"ACGME Case Log System - DOC"
ACGME Case Log System The resident case log system was created by the Accreditation Council for Graduate Medical Education (ACGME) and its use by all pediatric training programs is mandated by the Pediatric Residency Review Committee (RRC), a branch of the ACGME. All procedures (LP, venipuncture, etc.) must be documented. The Pediatric RRC also mandates documentation of all continuity clinic visits, and our program uses the same case log system used for procedures for this purpose. It is essential that each resident keep his/her log current. Username and Password Each resident has a unique user ID. Your user ID is the same as your TCH username. It consists of your first initial, middle initial (x if no middle initial), and the first 6 letters of your last name. The initial password is bcmpeds. You will be prompted to create a unique password. Procedures to Record You may record any procedures you wish, but at a minimum, please document your performance of any of the following procedures (find CPT codes in table below): 1. endotracheal intubation 2. placement of intraosseous lines 3. placement of intravenous lines 4. arterial puncture 5. venipuncture 6. umbilical artery and vein catheterization 7. lumbar puncture 8. bladder catheterization 9. gynecologic evaluation of prepubertal and postpubertal females 10. wound care and suturing of lacerations 11. subcutaneous, intradermal, and intramuscular injections 12. developmental screening test 13. procedural sedation 14. reduction and splinting of dislocations/fractures 15. circumcision 16. tympanometry and audiometry interpretation 17. vision screening 18. hearing screening 19. simple removal of foreign bodies (e.g., from ears or nose) 20. inhalation medications 21. incision and drainage of superficial abscesses 22. chest tube placement 23. thoracentesis Continuity Clinic Visits You must record every continuity clinic visit using a unique patient identifier and provide a diagnosis. Page 1 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Step-By-Step Instructions for Using the ACGME Case/Procedure Log Step 1 Navigate to the following URL: https://www.acgme.org/residentdatacollection/ You should see the following screen: Step 2 Enter your User ID and Password (see above for specific instructions). Page 2 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Step 3 Click on the tab labeled Case Entry Step 4 You should now see a screen like that pictured below. Page 3 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Step 5 Complete the data fields. The table below has instructions for doing so. Data Field Instructions *Resident This field should automatically populate with your name Supervisor Optional Location Optional *Resident Year This field should automatically populate with your level of training Competence Lvl Optional *Rotation Optional for procedures; must be set to “Continuity” for continuity clinic patients Patient Age Optional, but desirable Gender Optional, but desirable *Panel Check for any continuity clinic visits *Date Defaults to current date; make sure to set to date procedure actually performed or continuity patient seen *Case Id For Ben Taub and TCH, use medical record number; for patients seen in a community physican’s office use patient intitials and date of birth (e.g John Jones with date of birth 3/14/06 would be “jj031406”) *Code See detailed instructions below Comments Optional Selected Codes Will automatically populate once a code is selected Full Code Desc Will automatically populate once a code is selected Area Will automatically populate once a code is selected Type Will automatically populate once a code is selected *Required fields are indicated by bold italicized font Selection of Codes There are two types of codes: procedure codes (aka CPT codes) and diagnosis codes (aka ICD-9 codes). When documenting procedures (e.g. lumbar puncture) it is necessary to select the correct CPT code. When documenting continuity clinic visits, you should select a diagnosis (ICD-9) code. If you perform a procedure (e.g. venipuncture) on a continuity clinic patient, please document both a CPT code and an ICD-2 code. Page 4 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM If you already know the specific ICD-9 or CPT code number, you may enter it directly in the code field. If you do not already know the specific code number you must search the database by clicking on the search button. That should open a window with the following appearance: In the CPT/ICD9 Desc field enter the procedure or diagnosis name you are looking for, and a list of possibilities will appear. For example, if you are looking for the code for venipuncture, enter that term in the CPT/ICD9 Desc field and the following screen will appear: Page 5 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Select the code of choice from the list and it will populate the code field on the previous screen. Commonly Used Codes Following are tables containing the more commonly used CPT (procedure) and ICD-9 (diagnosis) codes: Procedure Code Arterial puncture 36600 Bladder catheterization 51701 Chest tube placement 32002 Circumcision 54160 Developmental screening 96110 Endotracheal intubation 31500 Foreign body removal, ear 69200 Foreign body removal, nasal 30300 Foreign body removal, subcutaneous 10120 Gynecologic exam, prepubertal V72.31 Hearing screening (pure tone audiometry) 92553 Incision and drainage of superficial abscess 10060 Inhalation medication administration 94640 Intramuscular injection of antibiotic 90788 Intraosseous line 36680 Intravenous line placement 36000 Lumbar puncture 62270 Procedural sedation, age < 5 years of age 99143 Procedural sedation, age > 5 years of age 99149 Splint, finger 29130 Splint, long arm (shoulder to hand) 29105 Splint, long leg (thigh to ankle or toes) 29505 Splint, short arm (forearm to hand) 29125 Splint, short leg (calf to foot) 29515 Suturing, layer closure of wounds of face, ears, eyelids, nose, lips 12051 and/or mucous membranes < 2.5cm Suturing, layer closure of wounds of face, ears, eyelids, nose, lips 12052 and/or mucous membranes > 2.5cm Suturing, layer closure of wounds of neck, hands, feet and/or 12041 external genitalia < 2.5cm Suturing, layer closure of wounds of neck, hands, feet and/or 12052 external genitalia > 2.5cm Suturing, layer closure of wounds of scalp, axillae, trunk and/or 12031 extremities (excluding hands and feet) < 2.5cm Suturing, layer closure of wounds of scalp, axillae, trunk and/or 12032 extremities (excluding hands and feet) > 2.5cm Suturing, simple face, ears, eyelids, nose, lips and/or mucous 12011 membranes < 2.5cm Suturing, simple face, ears, eyelids, nose, lips and/or mucous 12013 membranes > 2.5cm Suturing, simple repair of superficial wounds of scalp, neck, 12001 axillae, external genitalia, trunk and/or extremities (including Page 6 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Procedure Code hands and feet) < 2.5cm Suturing, simple repair of superficial wounds of scalp, neck, 12002 axillae, external genitalia, trunk and/or extremities (including hands and feet) > 2.5cm Thoracentesis 32000 Tympanometry 92567 Umbilical artery catheterization 36600 Umbilical vein catheterization 36510 Vaccine administration (percutaneous, intradermal, 90465 subcutaneous, or intramuscular) < 8 years of age Vaccine administration (percutaneous, intradermal, 90471 subcutaneous, or intramuscular) > 8 years of age Venipuncture 36415 Vision screening 99173 Diagnosis Code Abnormal Loss of Weight 783 Abnormal Weight Gain 783.1 ACNE, NOC 706.1 Adenitis, Acute 683 Allergic Rhinitis, Cause Unspecified 477.9 Allergy, Adverse Effect of Drug 995.2 Allergy, Unspecified 995.3 Alopecia 704.00 Anal Fissure 565.0 Anemia, Iron Deficiency 280.9 Anemia, NOS 285.9 Appendicitis 541 Arrhythmia 427.9 Arthritis, Site Unspecified 716.90 Asthma, w/Status Asthmaticus 493.91 Asthma, w/o Status Asthmaticus 493.90 Attention Disorder with Hyperactivity 314.01 Attention Disorder w/o Hyperactivity 314.00 Bacteremia, NOS 041.9 Bronchiolitis, Acute 466.19 Bronchitis 490 Camp/Sports Exam V70.3 Candidiasis of Mouth 112.0 Candidiasis of Skin, Nails 112.3 Cerebral Palsy, Unspecified 343.9 Chest Pain 786.50 Coagulation Defect 286.9 Colitis, Ulcerative 556.9 Concussion, Unspecified 850.9 Condyloma Acuminatum 078.11 Conjunctival Hemorrhage 372.72 Conjunctivitis 372.30 Page 7 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Constipation 564.0 Coordination Disorder 315.4 Corneal Abrasion 918.1 Costochondritis 733.6 Cough 786.2 Curvature of Spine 737.8 Cyanosis 782.5 Cystitis, Acute 595.0 Cystitis, Chronic; Other 595.2 Dacryostenosis 375.56 Dehydration 276.5 Dermatitis, Atopic; Other 691.8 Dermatitis, Contact; Unspecified 692.9 Development Delay; Physiology 783.4 Developmental Disorder, Unspecified 315.9 Developmental Disorder, Other Specified 315.8 Developmental Disorder, Mixed 315.5 Developmental Language Disorder 315.31 Diabetes, Insulin Dependent; Controlled 250.01 Diabetes, Insulin Dependent; Uncontrolled 250.03 Diabetes, Non-insulin Dependent; Controlled 250.00 Diabetes, Non-insulin Dependent; Uncontrolled 250.02 Diaper Rash 691.0 Diarrhea 787.91 Dysuria 788.1 Eczema 692.9 Encopresis 307.7 Epistaxis 784.7 Erythema, NOS 695.9 Esophageal Reflux 530.81 Esophagitis, Unspecified 530.10 Esophagitis, Other 530.19 Failure to Thrive 783.4 Febrile Seizures 780.31 Feeding Difficulty 783.3 Fever 780.6 Folliculitis 704.8 Follow Up Exam Following Treatment V67.59 Follow Up, Illness V67.9 Foreign Body Granuloma of Skin 709.4 Foreign Body – Ingested 938 Fracture Follow-Up Care V67.4 Fungal Infection, NOS 117.9 Gastroenteritis 558.9 Growth Failure 783.4 Hay Fever, Cause Unspecified 477.9 Headache, NOS 784.0 Heart Disease, Congenital; Unspecified 746.9 Heart Murmur, Undiagnosed 785.2 Heat Rash 705.1 Hemangioma 228.00 Page 8 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Hematoma, Specify Site ____________________________ * Hematuria 599.7 Hepatitis, Viral NOS 070.9 Hepatomegaly 789.1 Herpangina 074.0 Herpes Simplex w/o Complication 054.9 Hives 708.9 Immunization Delay V15.89 Impacted Cerumen 380.4 Impetigo 684 Incontinence, Unspecified 788.30 Influenza 487.1 Ingrown Nail 703.0 Inguinal Hernia, Bilateral NOS 550.92 Inguinal Hernia, Unilateral NOS 550.90 Insect Bite-Site: __________________________________ * Irritable Bowel Syndrome 564.1 Jaundice 782.4 Joint Pain, Specify Site: ______________________________ *719.4 Loss of Appetite 783.0 Lymphadenopathy 785.6 Malaise/Fatigue 780.79 Melena 578.1 Meningismus 781.6 Meningitis, Viral; Unspecified 047.9 Migraine, Common w/o Intractable Migraine 346.10 Molluscum Contagiosum 078.0 Mongolian Spot 757.33 Mononucleosis 075 Mumps, Parotitis 072.9 Muscle Spasm 728.85 Myalgia 729.1 Neutropenia 288.0 Nevus NOS 216.9 Nocturnal Enuresis 788.36 Obesity; Unspecified 278.00 Otitis, Serious, Acute 381.01 Otitis Externa 380.10 Otitis Media, Unspecified 382.9 Pain, Back 724.5 Pain, Generalized 780.9 Pain, Abdominal 789.00 Pelvic Exam V72.3 Pharyngitis, Acute 462 Physical Assault/Abuse, Alleged 995.54 Pinworms 127.4 Pityriasis Rosea 696.3 Pneumonia 486 Pneumonia, Broncho 485 Pneumonia, Viral 480.9 Post Varicella Encephalitis 052.0 Page 9 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Premature Birth 765.10 Preoperative Exam, Other V72.83 Pruritis, NOS 698.9 Rash 782.1 Reflux Esophagitis 530.11 Respiratory Distress 518.82 Rhinitis, Acute 460 Rhinitis, Allergic, Cause Unspecified 477.9 Roseola/Rubella 057.8 Scabies 133.0 School/Pre-School Exam V70.5 Seborrheic Dermatitis 690 Seizure Disorder 780.39 Sexual Assault/Abuse, Alleged V71.5 Short Stature 783.4 Sickle Cell Anemia 282.60 Sickle Cell Trait 282.5 Sinusitis, Acute 461.9 Sinusitis, Chronic 473.9 Skin Infection, NOS 686.9 Spina Bifida, NOS 741.90 Splenomegaly 789.2 Stomatitis, Acute 528.0 Strain/Sprain-List Site: ___________________________ * Strep Throat 034.0 Stye 373.11 Sunburn 692.71 Suture Removal V58.3 Swimmer’s Ear 380.12 Syncope 780.2 Synovitis 727.00 Syphilis, Congenital; Unspecified 090.9 Tachypnea/Shortness of Breath 786.06 Tachycardia 7850 Tall Stature 783.9 Teething 520.7 Telangiectasia NOS 448.9 Thrush, Oral 112.0 Tinea of ________________________________ *110.__ Tonsilitis, Acute 463 Tonsilitis, Chronic 474.0 Tracheoesophageal Fistula 530.84 Tuberculosis Skin Test: Positive 795.7 Undescended Testicle 752.5 URI (NOS) (Acute) (Viral) 465.9 Urinary Tract Infection 599.0 Urticaria 708.9 Vaccinations, Specify: * Varicella w/o Complication 052.9 Varicella (Hemorrhagic Pneumonitis) 052.1 Venereal Warts 078.19 Page 10 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM Viral Exanthem 057.9 Viral Infection NOS 079.99 Viral Warts, Unspecified 078.10 Vomiting/Nausea 787.0 Well Child Care; Routine V20.2 Wheezing 786.07 Page 11 of 11 83f013b0-c52d-4632-b901-dbe7a2704cc9.doc Last Saved 2/9/2012 12:17 AM