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Neurology Resident Case Log Ground Rules

General Information:
  1. The resident is responsible for logging in his/her own patient data.
  2. A log-in code and password is assigned to each resident by the program director.
  3. The program director is able to review each resident's data file, but will be unable to alter or change information entered.
  4. Depending upon computer/internet access, it is recommended that residents keep a written record of patients evaluated until the information can be entered by the resident. (2/2002 - currently could keep information of personal device).

Data Collection:
  1. Residents should enter the date of the evaluation, institution, name of attending physician, clinical setting, patient year of birth, and diagnosis(es).
  2. Diagnosis should include primary and secondary neurological diagnoses carried by each patient (e.g., complex partial seizures and migraine headaches) with a limit of no more than three per patient.
  3. The diagnosis(es) may either be entered using the tab for the categories of disease provided or typed in directly by the resident.

Clinical Setting: A resident should enter any patient for whom he/she has assumed a significant management responsibility; a rule of thumb is that the interaction should have been important enough to warrant a written note in the chart.
1. Inpatient: Consult service
Primary service
ANY SINGLE PATIENT IS TO BE ENTERED ONLY ONCE/RESIDENT INTENSIVE CARE PATIENTS ARE LISTED SEPARATELY
2. Outpatient: Clinic: New Patient
Follow up if new to resident or if seen in continuity clinic where each visit should be documented
ANY SINGLE PATIENT IS TO BE ENTERED ONLY ONCE/RESIDENT EXCEPT FOR CONTINUITY CLINIC PATIENTS WHO ARE TO BE ENTERED EACH TIME THEY ARE SEEN CONTINUITY CLINIC PATIENTS ARE LISTED SEPARATELY ER CONSULTS ARE LISTED SEPARATELY
Consult: Emergency
Non-neurology outpatient clinics
  1. If admitted from an outpatient setting, the patient can be counted as an outpatient and an inpatient if two different residents evaluate that patient (e.g., One resident evaluates the patient in the emergency room and another resident admits and/or manages the patient on the inpatient service).
  2. If admitted from an outpatient setting, the patient can be counted only as an inpatient if the same resident evaluated the patient as an outpatient and also manages or consults on that patient on an inpatient service.
  3. Only residents who are directly involved in the examination and management of a patient may count that patient in their log. Work/attending rounds do not count as patient encounters with the exception for those residents who have examined the patient and are directly involved in the management (e.g., admitting resident and upper-level resident).
  4. Patients who are evaluated by residents during cross-coverage periods (call and days off) should be counted by the cross-covering resident if their cross coverage necessitates significant and active management responsibility (e.g. if called to assess and treat a worsening neurologic deficit after admission for stroke, the cross-covering resident should enter the patient in his/her log). Passive responsibility for patients does not qualify.