Last Name:   (add a comma and initials if more than one person in the class with the same last name)
                              Password:
      Date of Patient Encounter: (mm/dd/yyyy)
  Reported this patient before: (Only check this box if you have filled out one of these forms on this patient before)
                                Location: Please select UAMS CAVHS ACH Private Practice
 
         Patient Information: Age: Please select less than 1 month 1 to 12 months 1 to 5 years 6 to 12 years 13-18 years 19-24 years 25-44 years 45-64 years 65-84 years greater than 84 years     Gender: Please select M F     Ethnicity: Please select African American White, non-Hispanic Asian or Pacific Islander Hispanic American Indian Other

All Information above this line must be filled in for each patient encounter reported.
Only fill out the items below that are appropriate

     Type of Encounter: Please select Inpatient Outpatient  

Diagnostic Category1: Please select Abnormal uterine bleeding Amenorrhea Abnormal pap smear Medical complications of pregnancy Bleeding in pregnancy Labor management Sexually transmitted disease Vaginitis Vulvar disease Pelvic pain Prenatal care Ectopic pregnancy Adnexal masses Complications of labor  
Diagnostic Category2:  Please select Abnormal uterine bleeding Amenorrhea Abnormal pap smear Medical complications of pregnancy Bleeding in pregnancy Labor management Sexually transmitted disease Vaginitis Vulvar disease Pelvic pain Prenatal care Ectopic pregnancy Adnexal masses Complications of labor
Diagnostic Category3:  Please select Abnormal uterine bleeding Amenorrhea Abnormal pap smear Medical complications of pregnancy Bleeding in pregnancy Labor management Sexually transmitted disease Vaginitis Vulvar disease Pelvic pain Prenatal care Ectopic pregnancy Adnexal masses Complications of labor
Diagnostic Category4:  Please select Abnormal uterine bleeding Amenorrhea Abnormal pap smear Medical complications of pregnancy Bleeding in pregnancy Labor management Sexually transmitted disease Vaginitis Vulvar disease Pelvic pain Prenatal care Ectopic pregnancy Adnexal masses Complications of labor

                Procedure: Please select Insert IV Participate in Normal Delivery Observe Normal Delivery Observe Complicated Delivery Observe C-Section Observe Cancer Surgery endometrial biopsy pap smear wet prep cervical cultures pelvic exam breast exam hysterectomy oophorectomy rectocele repair cystocele repair vaginal suspension bladder neck suspension laparoscopy tubal ligation hysteroscopy hysterosalpingogram

Please click the button in front of the Educational Competency that you feel this patient encounter addressed (click all that apply):
     Medical Knowledge
     Patient Care
     Professionalism
     Interpersonal and Communication Skills
     Medical Informatics
     Population Health and Preventive Medicine
     Practice-Based and Systems-Based Medical Care

Comments:
(Please do not put any patient identifying information in this comment)