TSWF Nursing Services AIM Form User Guide January 2019 Form Version: Jan-Apr 2019
Table of Contents Nursing Services AIM form Introduction 2 General Information..... 3 Best Practice Procedures and Workflows. 4 Form Tabs HPI/PFSH/ROS. 6 Well Female..... 7 Immunizations..... 8 Meds 1.... 9 Meds 2 10 Procedures 1 12 Procedures 2 13 Patient Education 1.... 14 Patient Education 2. 15 Adding Form to Favorites Instructions.. 16 Copy Forward Instructions 19 AHLTA Options. 23 1
Introduction to Nursing Services 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. Who is this form made for? The TSWF Nursing Services AIM form is recommended to be used to document clear nursing notes for ADULT patients within Patient-Centered Medical Home (PCMH) clinics. The Nursing Services AIM form may be incorporated into scheduled Provider Visit workflows or stand-alone Nursing Visit workflows and T-Cons. Use this form to document intake, screening, administered immunizations, medications, nursing procedures, and patient education & counseling performed at the point-of-care during acute, routine, or other scheduled patient visits. The Nursing Services AIM form is NOT intended for pediatric patients 0-17 years of age (utilize the Pediatric Nursing Services AIM form instead). Additionally, this form is NOT intended to be utilized by Immunization clinics outside of the PCMH clinic. Air Force specific, this form also replaces the need to use the AFMOA-approved support staff protocols questionnaires as they have been incorporated into the TSWF Nursing Services AIM form. Not all elements are completed at every visit or encounter only document what is necessary. The form went live on the AHLTA Enterprise in June 2014. 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 p19 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 Nursing Services AIM form, primarily highlighting the differences between it and the CORE. For full details about the use of the CORE AIM form, please reference the CORE User Guide. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: www.tswf-mhs.com. If you have questions or feedback about this User Guide, please contact us via the following link on MilSuite: https://www.milsuite.mil/book/groups/tswf. 2
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 information forward from one appointment to the next via 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!!) Form Basics: Website for TSWF training, contacting the TSWF team, and many other resources. Access any TSWF form from the Navigator via this link. The Change Log shows the updates made with each version. Clinical clues are found throughout and give relevant information. 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
There are two scenarios where the Nursing Services AIM form can be used; either in conjunction with a provider s visit or during a nursing-only encounter. The way this form is used will differ depending on which scenario is being used. Best Practice Procedures and Workflows (Scenario 1: using the Nursing Services AIM form in conjunction with a provider s visit) Recommended Documentation Workflow for Scenario 1 a. Clinical support staff (CSS) copies forward previous essential encounter information (highlighted in yellow on the AIM forms), up to week prior to the visit via the Open, Not Checked-In option. b. On the day of the visit the CSS checks the patient in, and reviews/updates all copy-forward information (e.g. past history, etc.) in the note with the patient. c. The CSS also enters all required screening information on the screening tab (per MTF protocol) and enters a few details into the HPI section on the first tab of the AIM form. d. The provider then takes ownership of the note (i.e. edits S/O portion of the note) and reviews all copied forward information, and everything entered by the CSS. e. The provider documents encounter and orders point-of-care services as necessary. f. CSS adds an additional S/O note to document completed point-of-care services and notifies provider when completed. g. Provider reviews documented services and signs note when completed. 4
Best Practice Procedures and Workflows (Scenario 2: using the Nursing Services AIM form for nursing-only procedures) Patient Patient Signs In Patient Enters Data on Paper Intake* Clinical Support Staff Completes and Signs Encounter Documents Point-of-Care Services Utilizing the AIM Form Adds a Supervising Provider to the Encounter** Data Entered into AIM Form** *in failover mode **per Service/MTF protocol Note is Opened When using the form for stand-alone nursing procedures, the staff should change their role and add a supervising provider. To do this, from the Current Encounter module, choose Providers from the menu bar along the top of the screen and change the role to Nurse or Paraprofessional. Then add the provider, changing their role to Supervising Provider. NOTE: Copy-forward is important even for nursing-only encounters where this form is used, since it is compatible with the rest of the CORE suite of forms. Remember that only elements placed in yellow fields will copy-forward. The TSWF repository for training/educational materials and updates: www.tswf-mhs.com 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. 5
HPI/PFSH/ROS Tab The Nursing Services 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. DO NOT USE this form for pediatric patients. Instead, utilize the Pediatric Nursing Services AIM form. Under military specific screening, if the question Is the patient currently on a profile/limited duty chit is answered yes, answer the questions below. It is expected that the Service-specific system will be consulted to see if the patient is on profile or not. Text field to input name of patient s primary opioid prescribing provider. All medication charting should include dosage, route and frequency. These statements can be used as shortcuts for documenting steps associated with reconciling medications. Use the AHLTA allergies module to document pharmaceutical allergies. 6
Well Female Tab The Well Female tab contains a lot of information for screening a woman with any femalerelated complaints. You will notice that many of these are in yellow and copy-forward, so you won t have to complete this information every time. Two contraceptive counseling links are included. You ll see several of these buttons in our forms. Clicking here will open a ribbon to show more details. Small boxes throughout the form allow additional free text entry. 7
Immunizations Tab IMPORTANT: This tab is not intended for stand-alone immunization clinics. It is intended to document immunizations performed in the normal workflow of a PCMH clinic that has pointof-care protocols for administering immunizations. Be sure to annotate if the patient is pregnant and verify patient identification. Make sure to complete the Outcome of Patient section. NOTE: once filled out, it will be greyed out on other tabs. Link to CDC Vaccine Information Statements and Immunization Schedule. If needed, open the notepad to document additional vaccinations. Users do not have to document this portion in the AP module, but still must document the CPT code. Each ribbon from this point on (until you get to the Pt Education tabs) includes prepositioned text written in S.O.A.P. note format for easy documentation. All prepositioned text in the documentation boxes can be edited/deleted according to specific needs. ICD-10, CPT, and E&M codes are displayed in blue for easy reference and coding help. Click here for instructions on List Management (found on our TSWF-MHS website). 8
Meds 1 Tab Next are two tabs for the documentation of medication administration. Medications are grouped together by class or how they are used. Adding yourself as a paraprofessional in the beginning of documentation will save you a step later on. See instructions on p5 of this Guide. To make a selection, place an x in between the brackets or simply delete the other option. You will find many multiple choice options such as this as well as Y/N questions that must be answered. It is very important to document everything in this section, especially Time administered. There is a place to document medication verification in each separate medication field. 9
Meds 2 Tab This tab contains the remainder of the medications as well as an area for documentation of IV placements. There is also an Other Meds ribbon for you to add additional medications which may not be listed. Again, it is important for clinical support staff to document the Outcome of Patient after administering medications. Here is the checkbox to document that education was given. Every text box in AHLTA has a 2000-character limit. In boxes like this one with a lot of text, you may need to erase inapplicable content in order have space to add pertinent information. Here is an additional text box for Depo-Provera documentation. Every statement with a Y/N must be addressed by erasing the answer that doesn t apply. On some of the ribbons you will notice a block annotated with AF SSP used. Check if an Air Force support staff protocol (SSP) was used. 10
Meds 2 Tab, cont. Use this field for Lab Draw documentation. This free text field is available to document additional nursing notes regarding IV hydration. CPT and coding blue clinical cues were added to assist the services that allow their clinical support staff to document in the A/P and Diagnosis areas of the encounter. 11
Procedures 1 Tab Following the Medications tabs are two Procedures tabs, grouped by system. At the top of each is a place to verify the patient s identification. The next sections of blocks will provide you with the Counseling and Education (including verification of consent) and Confirmation of patient, procedure and site. Link to imedconsent is a way to virtually sign a consent form. Important information throughout the form is in red. Make sure to complete the Counseling and Education and time-out section. NOTE: once filled out, it will be greyed out on other tabs. The throat culture questions will emit into the note as well as the score. When this section is addressed, these items must be marked with a Y, N or n/a. Centor Scoring Criteria 12
Procedures 2 Tab Similar to Meds, the Procedures are divided into 2 separate tabs. As a reminder, if the Counseling and Education and/or time-out sections have already been completed, they will be greyed out on this tab. There is an Additional Procedures ribbon to document other procedures not found on the form. Clicking the x at the very top of the field populates all the prepositioned text into the note. You must type within the brackets to denote specific selections. 13
Patient Education Tab 1 Use the Patient Education tabs to document items discussed with the patient and to utilize links to patient education materials. Each of these are designed in text box format so they can be easily modified to capture the specific counseling that took place. Patient Education should be documented whenever it is given. The General Information Ribbon includes patient education for Medication counseling, Consult counseling, and Follow-up counseling. Place an x in the bracket of any information that the patient is counseled on. Click the x to indicate that the patient was counseled on the pre-populated text (which again, can be modified as needed). 14
Patient Education Tab 2 Cues in blue as well as a link to Pregnancy educational handouts. The UTI patient education includes a link to helpful information. 15
TSWF Nursing Services AIM Form: Adding Form to Favorites Instructions 16
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 17
7. In the Search Results list: Right click on the TSWF- Nursing Services- 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. 18
TSWF Nursing Services AIM Form: Copy-Forward Instructions 19
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 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. 20
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. 21
8. Select TSWF-Nursing Services 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. 22
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 23
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. 24