Piedmont Access to Health Services. Standing Orders for Patient Work-ups
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1 Piedmont Access to Health Services Policy Number: SUBJECT: Standing Orders for Patient Work-ups EFFECTIVE DATE: 8/3/09 REVIEWED/REVISED : 4/10/2012 POLICY: PATHS is committed to allowing each of PATHS Community Medical Centers clinical staff to act at his or her highest level of training and licensure in order to achieve the highest quality care and efficient patient flow. Within PATHS Community Medical Centers clinical staff (nurses and experienced CMAs) is permitted to execute standing orders as if they were unique orders for individual patients. The Medical Director and providers will maintain and revise these standing orders periodically to reflect best practices. PERSONNEL: Medical Director, s, RNs, LPNs, CMAs with supervision PROCEDURE: Rooming Patients The nurse shall provide an initial assessment of the patient in preparation for the provider s visit. In addition, the nurse will provide supportive services as ordered by the provider. 1. Obtain weight, temperature, pulse, respirations, and blood pressure as appropriate. Verify height and enter to allow BMI calculation. 2. If the patient is a female, document the following under OB/GYN history: a. Document date of LMP and last PAP. b. If pap was done by a provider outside of PATHS, have the patient sign a record release to obtain documentation of this. Document date, location and effort to obtain documentation in chart. c. Document whether or not the patient has ever had an abnormal pap smear. d. If no PAP has every been done, document for provider to educate the patient e. Document number of pregnancies and their outcomes (i.e., miscarriage, abortion, etc ) 3. Document patient s chief complaint. Additionally: a. Review for labs, diagnostic testing or referrals that need to be followed up on with the patient and document status and/or need for provider follow up. 4. Review and update medication list by going through each medication that the patient is taking to ensure that no changes have been made since last visit. Verify that this has been done by checking the medications verified box. If patient needs medication refills, document needed prescriptions. 5. Verify medication allergies and check the allergies verified box to document that this has been done. Page 1 of 7
2 6. Review and update the Family history, Surgical history and Hospitalizations with the patient. a. Each nurse should speak with their assigned provider to find out what information they would like to have recorded. 7. Review social history with the patient, making sure to document each of the following: a. Smoking Status i. If patient is a smoker, fill out Tobacco Smart Form and clarify the amount of tobacco used daily under the tobacco use section. b. Drug Use c. Marital Status d. Number of children e. Occupation 8. Pneumovax if patient is 65 years of age or has condition that increases the risk of invasive pneumococcal disease a. Patients aged years with chronic cardiovascular disease (including congestive heart failure and cardiomyopathy), chronic pulmonary disease (including asthma and chronic obstructive pulmonary disease), diabetes mellitus, alcoholism, chronic liver disease (including cirrhosis), cerebrospinal fluid leak, cochlear implant, cigarette smoking b. Patients aged years who are residents of nursing homes or long-term care facilities c. Patients with compromised immunity (renal failure, HIV, malignancy, organ transplant recipients, etc ) 9. Tdap booster every 10 years or Tdap if Td > 5 years. 10. Influenza vaccine yearly (if no contraindications) a. Egg or mercury allergy b. History of Guillian-Barre Syndrome c. Sick with fever 11. Urine dipstick for patients with a complaint of dysuria 12. Rapid strep for patients with a complaint of pharyngitis 13. Urine pregnancy test by request 14. Alert provider to review findings as needed. Rooming Diabetic Patients Newly diagnosed diabetic Obtain: blood glucose document fasting or non fasting a. If blood glucose > 300, obtain a urine dip to assess for ketonuria Liver Function tests Random urine for microalbumin Electrocardiogram Page 2 of 7
3 Pneuomovax if patient has never received and has no contraindications a. Contraindications for the administration of pneumovax include: i. Moderate or severe acute illness ii. Severely compromised cardiovascular or pulmonary function iii. Use of antibiotic prophylaxis iv. Impaired immune system Annual Flu shot if patient has not received and has no contraindications a. Complete documentation for provider s review b. Record last dental exam and eye exam c. If patient has not had, document so that provider is notified. This needs to be documented under Preventative medicine i. Click on PREVENTATIVE MEDICINE 1. Click on counseling 2. Click on annual eye exam and or dental assessment d. Have patient remove shoes for foot inspection Ongoing Management of Diabetic Annual EKG o Every (3) months if > 7.0 o Every (6) months if < 7.0 Fasting Lipid Panel o Check annually o When initiating or changing medication Check at (3) months Check liver functions every (3) months Urine Microalbumin o Annually o If > 30mg. repeat in (3) months o Once treatment is started, monitor every (6) months Annual Flu shot (with exceptions as noted previously) Acute/Sick Visit o Blood sugar, document fasting or non-fasting o If > 300, obtain urine dip to assess for ketonuria o Complete documentation for provider s review o Record last dental exam and eye exam o Have patient remove shoes for foot inspection Page 3 of 7
4 Hypertensive Patients on diagnosis and on-going Lipid Panel initially and annually CMP panel initially and annually Electrocardiogram initially and annually Urine initially and annually for microalbumin/creatinine Well Woman Exams Document date of LMP and of last PAP. If pap was done by a provider outside of PATHS, have the patient sign a record release to obtain documentation of this. Document date, location and effort to obtain documentation in chart. Document whether or not the patient has ever had an abnormal pap smear. If no PAP has every been done, document for provider to educate the patient Document number of pregnancies and their outcomes (i.e., miscarriage, abortion, etc ) If patient will need a mammogram, place the form in the room for the provider Signatures: Medical Director Page 4 of 7
5 Director of Clinical Operations Page 5 of 7
6 General Patient Work Up 1. Get T-P-R, B/P Ht. and Wt 2. Document LMP-obtain copy of most recent pap smear report 3. Document patient s chief complaint and Review for labs, diagnostic testing or referrals that need follow up with patient and document status and/or need for provider follow up. 4. Review and update medication list and drug allergies. If patient needs medication refills, document needed prescriptions. 5. Alert provider to review findings as needed. Hypertensive Patients on diagnosis and ongoing Lipid Panel initially and annually CMP panel initially and annually Electrocardiogram initially and annually Urine initially and annually for microalbumin/creatinine Standing orders for Patient Work ups (8/09) Rooming Diabetic Patients Newly diagnosed diabetic Obtain: blood glucose document fasting or non fasting Liver Function tests Random urine for microalbumin/creatinine ration of no blood found in urine dip Electrocardiogram Pneuomovax ( if not previously done) Annual Flu shot a. Complete documentation for provider s review b. Record last dental exam and eye exam c. Remove shoes for foot inspection Ongoing Management of Diabetic o Every (3) months if > 7.0 o Every (6) months if < 7.0 Fasting Lipid Panel o Check annually o When initiating or changing medication Check at (3) months Check liver functions every (3) times (1) year Urine Microalbumin/Creatinine ration: o Annually o o If > 30mg. repeat in (3) months Once treatment is started, monitor every (6) months Annual Flu shot Acute/Sick Visit o Blood sugar (document fasting or non-fasting o Complete documentation for provider s review o Record last dental exam and eye exam o Remove shoes for foot inspection Page 6 of 7
7 Page 7 of 7
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