TSWF Pulmonary CPG AIM Form User Guide September 2018

Transcription

1 TSWF Pulmonary CPG AIM Form User Guide September 2018 Form Version: Sep-Dec 2018

2 Table of Contents Pulmonary CPG AIM form Introduction 2 General Information Best Practice Procedures and Workflows. 4 Form Tabs HPI/PFSH/CCP.. 5 ROS... 7 PE... 7 Exit/CCP. 8 Initial... 9 Potential Alternate Diagnoses Severity Assessment. 11 Follow-Up.. 12 Exacerbation Medications.. 14 Adding Form to Favorites Instructions.. 15 Copy Forward Instructions 18 AHLTA Options

3 Introduction to Pulmonary 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 Pulmonary CPG AIM form is used 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. Who is this form made for? This form specializes in targeted care for patients with symptoms of ASTHMA and/or COPD and can be used for any encounter for these patients. The Pulmonary CPG AIM form can support your evaluation, documentation, and management of patients with these conditions. The form contains key elements of two 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 Pulmonary 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 Pulmonary CPG 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 users can ask questions, provide input, and obtain training materials. Website for TSWF training, contacting the TSWF team, and many other resources. Access any TSWF form from the Navigator via this link. Helpful Tips are found throughout and give relevant information. The Change Log shows the updates made with each version. Do NOT delete the TSWF AIM form identifier (integral to the copy-forward process). Start the note below this text. 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 (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 A/P, Disposition, 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 copy-forward 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 supports continuity of care by allowing 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 copy-forward). 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 4 changes made with each version s update. Click here to access this presentation.

6 HPI/PFSH/CCP Tab The Pulmonary CPG AIM form is set up so that you can see most of the 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 for review during the encounter. You can identify CF PMHx by the yellow highlighted elements on the form. Attending physician field is intended for use at training programs only. Pulse Oximetry is on the HPI tab to highlight its importance. HPI box: for describing more detail about the presenting problem or reason for appointment. Most important! 6 individual questions regarding the last 12 months respiratory history. This offers a concise snapshot of items to review for chronic pulmonary disease. Focusing on answering these questions at each visit will help paint the best picture about your asthma or COPD patient. Asthma history and prior exacerbations should be documented in the PMHx field. Use the AHLTA Allergies module to document pharmaceutical allergies. These statements can be used as shortcuts for documenting steps associated with reconciling medications. 5

7 HPI/PFSH/CCP Tab, cont. The Clinical cue reminds providers that COPD diagnosis must be made on the basis of spirometry. The Asthma Control Test can be documented here, and a link out to the ACT is provided as well. For spirometry, it s important to document the date for tracking purposes. At the bottom of this field you see Interpretation/ Changes since prior spirometry that s an area for free text where the provider can note anything they may want to readdress at the next visit or to discuss any kind of changes seen (i.e. significant drop vs. gradual drop). The CCP for Pulmonary Disease is on the first tab. This comprehensive care plan field is 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 for the support staff to gradually, visit by visit (preferably in an open-notchecked-in mode) 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. There is a link to the Asthma Action Plan. It is an Excel file which can be printed as well as copied and pasted into the AddNote section of AHLTA. You ll see several of these buttons in our forms. Clicking here will open up a ribbon to show more details. 6

8 ROS Tab These tabs are color-coded with colors corresponding to elements that are specifically addressed in the VA/DoD CPGs. Remember, the CPGs are not written to instruct on history and physical exam. There may be important ROS or PE items for a condition that are not color-coded. Free-text boxes can be opened for additional documentation. All Normal button available for quick documentation of common ROS. Select All Normal and either deselect or change N to Y as appropriate. PE Tab Normal button for quick documentation of PE. Italics is used for items not routinely performed; these are not selected when the Normal button is selected, and must be marked manually. 7

9 Exit/CCP 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. Info from all yellow ribbons will copy-forward. Here you will find a link to CPG guidelines. Remember, the Pulmonary Disease CCP is on the first tab of the form. All the other CCPs can be found here. 8

10 Initial Reference Tab The remainder of the tabs on the Pulmonary CPG AIM form are for reference only- no patient data or information is recorded on them. This tab contains algorithms, charts, and other reference materials for diagnosis, classification, and treatment of Asthma and COPD. Additional ribbons open for more reference tools and resources. 9

11 Potential Alternate Diagnoses Reference Tab This tab will indicate diagnoses, any kind of symptoms you should be looking for, and alternate tests to run to rule in out a new diagnosis. It will also give you other possible diagnoses, and other tests to run to come up with your definitive diagnosis. The first ribbon is specifically for adults and the second for Pediatrics. 10

12 Severity Assessment Reference Tab The Severity Assessment tab will walk you through the differing levels (intermittent, mild persistent, moderate persistent or severe persistent) of respiratory disease. The charts gauge lung impairment based on how frequently symptoms are occurring, spirometry data and levels of dyspnea. If you need to send a patient to a specialty consultant, this ribbon will tell you what kind of things to look for as well as the rationale. This helps build your case on why the patient needs this consult. 11

13 Follow-Up Reference Tab If the patient doesn t need consultation and can be managed within your practice, the Follow-Up tab becomes very useful. The first ribbon shows the asthma algorithm for once the patient is stable and how to keep them not only there but continually improving. The next ribbon looks at asthma control. This is an expansion of the initial diagnosis table. Step-up care tells us where we either need to bring the patient up or down when it comes to their medication options. 12

14 Exacerbation Reference Tab Every so often even a well-controlled patient can get into a situation where they have an exacerbation. This tab helps define the severity of the exacerbation, suggests appropriate tests to perform to confirm the diagnosis, and what sort of intervention the patient requires. For COPD, there s a similar algorithm established. 13

15 Medication Reference Tab This color-coded tab gives more information about each of the medications that are prescribed for both COPD and asthma patients. 14

16 TSWF Pulmonary 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 Metabolic- 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 Pulmonary 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 Encounters module from the Folder List. Consider including cancelled/lwobs visits when reviewing this module. 3. Click on the most recent and compatible TSWF encounter listed (e.g., includes <<Note accomplished in TSWF- >> 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. 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. 7. Click AutoEnter. 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- Pulmonary-CPG AIM form 9. Once in the encounter, go to the Obsolete Terms tab. Click the Uncheck ALL the Items Below button to remove 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: Recommend Outpatient for Setting, Outpatient Visit for Service Type, and General Multi-System for Exam Type. 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