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 Arkansas State Hospital UAMS Little Rock VA North Little Rock VA Arkansas Children's Hospital
                                  
         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 New patient interview Follow-up visit  

Diagnostic Category1: Please select Psychosis Mood Disorder Anxiety Disorder Substance Abuse Disorder Delirium Dementia Personality Disorder ADHD Conduct Disorder Eating Disorder Developmental/Learning Disorder   Diagnostic Category 1 is the main Category.  Only use
Diagnostic Category2:  Please select Psychosis Mood Disorder Anxiety Disorder Substance Abuse Disorder Delirium Dementia Personality Disorder ADHD Conduct Disorder Eating Disorder Developmental/Learning Disorder   Category 2 - 4 if the patient has multiple diagnoses.
Diagnostic Category3:  Please select Psychosis Mood Disorder Anxiety Disorder Substance Abuse Disorder Delirium Dementia Personality Disorder ADHD Conduct Disorder Eating Disorder Developmental/Learning Disorder
Diagnostic Category4:  Please select Psychosis Mood Disorder Anxiety Disorder Substance Abuse Disorder Delirium Dementia Personality Disorder ADHD Conduct Disorder Eating Disorder Developmental/Learning Disorder

     
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)