TSWF Geriatrics AIM Form User Guide January 2018

Transcription

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

2 Table of Contents Geriatrics AIM form Introduction 2 General Information Best Practice Procedures and Workflows. 4 Form Tabs HPI/PFSH... 5 Screening.. 6 BH/Other Screening 7 ROS. 8 PE 9 FIM Incontinence. 11 Falls Dementia Frailty.. 14 OA (Hip/Knee) Hearing Loss 16 Exit/CCP. 17 Procedures 18 Adding Form to Favorites Instructions.. 19 Copy Forward Instructions 22 AHLTA Options

3 Introduction to Geriatrics 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 Geriatrics AIM form is used in the Primary Care setting and can be used alone or in conjunction with the CORE form during an encounter. The form also provides easy access to clinical decisionmaking tools. We ve tailored the form to get the most legible note in the shortest amount of time possible. Who is this form made for? This form is created for Primary Care providers with a focus on geriatrics. It provides additional guidelines for review and documentation of incontinence, falls, dementia, frailty, osteoarthritis (hip/knee), and hearing loss. 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 p22 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 The Geriatrics AIM form is largely similar to the TSWF CORE form in layout, function, and appearance. 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: 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 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: 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. Do NOT delete the TSWF AIM form identifier (integral to the copy-forward process). Start the note below this text. Helpful Tips are found throughout and give relevant information. 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) Based on manning, clinic workflow needs, and leadership preference Data Entered into 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) copies forward previous essential encounter information (highlighted in yellow on the AIM forms), preferably before the day of 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, 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 then completes the rest of the documentation and signs the encounter. 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 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 changes made with each version s update. Click here to access this presentation. 4

6 HPI/PFSH Tab The Geriatrics 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 these past medical history elements. You can identify these because they are highlighted in yellow like you see in the red box below. 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. 5

7 Screening Tab Much of the documentation done by clinical support staff is completed on the Screening tab. Pre-travel counseling and Zika Risk Assessment. Complete if appropriate. This area may change to follow evolving CDC recommendations. The Geriatric Wellness ribbon includes places to document goals of care, living situation, caregiver information, counseling, ADLs and functional ability. The remainder of this tab mirrors the CORE. Begin Health Literacy screening with the SILS question (in Annual Questions). If SILS is positive, further Health Literacy Assessment can be documented in this section using REALM-SF or other appropriate tools. Follow Service or MTF policy. 6

8 BH/Other Screening Tab The Behavioral Health/Other Screening tab has fields that would only be completed if necessary for a particular patient. The provider should let you know if any of these need to be completed for a visit. The only exception is the Suicide Rating Scale. If the patient mentions any kind of suicidal thoughts, complete this area and make sure to inform the provider before they go in to see the patient. As an example, the Geriatric Depression Screening (GDS) ribbon opens to a list of screening questions as well as a checklist of depression symptoms. Blue cues offer clinical guidance on scoring, evaluation and management of geriatric depression. 7

9 ROS Tab Depending on your clinic, either the support staff or the provider might be responsible for completing the ROS tab. A comprehensive review of systems covering the majority of systems is found in the top left grey box. Select All Normal and either deselect or change N to Y as appropriate. Free text option for documenting ROS. To the right of the ROS buttons are buttons with a square in them. That s an area where you can add free-text to expound upon an entry if needed. And once there is text in that box, you ll see the box change to look like this: By clicking on this button you can see what was written, and either add/edit or delete the text as appropriate. These free-text boxes are found throughout the form. 8

10 Physical Exam Tab Click the icon next to each system to see additional MEDCIN tree terms available for that system. (Click Close Trees to exit out). If you document that something is abnormal, further explanation is frequently needed. Free text can be added to any of the exam findings by clicking on the free text box next to the item. Features the auto-normal button which will select those elements to the left of the bar that are not gold. 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 used, and must be marked manually. 9

11 FIM Tab The Functional Independence Measure tab assesses physical and cognitive disability. 10

12 Incontinence Tab The Incontinence tab contains information for evaluation and management of urinary incontinence. Here, the Evaluation and management of urinary incontinence in primary care ribbon is shown expanded. 11

13 Falls Tab The Falls tab is used to assess the risk for falls among geriatric patients. A link to the Johns Hopkins Adult Fall Assessment Tool is provided, which is the standard of care when it comes to assessing falls risk among aging patients. 12

14 Dementia Tab The Dementia tab provides multiple tools for the assessment and management of dementia. The last ribbon offers helpful information on differentiating dementia from depression and delirium. The Screening and Diagnostic Algorithms for Dementia ribbon is shown expanded here. 13

15 Frailty Tab The Frailty tab provides tools for the identification and risk assessment for frailty. The CSHA Clinical Frailty Scale ribbon is shown expanded here. 14

16 OA (Hip/Knee) Tab The OA (Hip/Knee) tab focuses on the diagnosis and management of osteoarthritis. As examples, the Pharmacologic Agents and Algorithm ribbons are shown expanded here. 15

17 Hearing Loss Tab The Hearing Loss tab allows for an extensive hearing assessment and evaluation...helpful clinical guidance is found on the right side of the tab. 16

18 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. Links to RelayHealth and CPGs. The comprehensive care plan (CCP) for Low Back Pain is shown open as an example. Each CCP: Has pre-populated text that can be edited/modified as desired Will copy-forward from visit to visit Includes a Date last updated area which should contain the date the field was last reviewed/updated if not during the current encounter. 17

19 Procedures Tab A link to the TSWF Procedures AIM form is available from this tab but we ve made available items that could be applicable to almost any procedure here within the CORE AIM form (such as documentation of counseling and education as well as the time out information which is required by the Joint Commission). Because ECGs and Spirometry are done fairly often in our clinics, they ve been included here. Remember, for actual documentation of other procedures you are doing (i.e. skin biopsy), utilize the link to the TSWF Procedures AIM form. 18

20 TSWF Geriatrics AIM Form: Adding Form to Favorites Instructions 19

21 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 20

22 7. In the Search Results list: Right click on the TSWF- Geriatrics- (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. 21

23 TSWF Geriatrics AIM Form: Copy-Forward Instructions 22

24 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. 23

25 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. 24

26 8. Select TSWF-Geriatrics AIM form 9. Once in the encounter, go to the Obsolete Terms tab which contains terms from other forms that may Copy-forward to the note, but will NOT appear on the TSWF AIM form. Use the uncheck ALL at every visit to delete any such unwanted documentation. This should be your final step in the copy-forward process. 25

27 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 26

28 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. 27