom. At NO time should any food or drink be brought into any other part of the clinic; to do so
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would violate OSHA rules that could result in significant fines to the University. All food and drink and utensils should be cleared before the students end their day. It is the students' responsibility to clean student workrooms and the orthotic adjustment room before leaving the clinic.

Infection Control/Body Substance Isolation

It is the students responsibility to make an effort to prevent the spread of nosocomial infections or those infections acquired in the hospital/clinic. Body substance isolation/prevention assumes that all body substances (oral and body secretions, blood, feces, urine, droplet or airborne spray from a cough, tissues, vomitus, wound and other drainage) are potentially infectious. The goal of body substance isolation procedures is to isolate the patients blood and moist body substances. The following basic precautions aid in preventing the spread of infections and disease: 1. Hand washing is indicated whenever the hands are soiled, after removing gloves, and before and after each new patient contact. 2. Gloves must be worn just before contact with oral and body secretions, blood, feces, urine, tissues, vomitus, wound and non-intact skin. Hands must be washed immediately after taking off the gloves and prior to leaving the patient care area. New gloves should be used when going from one event to another with the same or different patient. Gloves should be replaced during treatment if the efficacy of the gloves has been compromised (i.e., torn or damaged). 3. Gowns must be used when it is likely the students clothing could become soiled. Gowns must be removed and placed in a laundry bag prior to leaving the patient care site. Gowns should be replaced during treatment if the efficacy of the gown has been compromised (i.e., torn or damaged). 4. Masks must be used if the suspicion of or confirmation of a respiratory communicable disease (i.e., RSV, meningococcal meningitis, tuberculosis) is present. Masks are also indicated if significant exposure to droplet or airborne spray from a cough is likely or if splattering of body fluids may occur. Masks should be replaced during treatment if they become soiled with moist body fluids. Surgical masks may be used for suspected or confirmed respiratory communicable disease except tuberculosis. Special filters must be used for tuberculosis control. 5. Other protection devices such as goggles, hair covers, and shoe covers are indicated when splattering of body fluids may occur. 6. Private rooms are needed for patients with suspected or confirmed communicable diseases transmitted via the air (i.e., RSV, meningococcal meningitis and tuberculosis). Private rooms are also used for patients who soil the room with body substances in a manner that may inadvertently infect the roommate. A warning sign may be placed on the door when precautions are necessary prior to entering. 7. Exceptions: For childhood diseases in which immunity offers the best protection against student acquisitions (e.g., measles, mumps, rubella, and varicella), susceptible students will not be permitted to care for the patient.

Blood and Body Fluid Exposure Prevention

1. Always handle sharps with care. 2. Dispose of sharps in sharps disposal containers immediately after use. 3. Do not recap, bend or break needles. If you are exposed to blood or body fluids, report this immediately to the clinician or Diane Marshall. This will provide them with the opportunity to protect you and will also help track exposure events to identify opportunities for prevention

Patient Protocol
1. Students will assist the CMAs in rooming the patients; however, when possible all NEW patients will be seen first by the attending then introduced to the student. 2. Students must be supervised by the attending clinician at all times when providing any hands-on-care to the patients. 3. All patients must be seen by the attending clinician prior to discharge from the clinic.

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Patient Care
1. The first rule of patient care is to remember these patients have entrusted us with their treatment. Everything you do in the clinic should be for the betterment and comfort of the patient. 2. Never initiate patient contact without the supervising clinicians permission. Before entering a treatment room, knock first and wait for an appropriate response from the patient. Introduce yourself by your first and last name, with the designation of being a student of podiatric medicine (for example: "Hello, Mrs. Smith, I am John Doe, a second-year podiatric medical student"). Patients, in respecting your opinion, will often ask questions about their diagnosis and treatment plans. Remember not to volunteer information unless your supervising clinician has instructed you to do so. Be sure to document such information in the patients chart. 3. Address each person with respect. Never call an adult patient by his/her first name unless the patient has specifically requested you do so. If the person has a title of importance, use that title in addressing the person (i.e., Doctor, Reverend, Colonel, etc.). 4. Always use the utmost care in respecting each patient. Provide assistance to everyone, especially the aged and physically challenged. Help people into and out of the treatment chairs and ensure they are comfortable. 5. It is important that patients be protected from injury while they are in the clinic. Never leave a patient in a room alone with the treatment chair in an elevated position. Never leave a patient alone after injection of any medication or anesthetic. Never leave a patient alone with drugs, syringes or other dangerous medical equipment or material exposed. 6. If a patient is suspected of having a fracture, treat the patient as if he/she actually does have a fracture until it is proven that he/she does not. Therefore, if you are taking a patient to X-ray, the patient should be taken in a wheelchair. Likewise, if you have a patient who is not fully ambulatory (e.g., on crutches, etc.), use a wheelchair if you need to transport them to another part of the clinic. Never put yourself in a situation where a patient could even remotely accuse you of harming them. 7. Students must remember that any examination, diagnosis or treatment provided by them is done under the license of the clinician with whom they are working. At NO time may a student provide any examination, diagnosis or treatment without the clinicians instruction. 8. Never be drawn into a conversation with a patient where you could give a judgment about any clinician or medical provider. Avoid talking with patients on controversial subjects. 9. It is important students never make remarks which are critical of the clinic, its personnel, clinician or any previous treatment received by the patient. Your statements carry great weight in patients minds. 10. It is expected students will have numerous questions about patient problems. This is encouraged, as the more questions you ask the more you will learn. However, it is very distressing for patients to hear medical jargon about problems discussed in front of them while they are being examined or treated. Therefore, students should not ask questions about patient pathology until they are out of hearing distance of the patient. The proper place for this is in the student workrooms. Never disagree nor question the diagnosis or treatment with a clinician in front of a patient. 11. After completing the examination and treatment, make sure the patient is able to put on his/her socks and shoes. The student should escort the patient to the front desk with their charge ticket and for possible reappointment. After the patient is escorted out, the student should then complete the chart.

Radiology
When taking patients to the radiology department, students will assist the radiology technician in all aspects of radiographic performance: 1. Students will attend a one-hour orientation to the radiology department on the date assigned by the Office for Clinical Affairs. 2. Students will have the radiology technician check off on the student evaluation each competency performed during the visit to the radiology department.

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Instruments
All instruments used in the clinic must be autoclaved. Students are required to use their own instruments first and then they may use the clinics instruments. All clinic instruments are locked in the cabinet in Room 730 to prevent instrument loss. Do not use or borrow other students instruments. Put dirty instruments (any instrument that has been used on a patient) in the plastic container in the sink in Room 730. All blades are to be removed prior to putting instruments in the container. Instruments will be cleaned and sterilized by clinic staff at the end of each clinic session. Clean instruments will be next to the autoclave in Room 735. Please carefully check the engraving and claim only your instruments.

Medical Supplies
1. Students found removing drugs/syringes or medical supplies from the clinic and/or found to be using these materials or are accomplices in providing these materials to another person or unauthorized users of these materials, will be immediately reported to the proper law enforcement authorities and University disciplinary committee. The falsification of any prescription form is considered a felony and will be reported to law enforcement authorities and the University disciplinary committee. 2. Duplicate prescription order blanks are kept by the practice manager. The original top copy is completed with the date, patient's name, address and age. The prescription contains the name of the medication, the quantity to be dispensed and the instructions. The box for the number of refills must be filled in even if the number is zero. All numbers in the prescription should be made so as to be unalterable without recognition. This may be done by putting parentheses around the numbers or by writing them out or by using Roman numerals. The number zero should have a slash through it. The clinician prescribing the medication must sign it and write his/her DEA number below the signature. A duplicate copy of all prescriptions written must be filed in the patient chart. 3. Students should check the supply drawers in the treatment rooms before seeing patients to determine if anything is missing (see Supply Locations in forms section). 4. Students are required to have their own basic podiatric examination and treatment instruments with their initials engraved. Students should not borrow each other's instruments. 5. Students needing any medical supplies must request them from a CMA and/or practice manager.

Electronic Medical Records (EMR)

1. Des Moines University Clinics have transitioned to an electronic medical record system (EMR). Students will receive training and be issued a log-in for the EMR system. Medical records are confidential legal documents and must be treated in such a manner. Students are not permitted to copy a patient's chart, however may request permission to use de-identified records for case presentations. Breaking of confidentiality is considered a breach of ethical conduct and may be referred to the appropriate disciplinary councils of the institution. In addition to utilizing EMR, students will write a chart note on each patient. 2. Students must finish writing patient notes on the day the patient is seen before they leave the clinic and give to the clinician. 3. Never leave medical records lying where confidentiality may be compromised. Do not leave an open/active EMR or medical records in the patient room. 4. Students are required to follow instructions of the CMA and/or radiology staff in the proper handling of Xrays. X-rays are part of the medical record and the same precautions must be taken in protecting patient confidentiality. 5. Guidelines for writing medical records: a. All pages in the record must contain the patient's name and chart I.D. number. b. All entries are made in black ink and must be legible and neat. All abbreviations must be standard medical abbreviations. Any mistakes must be crossed out with just one line through the mistake and initialed. White-out and erasures by the note writer are not permitted. c. There should be no blank lines between the beginning and the end of the entry. d. All entries should indicate the date and time. e. Patient refusal of a treatment or procedure should be well documented. A separate consent form must be completed, signed and witnessed for all surgical procedures. f. All notes must be co-signed by the person making the entry as well as the attending clinician. 6. History and podiatric physical examinations should follow the format of the enclosed sample form.
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7. All progress notes should be in a SOAP format. The general format for progress notes is as follows: Patient Name Date Time

S Subjective Data Data obtained by interviewing the patient and/or parents, other relatives or guardians. It is important to detail in the subjective portion of the record whether the patient was the informant and what information was given by other people present. Subjective information includes the chief complaint and history of the present illness. If you quote the patient directly in the chart, put that portion inside quotation marks. O Objective Data All findings you make by examining the patient. You should record all positive as well as negative findings. Use a logical progression. Make sure there is a good description of the painful area. Also include vital signs, a description of the dermatological, vascular, neurological, orthopedic, and biomechanical, gait, shoe exam, and any other body parts examined. Laboratory and X-ray findings should also be in the objective data. A Assessment This is where you can discuss what the possible diagnoses are and why you believe a certain diagnosis should be included in the differential. The way to determine if your progress note is sufficient is whether a person who has never seen the patient can read it and come to the same conclusions you have. P Treatment Plan List steps you are taking to treat the problem; what instructions, prescriptions or medications you gave the patient. Record when the patient will be seen again. Record what you plan to do the next time you see the patient; if the treatment plan worked; and what you plan to do if the treatment plan did not work. Finally, record the attitude and the reaction of the patient. Was he/she cooperative and agreeable or was he/she unhappy? What requests did he/she make and how did you respond to those requests? 8. The student, CMA, and attending clinician who saw the patient must sign the chart. Student signatures should be clearly legible, and if not, the student should print his/her name below the signature. After signing ones name, the student should place a comma, the initials, P.M.S. (Podiatric Medical Student) and the Roman numeral of current matriculation year (for example: John Doe, P.M.S. II). 9. Prescriptions in EMR: Most prescriptions are generated in EMR and faxed to the pharmacy or printed in clinic. In order to enhance the students learning experience practice prescription forms are available. 10. Duplicate prescription order blanks are kept by the practice manager and/or the CMAs. The original top copy is completed with the date, patient's name, address and age. The prescription contains the name of the medication, the quantity to be dispensed and the instructions. The box for the number of refills must be filled in even if the number is zero. All numbers in the prescription should be made so as to be unalterable without recognition. This may be done by putting parentheses around the numbers or by writing them out or by using Roman numerals. The number zero should have a slash through it. The clinician prescribing the medication must sign it and write his/her DEA number below the signature. A duplicate copy of all prescriptions written must be filed in the patient chart.

STUDENT EVALUATION AND GRADES

1. Each clinical rotation will be graded on a pass/fail system. An (I) incomplete grade will be given when all requirements have not been met. A passing grade will be given after completion of the following: a. Students will receive an evaluation form from their clinician at the beginning of each rotation. Students are to carry the evaluation form with them at all times while in the clinic. The evaluation is designed so the attending clinician can evaluate the students performance at the time the skill is performed. Once the clinician observes and evaluates the student during real time, he/she will mark whether or not the student has successfully performed the competency and place his/her initials in the space provided on the evaluation. During the course of the third year, students must successfully complete ALL clinical competencies (podiatric medicine; podiatric radiology; podiatric

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surgery; and podiatric orthopaedics/biomechanics). It is the responsibility of the student to complete each competency and have the clinician sign off on. b. Students are to submit their patient logs via the Patient Encounter System (PxDx) in the E*Value system within one week following each rotation. If patient logs are not submitted within this time frame, the student will receive a letter from the Associate Dean for Clinical Affairs requiring logs to be submitted one week following receipt of the letter. Continued failure to submit will result in immediate suspension until logs and evaluations are submitted. Missed clinic days during the suspension will be considered an unexcused absence and will require three make up sessions for each session missed. c. The attending clinician will subjectively evaluate the student on the Professionalism Objectives stated in the student evaluation, and an average grade of 2.0 or greater is required for successful completion. A student with an average grade below 2.0 will be interviewed by the Associate Dean for Clinical Affairs to determine why the grade was given. After consulting with the student and the clinician who gave the failing grade, the Associate Dean will render a decision if additional time in clinic is necessary. Students are encouraged to review their evaluation with the attending clinician at the end of their rotation before its submission.

d. Students are required to complete an evaluation of the physician at the end of each rotation and submit it to the Office of the Dean. Although evaluations will be kept anonymous, it is mandatory to complete one on each clinician for each rotation. It is requested that you be completely honest in your evaluation because physicians never see these evaluations, but rather they receive a composite spreadsheet of their evaluations twice a year; one midway through the academic year and one after the academic year is complete.

PATIENT ENCOUNTER SYSTEM (PxDx)

Overview: The Patient Encounter System (PxDx) is a versatile electronic solution allowing The College of Podiatric Medicine & Surgery to collect and analyze patient encounter information. To provide a superior learning environment, PxDx has powerful reporting and quota features that ensure students are seeing the right numbers and types of encounters, and benchmarks the quality of education provided to other facilities. Students are similarly able to track their progress and have a permanent record of patient encounters detailing their diagnoses and applied clinical skills. Each student will have their own log-in and password to use. A direct link to the site: https://www.evalue.net/index.cfm will take you to the home page to enter log-in and password, you will not need to enter anything in the institutional code box for access, only log-in and password are needed. If at any time you forget your log-in and/or password, you can click on link for E*Value for them to re-send your information or contact the DMU Helpdesk at any time Logging Procedures and Diagnoses (PxDx) After logging onto the E*Value site, begin by looking at the menu on your left, going to Users, then PxDx, then to Add New. You will see four tabs across the top; Main, Diagnoses, Procedures, and Review. For each patient encounter you enter, you will need to complete the required sections of the first tab, clicking next when finished to move to the next tab. You will then move to the Diagnoses tab, then onto the Procedures tab. When the fields were setup they could be defined as required for Procedures Only, Diagnoses Only or Both. Those definitions are color coded on this screen. If you have created and saved an interaction log template you can select to load the template and then modify as needed. Templates are created on the Review tab. Enter in the first letter, a keyword or a code to narrow down the procedure/diagnoses list. Please note that you can only search by code if the relevant codes have been entered by your administrator (if you need a procedure and/or diagnoses added, please contact your Clerkship Coordinator in the OCA office via email describing/exact spelling for entry). Select the diagnosis/procedure. You can multiple select using the Shift, Ctrl or APPLE key. Select the trainees role in this diagnosis/procedure and click Add. Once a diagnosis/procedure has been added it will appear in the table below. There is no limit to the number of diagnoses/procedures that can be added. Once a diagnosis/procedure has been logged it can be removed or moved up/down in the list and edited anytime.
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If there is nothing else to log you can click Save Record at this point. Otherwise, click Next to the proceeding tab. If the program is using both procedure and diagnosis tracking you will have one of two tabs that will enable me to link procedures and diagnoses together. In this example you can link procedures to the diagnosis. 1. Select the diagnosis to which you would like to link procedures 2. Select the procedure(s) that should be linked to this diagnosis. 3. Click Save Relationship. The relationship will save at the bottom of the tab. 4. Once a relationship has been created it can be removed. 5. Alternatively, your program may be using the Relationship by Procedure method. In this begin by selecting the procedure and then select the diagnoses that should be linked to it. The structure of the tab is identical to this one. At any point during the logging process you can click on the Review tab to see what would be recorded if you were to hit Save Record. You have the option to Print This Page for your records. You can save this record as a template to be used again. Logging PxDx on a PDA If your program has chosen to use the PxDx function in E*Value, you will be able to record your interactions on your PDA using a set of software tools called EVPxDx. These applications also serve to communicate between Palm or Pocket PC devices and E*Value. Procedures and diagnoses recorded into the EVPxDx applications on the PDA devices are sent to E*Value over the Internet during synchronization. These items are treated the same way as if they had been entered into E*Value using the traditional interface. In addition, the synchronization will also allow you to automatically download updated lists of Activities, Procedures, Diagnoses, and Supervisors pertinent to your program. User Manual You can download the EV PxDx user manual in PDF format to assist you in the installation and use of this utility. Requirements for Palm OS Devices In order to use EV PxDx on a Palm OS Device you must have access to the following: A handheld device running a Palm OS version 3.0.1 or higher, and about 300 KB of free memory. A PC running Windows 95 or higher and capable of connecting to the Internet. This PC should have 7 MB of free disk space. This PC must also have the proper Palm HotSync software installed for each Palm user who will use this PC to HotSync. Requirements for Pocket PC Devices In order to use EVPxDx on a Pocket PC Device you must have access to the following: A device running Pocket PC or Pocket PC 2002 and about 1 MB of free memory. ActiveSynce 3.5 or higher installed on your PC. A PC running Windows 95 or higher and capable of connecting to the Internet. This PC should have 5 MB of free disk space. iPod Touch Charging: Charge your device every night! Sync your device with iTunes weekly this is your backup! Should the battery become completely exhausted, all data since the last backup and all logs not synchronized will be lost! E*Value: Enter your patient logs daily either on E*Values web site or the iPod touch. Sync the iPod touch data with E*Value daily, this is a preventative measure to ensure your data is safe.

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Problems: Any student who has technical difficulties while submitting logs, synchronizing the iPod touch or connecting to the Internet may call the Help Desk (515-271-1522) for assistance Monday Friday: 7:30am to 8:00pm, Saturday: 9:00am - 8:00pm and Sunday: 12:00pm - 8:00pm (CST). Or email Help.Desk@dmu.edu

CAMPUS OFFICE NUMBERS

The Office for Clinical Affairs expects students to read and follow policies of this manual before contacting the University to discuss topics covered. If the student has not yet read the appropriate sections, they should anticipate being directed to these guidelines for answers to their questions by campus offices.

CPMS CLINICAL AFFAIRS

Dr. Smith ........................................................................................................................ 515.271.1489 Toll-free...................................................................................................... 800.240.2767, ext. 1489 FAX .......................................................................................................................... 515.271.7131 Email ........................................................................................................... Kevin.Smith@dmu.edu Email ..................................................................................................... JoAnn.Williams@dmu.edu

CPMS DEAN
Kelly Gross ..................................................................................................................... 515.271.1464 FAX ............................................................................................................................. 515.271.7017 Email ............................................................................................................. Kelly.Gross@dmu.edu

REGISTRAR
Melinda Sherzer ............................................................................................................. 515.271.1460 FAX ............................................................................................................................. 515.271.7025 Email ..................................................................................................... Melinda.Sherzer@dmu.edu

STUDENT AFFAIRS .......................................................................................... 515.271.1684 FINANCIAL AID OFFICE ................................................................................... 515.271.1470 MATTHEWS BOOKSTORE ............................................................................... 515.271.7823 STUDENT ACCOUNTS ...................................................................................... 515.271.1473 MAIN SWITCHBOARD ...................................................................................... 515.271.1400

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EMR PATIENT FLOW-CHART IN CLINIC OPERATION

Staff and student notified through EMR

Receptionist registers patient

EMR chart reviewed and assigned to student

Patient placed in exam room by CMA and/or student

CMA & student review chief complaint, allergies, meds & history

Student reviews case and presents to attending physician

Attending physician and student interview and examine patient

X-ray, lab ordered and performed

Attending physician and student instruct the patient

Procedure and/or further testing ordered and/or performed by attending physician and student Receptionist discharges patient

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