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 Inpatient wards Outpatient specialty clinics GPC (General Pediatric Clinic) Newborn nursery ER
                                  
         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

        Diagnostic Category  A - C : Please select Asthma Abdominal pain Acute scrotal pain or swelling Adverse drug reaction Amenorrhea/dysmenorrhea Atopic dermatitis/eczema Allergies-food or seasonal Attention deficit disorder (ADHD) Anemia Apnea Adrenal disease Breath holding spells Behavior problems Bone or mineral disease Biliary atresia Bronchiolitis Cellulitis or skin infections Cerebral palsy Child abuse Conjunctivitis Concussion or head injury Cystic fibrosis Constipation Colic Croup Congenital heart disease Chromosomal syndromes  
        Diagnostic Category  D - K : Please select Diarrhea Dehydration Diabetes mellitus Developmental delay Eating disorders Enuresis Failure to thrive Fever/febrile illness Foreign body (ingestion/in ear or nose) Gastroesophageal reflux Gastroenteritis Health supervision visit (Well child visit) HIV disease Heart failure Hemophilia Hypertension Headache Intussussception Inflammatory bowel disease Inborn errors of metabolism Impetigo Juvenile chronic arthritis Kawasaki disease  
        Diagnostic Category  L - R  : Please select Limp Lead poisoning Lymphadenitis Leukemia/lymphoma Meningitis Muscular dystrophy Nursemaid's elbow Nephrotic/nephritic syndrome Neurocutaneous syndromes Osteomyelitis Osgood Schlater disease Otitis media Pyloric stenosis Pneumonia Pinworms Poisoning/overdose Primary immune deficiency Pharyngitis Rashes  
        Diagnostic Category  S - Z  : Please select Sinusitis Scabies SCFE or avascular necrosis of femoral head Sepsis syndrome Sexual abuse Spinal bifida Sickle cell disease Seizure disorder Stridor Systemic lupus erythematosis Septic arthritis Substance abuse Sexually transmitted disease Tinea (any location) Toxic synovitis Tuberculosis Thyroid disease Thrush Tumors (Wilm's, neuoblastoma, etc.) Upper respiratory infection Urinary tract infections Viral infection Vomiting Vesicoureteral reflux  
Diagnostic Category Neonatology: Please select Routine newborn care Hyperbilirubinemia Infant of a diabetic mother Neonatal sepsis Congenital/TORCH infections Respiratory distress Prenatal drug exposure Birth trauma Prematurity Polycythemia Cyanosis
If none of the Diagnostic Categories above apply, please type in the diagnosis here:

                Procedure: Please select

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)