Associating your clinical notes to VC3 patient problems in VPEN without Star Panel

Associating your clinical notes to VC3 patient problems in KM Portfolio without Star Panel

The Vanderbilt School does not require you to add notes from patients you encounter out of the Vanderbilt Medical Center System. Though not required of you, you can create notes on patients you have seen, either formally as a note, or just a strong paragraph of summarizing the case. You can do this in KM notes in KM Portfolio. It is located on the left navigation bar.

If your patient is not in the Vanderbilt Medical Center System, then YOU MUST de-identify important patient information.  According to the U.S. Department of Health & Human Services, the following information must be removed:

Deletion of 18 Identifiers

To de-identify using this method, the following identifiers of the individual or of relatives, employers, or household members of the individual, are removed:

  1. Names;
  2. All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census:
    1. The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and
    2. The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.
    3. Currently, 036, 059, 063, 102, 203, 556, 592, 790, 821, 823, 830, 831, 878, 879, 884, 890, and 893 are all recorded as “000”.
  3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;
  4. Telephone numbers;
  5. Fax numbers;
  6. Electronic mail addresses;
  7. Social security numbers;
  8. Medical record numbers;
  9. Health plan beneficiary numbers;
  10. Account numbers;
  11. Certificate/license numbers;
  12. Vehicle identifiers and serial numbers, including license plate numbers;
  13. Device identifiers and serial numbers;
  14. Web Universal Resource Locators (URLs);
  15. Internet Protocol (IP) address numbers;
  16. Biometric identifiers, including finger and voice prints;
  17. Full face photographic images and any comparable images; and
  18. Any other unique identifying number, characteristic, or code, except as permitted by the re-identification rules and
    1. The covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.

To create a note:

You must first create a patient. Once you do that, then you will be able to choose a template to use (like an H and P template under Medicine) which allows you to type or paste your work into that template.

First, logon to VSTAR PEN.

Next, Click on Patient Notes found in the left-hand side Navigation panel:

Then, click on Add New Patient:

Then, fill in the patient information. A real name or made up name is fine:

Now, when you click back on KM Notes (as in the first step above) you will find that patient in your list, and choose a temple to use in order to write your note or copy and paste your info into that template.

Once a patient is selected you see:

 

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