TSWF Pulmonary CPG AIM Form Training May-Aug 2020 Form Version “Medically Ready Force…Ready Medical Force”
Disclaimer Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data. “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force”
Recent Changes The following group of slides reflect changes made to the form. “Medically Ready Force…Ready Medical Force”
CORE Compatible le Updates Updated the Hepatitis C screening recommendation on the 'Preventive Services Recommendations-All Patients' Ribbon. The new recommendation: 'The USPSTF recommends screening for hepatitis C virus infection in adults aged 18 to 79 years.' “Medically Ready Force…Ready Medical Force” 4
CORE Compatible le Updates Updated the wording in the 'Self-Reported Level of Functioning' row on the PHQ-9 OLD NEW “Medically Ready Force…Ready Medical Force” 5
CORE Compatible le Updates Updated 'Pain Treatment history' section on the Exit CCP tab “Medically Ready Force…Ready Medical Force” 6
CORE Compatible le Updates Updated 'Chronic Pain' ribbon label to say 'Pain Management Care Plan' and verbiage updated within section. Also changed the 'Pain care agreement on file’ to 'Pain Care Informed Consent on File’ “Medically Ready Force…Ready Medical Force” 7
Objectives Training Objective: Identify the clinical workflows, screeners and tools available in the TSWF Pulmonary AIM form as they relate to the VA/DoD Clinical Practice Guidelines Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Understand the importance of the intake questions regarding respiratory history • Understand the documentation requirements found on the HPI tab (Patient Intake/Med Rec/Preventive Services) • Understand the use of various screeners (Travel/Audit-C/Tobacco Use/Annual Questions/Learning Assessment/Military Specific Screening) • Demonstrate the purpose and use of the Pulmonary Disease Chronic Care Plan • Describe the different documentation elements found on the various other tabs (i.e. Initial/Follow- up/Exacerbation, etc.) “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force”
Why Use a TSWF CPG AIM IM Form? • Integrates recommendations from VA/DoD CPGs • Provides easily accessible references for clinical decision-making • Improves continuity of care and healthcare outcomes • Provides links to references for patient education materials • Standardizes documentation “Medically Ready Force…Ready Medical Force”
Why The Training Materials? • To interpret aspects of the TSWF Pulmonary CPG AIM Form that can be incorporated to improve outcomes and prognoses • To identify resources/materials to assist in the evaluation and management of asthma and chronic obstructive pulmonary disease “Medically Ready Force…Ready Medical Force”
TSWF Pulmonary CPG AIM IM Form “Medically Ready Force…Ready Medical Force”
Asthma & COPD “Medically Ready Force…Ready Medical Force”
Not All ll That Wheezes is is Asthma Diagnosis of Asthma • Complete thorough history of asthma symptoms • Rule out alternate diagnosis with testing as indicated • Perform spirometry to establish airway obstructions • FEVI <5 th percentile • Repeat with bronchodilators to establish reversibility DO NOT RELY ON SYMPTOMATOLOGY ALONE! “Medically Ready Force…Ready Medical Force”
Workflow Key Points • Nurse/clinical support staff (CSS) completes CORE • Nurse/CSS loads Pulmonary form if COPD or asthma is reason for visit • Provider takes ‘ownership’ of nurse/CSS note or loads the Pulmonary form if indicated • Provider reviews and completes the note “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Document pulse oximetry “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Answering these six questions at each visit will help paint a clearer clinical picture of your patient “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Text field to input name of patient’s Primary Opioid Provider Support staff updates med list, Provider completes this section *Primary Opioid Provider means that a patient has an agreement in place that authorizes a single provider to write or renew prescriptions for opioid medications. “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Test for colorectal cancer screening HEDIS measure can be documented here “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Remember to document the date of completion for tracking purposes Access the Asthma Control Test thru this link when needed “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Pulmonary Disease Comprehensive Care Plan (CCP): • includes elements recommended by the Pulmonary CPG • is pre-populated, but can be modified as desired by the provider • may be completed gradually, visit by visit, and can be copied forward “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab This is a link to an Asthma Action Plan. It is an excel file, which can be printed as well as copied and pasted into the AddNote section of AHLTA “Medically Ready Force…Ready Medical Force”
HPI/PFSH/CCP Tab Preventive Se Services Recommendations “Medically Ready Force…Ready Medical Force”
Screening Tab Travel Sc Screening/Infectious Di Disease Travel l Sc Screen If appropriate or according to local protocol, complete pre-travel counseling and Infectious Disease Travel Screen Note: blue clinical clues about various diseases “Medically Ready Force…Ready Medical Force”
Screening Tab Links to HHS and smokefree.gov next to Tobacco Questions “Medically Ready Force…Ready Medical Force”
Screening Tab Annual l Questions/Health Lit Literacy These questions need to be completed annually. If more than 12 months have elapsed since last updated, uncheck the red “ X ” to reset the questions to current requirements. The Single Item Literacy Screener (SILS) for assessing health literacy is in the Annual Questions field. If patient’s response is either “often” or “always,” conduct a more thorough assessment (see next slide). “Medically Ready Force…Ready Medical Force”
Screening Tab Healt lth Lit Literacy (c (cont.) If the SILS response is either “often” or “always,” further assessment of the patient’s health literacy is documented here along with an action plan if indicated. While a link to REALM-SF is provided here, any appropriate assessment can be used. “Medically Ready Force…Ready Medical Force”
Screening Tab “Medically Ready Force…Ready Medical Force”
BH/Other Screening Tab De Depression Sc Screening Note clinical clue on the Depression Screening ribbon “Medically Ready Force…Ready Medical Force”
BH/Other Screening Tab C-SS SSRS (c (cont.) Clues give instructions on how to ask the questions “Medically Ready Force…Ready Medical Force”
BH/Other Screening Tab C-SS SSRS (c (cont.) • Complete the summary statement including actions taken • Pre-positioned text is included “Medically Ready Force…Ready Medical Force”
ROS Tab Click to open the ribbon Color-coded ROS items are taken directly from the VA/DoD CPGs “Medically Ready Force…Ready Medical Force”
ROS Tab Open ribbon shows Clinical Features Differentiating COPD and Asthma “Medically Ready Force…Ready Medical Force”
PE Tab Color-coded PE items are taken directly from the VA/DoD CPGs “Medically Ready Force…Ready Medical Force”
PE Tab Ribbon includes a place to document Pre & Post Bronchodilator Spirometry Here are links to resources on the detection of cognitive impairment “Medically Ready Force…Ready Medical Force”
Exit/CCP Tab Document the patient’s understanding of their medication regimen and administration This field includes several NCQA elements for Medical Home recognition. It can be adapted, but we recommend retaining the information listed. “Medically Ready Force…Ready Medical Force”
Exit/CCP Tab • Patients who have multiple chronic conditions may require additional documentation • Document/update additional chronic care plans (CCPs) here “Medically Ready Force…Ready Medical Force”
Exit/CCP Tab “Medically Ready Force…Ready Medical Force”
Obsolete Terms Tab The Obsolete Terms tab removes AHLTA past medical history MEDCIN terms which copy forward and are no longer used, or emit in different areas of the TSWF-AIM forms. “Medically Ready Force…Ready Medical Force”
Reference Tabs The remaining tabs are reference tabs. They do not require input of any patient data. Materials were taken directly from the VA/DoD Guidelines unless otherwise noted “Medically Ready Force…Ready Medical Force”
Initial Tab In “Medically Ready Force…Ready Medical Force”
Initial Tab In “Medically Ready Force…Ready Medical Force”
Initial Tab In “Medically Ready Force…Ready Medical Force”
Potential Alt lternate Dia iagnoses Tab “Medically Ready Force…Ready Medical Force”
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