Documentation and Presentations Ashley Trane MD UNM Primary

Documentation and Presentations Ashley Trane, MD (UNM Primary Care Chief)

Documentation History and Physical/Transfer Notes LEVEL 1 LEVEL 2 LEVEL 3 CC Always HPI 4+ 4+ 4+ ROS 2 to 9 10+ Surgical Hx, FHx, SHX 1 to 2 3 3 7/8+ 8+ 8+ History Exam Progress Notes LEVEL 1 LEVEL 2 LEVEL 3 ID Always Subjective/ROS None 1 2 -9 Exam 1 Up to 7

Documentation: Assessment and Plan • Diagnosis: Document every disease, abnormality in vital signs, labs, imaging, cultures, or symptoms • Acuity: Present on admission, chronic, acute on chronic, exacerbation • Status: Worsening, improving, stable, resolved • Cause: E. g. , probable/confirmed infectious organism • “Suspected, likely, probable” are ok to use for uncertain diagnoses • Qualifiers: Laterality; Scoring (e. g. , MELD, A 1 c of 12, AKI Stage II) • Document Your Time: Reviewed outside records, talked to family/consults, reviewed imaging yourself

Documentation: ICD-10 with MCC • MCC: Major Complications or Comorbidity • COPD without CC/MCC: $3900 • COPD with CC: $5366 • COPD with MCC: $7166 HALE, D. (2009, JANUARY 15). BILLING AND CODING. RETRIEVED JUNE 15, 2020, FROM HTTPS: //WWW. ACPHOSPITALIST. ORG/ARCHIVES/2009/01/CO DING. HTM

Documentation Tips

Documentation Tips: ROS “ 10 or more review of systems negative, except those noted in the HPI”

Presentations: DDEMAP • Present to your senior resident on rounds • DDEMAP • • • Destination Diagnosis Equipment Medications Appointments Pending

Resources

Resources

QUESTIONS?

Intern class 20202021 UNM IM INTERNAL MEDICINE

Zach bruss I’m from Irvine in Southern California. I knew I wanted to come to UNM after I rotated here during my 4 th year. I was really impressed with the people I met and really enjoyed the culture surrounding the residency program. I’m sending a couple of photos with some of my family members (including my dog, Ginny) and including my twin brother who is currently finishing up his last year of medical school!

Mario flores Hello, my name is Mario Flores and I am from a few places. I was born and raised in New Jersey but moved down to Georgia when I was 12 years old. I finished off undergrad in Georgia and moved to Las Cruces, New Mexico where I went to medical school at the Burrell College of Osteopathic Medicine. I am currently interested in hospital medicine and pulmonary /critical care but I am keeping an open mind. I am happy to be here and excited to meet all of you!

Kashif abad I moved to UNM with my lovely family from Miami, Florida for my Nephrology fellowship. I completely fell in love with everything about UNM, its staff, the people in NM, the weather, and the program itself. I chose UNM because of its amazing residents, caring physicians, dedicated mentors, and overall, a great family-like environment. They love to share their experiences and genuinely love to teach. They care and treat patients and their families with respect. I previously worked at the University of Miami, Miller School of Medicine, which is amongst the top universities in America in research. I was honored to be one of the physicians scientists who submitted a research grant on the "Miami Project to Cure Paralysis" for the first Investigational new drug to FDA.

Kashif abad I find UNM to be outstanding and competitive academically and in all types of residency and fellowship programs. I love UNM, and I recommend UNM to other applicants because of its supportive environment and for the way the program allows us to be ourselves. I like traveling with my family, hiking, spinning, and cooking, I love drinking coffee and tea. If you like outdoors, New Mexico is the place to be, especially during the Covid-19 Pandemic, it was exceptional to get out and maintain social distancing while enjoying the breathtaking drives. We can't have enough of all the beautiful locations within New Mexico, and all around.

Quality Improvement and Patient Safety at University of New Mexico HSC Jessica Zimmerberg-Helms

Quality Improvement Chiefs • University Hospital – Jessica Zimmerberg. Helms • Veteran’s Hospital – Matthew Gerling

QI Timeline • R 1 Start working on clinic QI project and complete Curriculum A • R 2 Take on more leadership within your clinic QI project and complete Curriculum B/C • R 3 Work on completion of scholarly activity for your clinic QI project and complete Curriculum B/C

Timeline for this year • July – intern bootcamp session • August – 1 st TS session; initial project design/set goals • November – 2 nd TS session; identify initial barriers, define first set of interventions • February – 3 rd TS session; review progress from interventions • May – 4 th/last TS session; presentations between groups

Teaching Curriculum • 4 portions • Intern Bootcamp • Introduction to curriculum and PDSA cycles • Curriculum A • Interns • Basics of QI • Every year • Curriculum B & C • PGY 2/3 • Alternate years

Clinic Projects • All residents assigned to groups based on clinic location • 1 clinic project per group • Each group a mix of PGY 1, 2, and 3 • Pilot group Cross sectional with residents across different clinics working on 1 project

Scholarly Activity • End of each year – present at Thursday School • Potential for conference presentation or publication!

Intern class 20202021 UNM IM INTERNAL MEDICINE

Conor kirby My name is Conor Kirby, I grew up in Maine and went to medical school in Indianapolis. I am interested in going into hematology/oncology! I chose New Mexico because I love the state and thought the attitude toward healthcare was progressive, and I want to be a part of that. I've been surviving COVID by getting back into playing guitar, something I loved doing before medical school!

Chanhwa hong (Chan is also good). I was born in Seoul, Korea, and I have mainly lived in Dallas, Texas since coming to the US when I was 9. To survive COVID, I have been cooking a lot and spending time with family especially my younger brother, and yes, I did try to bake sourdough bread. I chose UNM because of the people I met and had conversations with during the interview. I had a profound sense that they are passionate about serving the community, and this is the type of community I wanted to join. I had to dig through 5 years worth of pictures to find these two very mediocre photos. Blame the photographer not the subject.

Lisa saa I'm from Houston, TX. I'm thinking about either Pulmonary & Critical Care or Sleep Medicine for fellowship. I've spent the last month or so moving to ABQ, exploring different restaurants, and trying my hand at gardening! I'm excited to live in New Mexico for its stunning outdoors and great food! My boyfriend grew up in Santa Fe and works at Los Alamos, so UNM seemed like a good fit for both of us!

Xuan thuy nguyen My name is Xuan Thuy Nguyen. Borne in Viet Nam, immigrated to Denver, Colorado since I was seven. I choose internal medicine as a way of life. Covid defenses: reading, painting, Skyping, long walks by myself, and Playing Jackbox with friends. I choose UNM because of the patient population and the sunny weather. I love cats, being silly, and am looking for people to possibly play Dungeons and Dragons with. Attached is my most recent painting and selfie! Looking forward to meeting everyone soon.