TSWF Cardiovascular CPG AIM Form User Guide January 2018

Transcription

1 TSWF Cardiovascular CPG AIM Form User Guide January 2018 Form Version: Jan-Apr 2018

2 Table of Contents TSWF Cardiovascular CPG AIM form Introduction 2 General Information Best Practice Procedures and Workflows. 4 Form Tabs HPI/PFSH... 5 ROS. 7 PE 8 Exit/Comprehensive Care Plan Hypertension (DoD/VA). 10 HTN (JNC 8).. 11 Dyslipidemia Ischemic Disease / HF Afib / CV Meds 14 Adding Form to Favorites Instructions. 15 Copy Forward Instructions AHLTA Options

3 Introduction to Cardiovascular CPG AIM Form Background/History: The Tri-Service Workflow (TSWF) Team has created AIM forms to bring team care to MTF workflow, save provider and staff time through standardization of AHLTA templates, and enhance documentation of the patient encounter. The focus of TSWF activities is to facilitate improvements by evaluating clinical workflows and creating standardized structured documentation tools that mirror clinical processes. This is done through the use of AIM (Alternate Input Method) forms with the goal of improving care and documentation in AHLTA and not just the use of a form for its own sake. The Cardiovascular CPG AIM form is intended for use in Primary Care and can be used alone or in conjunction with the CORE form during an encounter. In fact, all of the TSWF CPG AIM forms are compatible with each other and the CORE form and can be used interchangeably, either within an encounter or for different encounters. What patient conditions can this form help with? This form is intended for patients diagnosed with hypertension, dyslipidemia, ischemic heart disease, heart failure, and/or AFIB. These conditions are common and have several aspects of management in common. The Cardiovascular CPG AIM form can support your evaluation, documentation, and management of patients with these conditions. The form contains key elements from four VA/DoD Clinical Practice Guidelines, resulting in documentation that supports adherence to the guidelines. The form also contains and provides easy access to clinical decision-making resources. Like the other TSWF CPG AIM forms, the Cardiovascular CPG form is largely similar to the TSWF CORE form in layout, function, and appearance. Therefore, this guide will primarily highlight the differences between the two. For full details about the use of the CORE AIM form, please reference the CORE User Guide. Why would I want to use this form for my notes? This form and associated workflow was designed to standardize health documentation practices in the MHS. Standardization of documentation can result in the following: Integrating clinical support staff into the care of patients Obtaining more thorough and better documentation Guiding providers toward using evidence-based care Standardizing suicide and safety evaluations Improving the speed and efficiency of documentation Improving coding accuracy Building in items required for inspection Features of the Tri-Service Workflow AIM forms and associated workflows: The copy-forward process (see instructions on p18 of this Guide): o Maintains continuity of clinical information o Carries forward treatment planning and ongoing course of care o Improves note writing efficiency The forms include clinical clues and reminders VA/DoD CPG decision support is available right at the point of care This User Guide is a comprehensive AIM form reference that walks through tabs on the TSWF Cardiovascular AIM form. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: If you have questions or feedback about this User Guide, please contact us via the following link on Milsuite: 2

4 General Information on Form Use (Sequence of Clinical Workflow) Form Structure: - Mirrors clinical workflow (from left to right: intake, screening, ROS, PE, and care plan documentation) - Facilitates use of clinical support staff (technicians, medics, corpsman, etc.) for screening and intake documentation - Provides decision support from VA/DoD CPGs and other national level recommendations - Improves documentation efficiency - Carries important past medical history (PMH) information forward from one appointment to the next utilizing the copy-forward process (REMINDER: any information you want carried into subsequent notes must be placed into the yellow fields as these are the only fields that copy-forward!!) - Contains reference only tabs ( ) outlining reference material specific to the CPGs covered in the form Form Basics: MilSuite link AHLTA user can ask questions, provide input, and obtain training materials. Website for TSWF training, contacting the TSWF team, and many other resources. Access any of our forms from the Navigator via this link. Do NOT delete the TSWF AIM form identifier (integral to the copy-forward process). Start the note below this text. The Change Log shows the updates made with each version. Important information throughout the form is in red. A red X indicates this section will be included in the note. AHLTA automatically marks this X after text has been entered. Clicking on the X after typing in the box will reset the box to its default text by erasing what has been entered. The Undo button (at the top of the page) can be clicked if this was done accidentally. 3

5 Best Practice Procedures and Workflows Patient Patient Signs In Patient Enters Data on Paper Intake (if used) Clinical Support Staff (and/or Provider) (Local procedures determined by staffing, clinic workflow needs, and leadership preference) Data Entered into CPG AIM form Note is Opened Provider Provider Reviews/Edits Documentation Continues Encounter Documentation in AIM form Completes and Signs Note Recommended Documentation Workflow a. Clinical support staff (CSS): copy-forward PMH from previous encounter (highlighted in yellow on the AIM forms); consider Open, Not Checked-In prior to the day of the encounter to copyforward and enter information preparatory to the encounter. Consider use of the Comprehensive Care Plan (CCP) for patients diagnosed with CPG-relevant conditions. b. CSS: at the time of the encounter, perform Screening (2 nd tab on the form), Past History, etc. as directed by clinic leadership and workflow. The CSS should also verify all the copy-forward information with the patient. They then close (not sign) note. c. Provider takes ownership of the note, i.e. edits S/O portion of note. Provider reviews the existing documentation, edits as needed, and proceeds with documentation of additional history, physical exam in the AIM form. d. Provider reviews CPG AIM form reference material as desired. e. Provider updates the CCP as desired. f. Provider completes A/P, disposition, and signs the encounter note. Why Copy-Forward? Copy-forward allows staff to bring forward all of the past medical history and chronic care planning into the current encounter to be reviewed and updated (only elements placed in yellow fields will copyforward). In addition to this being best practice, performing a copy-forward is a significant time-saver as well. The TSWF repository for training/educational materials and updates: PLEASE NOTE: A comprehensive visual change log has been created to assist users in identifying the changes made with each version s update. Click here to access this presentation. 4

6 History of Present Illness/PFSH Tab The Cardiovascular CPG AIM form is set up so that you can see all of the most important details about the patient in one place, right on the front tab. Many of these pertinent details about the patient don t change much from visit to visit, so our workflow has the Clinical Support Staff copy-forward (CF) these past medical history (PMHx) elements. You can identify CF PMHx by the yellow highlighted elements on the form. Chief Complaint box for presenting problem. Cardiovascular specific clinical cues in blue help to assess pain specifically linked with cardiovascular diagnoses. Document all true allergies in the AHLTA allergies module. Medication Reconciliation supports Joint Commission and PCMH guidelines. You see one question that is specific for the clinical support staff to answer (was med list updated) and four for the provider (med compliance, orders evaluated, list of meds provided, patient educated on the importance of managing medications). A link to additional educational material is provided as well. This box contains reminders of interventions that have a demonstrated positive impact on morbidity and mortality in patients with these conditions. 5

7 History of Present Illness/PFSH Tab, cont. You ll see several of these buttons in our forms. Clicking here will open a ribbon to show more details (see below). The CCPs for Cardiovascular and Metabolic Disorders (shown here opened) are placed on the first tab. These comprehensive care plan fields are designed as a common documentation location for elements that are recognized by the CPGs as necessary for adequate continuity of care. This is an area where the support staff can participate in assisting the documentation, perhaps gradually, visit by visit (preferably in an open-not-checked-in mode) to fill in this information on the patient. These are copy-forward fields, which can be customized to the provider s or patient s needs. They are prepopulated with information, but you can modify them if you wish. Resources adjacent to the CCPs include links to the full CPGs and Risk Calculators (where appropriate). Dyslipidemia and Hypertension are covered in the Metabolic Disorders CCP, so it s readily accessible on the front tab. Includes a Date last updated area which should contain the date the field was last reviewed/updated if not during the current encounter. The VA/DoD Dyslipidemia CPG recommends use of one of these risk calculators. Providers are encouraged to become familiar with the calculators and use the one that you are comfortable with. 6

8 ROS Tab There is a complete ROS so that this form can be used for any complaint, not just cardiovascular issues. There is a specific Cardiopulmonary ROS that focuses on the symptoms of the diseases addressed in this form. All Normal buttons available for quick documentation of common and cardiopulmonary ROS. Select All Normal and either deselect or change N to Y as appropriate. Free text option for documenting ROS. This item won t be selected with the All Normal button. It s provided as an easy way for providers to indicate whether symptoms have changed since the last visit. 7

9 PE Tab The same physical exam elements that are on the CORE form are also available here so you don t need to spend time going between them to document any additional exam findings. Normal button for quick documentation of PE. A PE free text box allows for extra documentation of other PE. Gold font is used for items to the right of the bar and represent items not routinely performed; these are not selected when the Normal button is selected, and must be marked manually. The light blue shaded area outlines common focused cardiovascular exam elements. Free text boxes can be opened for additional documentation. 8

10 Exit/Comprehensive Care Plan Tab Several accreditation agency expectations (such as patient handouts and selfmanagement assessments) are on the Exit/CCP tab. This tab also contains comprehensive care plans that exist for a large number of chronic clinical conditions, and help to document the kind of data that would have been in a coversheet of a paper record. These include many aspects of the patient s care plan, like their goals, test results, etc. Although this is a lot of data, it only has to be filled out once. Once it s been started, it s relatively easy to keep up with. Clinical support staff can update a lot of this information when they do the Open, Not Checked-In scrub of the record. This copy-forward field documents important self-care management plans. As a text field, it can be adapted to fit your needs, but we recommend retaining the information listed. Checking the X denotes a selection. Links that provide educational resources and CPG guidelines. Remember, the Cardiovascular and Metabolic Disorders CCPs are on the first tab of the form. All the other CCPs can be found here. 9

11 Hypertension (VA/DoD) Tab The remainder of the tabs on the Cardiovascular CPG AIM form are for reference only- no patient data or information is recorded on them. This tab covers Hypertension recommendations from the 2014 VA/DoD CPG. There are a number of ribbons which can be opened to reveal different tables or algorithms from the CPG. For example, when the first ribbon is expanded, a flow diagram is presented that describes a screening and diagnosis decision tree. The sidebars are taken directly from the CPG itself. Additional Ribbons open up for more reference tools and resources. 10

12 HTN (JNC 8) Tab There is a second reference tab for hypertension because the JNC-8 information wouldn't fit on the same tab with the VA/DoD information tab. In general, TSWF forms emphasize the VA/DoD CPGs as resource material. However, the decision was made to include reference material from JNC-8 since that reference might be more familiar to some users. While the two guidelines are very similar, there are some differences. Both the JNC-8 and the VA/DoD CPG are reference material for educating providers on medical evidence. The material is presented for handy reference, not to dictate a certain practice. Clinical cues in blue offer additional help and recommendations for algorithms. This button links to the JNC 8 guidelines. 11

13 Dyslipidemia Tab The recommendations on the dyslipidemia reference tab are based primarily on the VA/DoD CPG. In addition, this tab includes a ribbon describing recommendations from the ACC (American College of Cardiology)/AHA (American Heart Association). The focus in both is lipid treatment for the purpose of cardiovascular risk reduction. Links to several cardiovascular risk calculators are provided both here and on the HPI/PFSH tab. Recommendations for initial labs are also noted at the top, then there are 4 ribbons with additional material. 12

14 Ischemic Disease Tab This tab contains an algorithm on the management of stable IHD as well as other reference materials. Link to the 2012 ACC/AHA IHD Guideline. HF Tab This tab contains extensive information on heart failure including a link to the 2013 ACCF/AHA HF Guideline. At the top in red you will see helpful information regarding medications to avoid or use with caution. Link to the 2013 ACCF/AHA HF Guideline. 13

15 Afib Tab In the Atrial Fibrillation Tab you will first see information for initial presentation and followups. In the ribbons below are algorithms and charts to help aid your encounter. Link to the 2014 AHA/ACC Atrial Fibrillation Guideline. CV Meds Tab This tab contains 4 ribbons which list the common medications used to treat cardiovascular conditions. 14

16 TSWF Cardiovascular CPG AIM Form: Adding Form to Favorites Instructions 15

17 The preferred method of accessing TSWF AIM forms is to have the Navigator in your Favorites. Loading from the Navigator will take you to the most current version of the form. Alternate Method: Add the specific TSWF AIM form to your Favorites 1. Open Tools 2. Select Template Management 3. Click Expanded Search to locate TSWF AIM forms 4. In Template Name line type TSWF 5. From Owner Type dropdown list select Enterprise 6. Click Search button 16

18 7. In the Search Results list: Right click on the TSWF-CV-CPG- (Department of Defense) AIM form 8. Select Add Favorite (Do not use Save As, as the form will not get updated properly see below) Do not use Save As when adding this template to your favorites list. Do not set this form as your default encounter template unless you have specific instructions on how to do it from your local clinical systems trainer. Save As will break the link to the Enterprise and keep the form from updating properly; setting as a default will also break the link if not done properly. We suggest cleaning out old and un-used templates from your favorites to help you quickly find the ones you most often use. 17

19 TSWF Cardiovascular CPG AIM Form: Copy-Forward Instructions 18

20 Copy-Forward Instructions 1. In Appointments view; Double-Click on the Patient. (This takes you to this Current Encounter view.) DO NOT OPEN S/O The copy-forward process is integral to the Tri-Service Workflow. Following these steps will ensure that the appropriate data you enter in today gets reused as efficiently as possible. REMINDER: only information placed in the yellow fields throughout the form will copy-forward!! 2. Select the Previous Encounter module from the folder List. Consider including cancelled/lwobs visits when reviewing this module. 3. Click on the most recent, compatible TSWF note (e.g., includes <<Note accomplished in TSWF- Form>> in the HPI section). 4. Click the Copy Forward icon on the tool bar. 19

21 AHLTA returns to the Current Encounter 5. Select S/O DO NOT MAKE ANY EDITS WITHIN THE COPY-FORWARD TEMPLATE! - If the Copy-Forward Template is not automatically loaded; select it from the Template drop down menu. 6. Select PMH tab to copy-forward 7. Click AutoEnter TSWF Copy-Forward process All copy-forward items are located on the PMH tab in this view, and are ONLY in the yellow colored fields throughout the AIM form. Critical Assumptions You MUST complete copy-forward and open the TSWF AIM form before editing the content. You MUST copy-forward from a TSWF standard primary care AIM form (CORE or any CPG AIM). 20

22 8. Select TSWF-CV- CPG AIM form 9. Once in the encounter, go to the Obsolete Terms tab. Utilize the uncheck ALL the items below button to eliminate any term found on this page as they are no longer used on TSWF forms. You will not see these terms in the form view but they would show up on the Note View. This should be your final step in the copy-forward process. 21

23 AHLTA Options Access by opening up any clinical encounter or tel-con to this screen. Click on the OPTIONS tab. Line 1-will default to your name Line 2-as directed by your MTF-in the LIVE system, AHLTA s default is PHYSICIAN/WORKSTATION Line 3-as directed by your MTF Co-signer-as directed by your MTF AUTO CITES- recommend checking Allergies and Questionnaires (if used). Uncheck anything else. VITALS/LABS/RADS-this will automatically place ANY vitals/results in your note for the time period you selected- i.e. for the last 7 days. We recommend leaving all these unchecked. WARNING-THIS FUNCTION WILL AUTOMATICALLY PLACE INFORMATION IN YOUR NOTE REGARDLESS OF WHO ORDERS THE LABS. Individual labs/rads can be added to the encounter when viewing those results. A/P Active Order Default: recommend checking all the boxes. 22

24 S/O Default- We recommend unchecking both of these boxes. Having them checked can cause unexpected behavior in the forms. Disposition Follow Up Discussed with Default: Defaults to Patient. Option to override for exceptions is located in the DISPOSITION tab E&M Calculator Defaults: Setting: Outpatient; Service Type: Outpatient Visit; Exam type: General Multi-System Do NOT check AUTO PRINT or SENSITIVE Include ICDCM/DoD Unique/CPT4/HCPCS codes in encounter note- check this box. This will place the codes on the signed encounter. No action required by user. Warn me if no procedure documented- for primary care, do not check this box. Auto Save- recommend unchecking this box. This used to be helpful but auto-saving freezes up AHLTA for a moment and it s really just not needed. 23