ALASKA COMMUNITY HEALTH AIDE PROGRAM Standing Orders-January CHA/P Name: Village:

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1 CHA/P Name: Village: Tribal Health Organization: is authorized to treat patients with the Alaska Community Health Aide/Practitioner Manual (echam) ASSESSMENTS that are initialed below according to the PLAN listed in the echam. It is not necessary for the Health Aide to contact the for the initialed ASSESSMENTS unless the problem is severe or the echam directs the Health Aide to do so. For all other ASSESSMENTS, the CHA/P must follow the PLAN in the echam and report according to the specific PLAN or local Tribal Health Organization protocol. These s should be re-authorized and signed every two years or when a change of (s) occurs. With the transition to the echam in January 2015, it is recommended that all CHA/Ps retake their s Exams to demonstrate that they can navigate the echam. On this generic s form, space has been provided for the s signature (and initials) as well as space for an alternate physician s signature. Two physicians signatures are not required; however, some Tribal Health Organizations have considered the advantage of having an alternate in the event that the primary is absent or leaves the position. The echam/clinical competence verification signature space should be signed by the person who can verify that the named Health Aide/Practitioner is clinically competent and consistently and accurately follows the echam to guide their practice. The verifying person could be the Field Staff, Training Center Instructor, or the. This is a generic form developed as a tool to assist organizations in implementing Standing Orders for the Health Aides. It can be modified to fit the needs of the Tribal Health Organization. It is advisable for each Tribal Health Organization to have a written policy regarding s. To learn more about s, please review the echam section, s. Page 1 of 7

2 Session II echam Plan Name and Number Circulatory 2 Digestive 1 Digestive 6 Digestive 10 Digestive 16 Ear 2 Ear 3 Ear 6 Ear 7 Eye 1 Eye 4 Eyelid 2 Eyelid 3 Eyelid 4 Mouth 1 Mouth 3 Mouth 4 Mouth 5 Mouth 6 Mouth 8 Teeth 8 Musculoskeletal 5 Musculoskeletal 6 Musculoskeletal 7 Musculoskeletal 8 Musculoskeletal 10 Respiratory 1 Respiratory 2 Respiratory 3 Anemia from Not Enough Iron in Diet Minor Abdominal Injury Gastroenteritis Hemorrhoids or Anal Fissure Constipation Otitis Media with Effusion Acute Otitis Media Ear Canal Infection Object in Ear Canal Conjunctivitis Blood on Sclera Blepharitis Insect Bite or Sting to Eyelid or Mild Allergic Reaction Stye Canker Sores Mouth Herpes, Recurrent Sores Sore Corners of Mouth Hand, Foot, Mouth Disease Thrush Irritation from Dentures Teething Pain Sprain Neck Pain with Muscle Strain Low Back Pain with Muscle Strain Minor Bruise Under Nail Other Musculoskeletal Injury Minor Chest Injury Common Cold Allergic Rhinitis Page 2 of 7

3 Session II (continued) echam Plan Name and Number Respiratory 5 Respiratory 6 Respiratory 7 Respiratory 11 Respiratory 19 Skin/Soft Tissue 1 Skin/Soft Tissue 2 Skin/Soft Tissue 3 Skin/Soft Tissue 4 Skin/Soft Tissue 5 Skin/Soft Tissue 8 Skin/Soft Tissue 9 Skin/Soft Tissue 10 Skin/Soft Tissue 11 Skin/Soft Tissue 12 Skin/Soft Tissue 13 Skin/Soft Tissue 14 Wounds 1 Wounds 3 Burn 3 Burn 4 Urinary 1 Laryngitis Viral Pharyngitis Strep Throat Bronchitis TB Screening: PPD Mild Allergic Reaction Insect Bite or Sting Dermatitis, Acute or Chronic Impetigo Chickenpox Lice Scabies Diaper Rash Fungus Skin Infection Acne Dandruff Warts Laceration, Abrasion, or Puncture Wound Small Foreign Body Under Skin Minor Burn, 1 st Degree Minor Burn, 2 nd Degree Bladder Infection Alternate * echam and Clinical may be demonstrated by such activities as: PEF and radio traffic review, on site clinical evaluation, and successful completion of s Test. Verifying this competency may be completed by Field Staff, Training Center Instructor, or. Page 3 of 7

4 ALASKA COMMUNITY HEALTH PROGRAM Session III echam Plan Name and Number Child 5 Child 7 Teen 1 Female 1 Female 6 Female 9 Birth Control 3 Birth Control 4 Birth Control 5 Birth Control 6 Male 3 Male 4 Male 6 Pregnancy 1 Pregnancy 2 Pregnancy 5 Pregnancy 15 Postpartum 1 Healthy Child, 2 Weeks to 5 Years Old Healthy Child, Age 6 to 10 Years Teen Health Care Vaginal Discharge, Possible Yeast Infection Patient with Positive Gonorrhea Test or Positive Chlamydia Test Sore or Rash on Genitals: Possible Genital Herpes, Recurrent Sores Starting Other Birth Control Method Refill Birth Control Pills, or Patch, or Vaginal Ring Repeat Depo-Provera Shot Emergency Contraceptive Pills (ECPs) Patient with Positive Gonorrhea Test or Positive Chlamydia Test Genital Rash, Possible Fungus Infection Sore or Rash on Genitals: Possible Genital Herpes, Recurrent Sores Woman Wants to Get Pregnant Negative Pregnancy Test Return Prenatal Visit Prenatal Glucose Tolerance Test Normal Postpartum Patient Alternate * echam and Clinical may be demonstrated by such activities as: PEF and radio traffic review, on site clinical evaluation, and successful completion of s Test. Verifying this competency may be completed by Field Staff, Training Center Instructor, or. Page 4 of 7

5 Session IV echam Plan Name and Number Alcohol/Drug 2 Circulatory 10 Circulatory 11 Digestive 18 *Female 17 Nervous 2 Nervous 20 Respiratory 18 Respiratory 21 Hangover High Blood Pressure, Chronic Care Heart Problem, Chronic Care GERD, Chronic Care *Breast and Cervical Cancer Screening Muscle Tension Headache Chronic Pain, Chronic Care Lung Disease, Chronic Care Patient on TB Medicine * Advanced skill, not part of CHAP Basic Training. Requires additional training. Alternate _ * echam and Clinical may be demonstrated by such activities as: PEF and radio traffic review, on site clinical evaluation, and successful completion of s Test. Verifying this competency may be completed by Field Staff, Training Center Instructor or. Page 5 of 7

6 Additional s For Plans in the echam without a option echam Plan Name and Number Alternate _ * echam and Clinical may be demonstrated by such activities as: PEF and radio traffic review, on site clinical evaluation, and successful completion of s Test. Verifying this competency may be completed by Field Staff, Training Center Instructor or. Page 6 of 7

7 s January 2015 ADDITIONAL STANDING ORDER NOT WRITTEN IN echam AUTHORIZING PHYSICIAN: PLEASE CHECK IF MEDICATION CHANGE OR NEW SKILL 1. List indications for medication or skill. 2. List the risks and benefits that were discussed with CHA/P. 3. List complications and contraindications that were discussed with CHA/P. 4. Describe demonstrated proficiency of knowledge by CHA/P. 5. Describe how the CHA/P demonstrated proficiency of new skill. 6. Describe your plan for skill maintenance. CHAP Director Signature/Date Medical Director Signature/Date Field Supervisor Signature/Date THIS FORM NEEDS TO BE ATTACHED TO THE CHA/P S STANDING ORDER FORM AND COPIES GIVEN TO:, CHAP Director, CHA/P, and Field Supervisor. This is valid ONLY if all signatures are obtained. This must be approved every 2 years. Page 7 of 7