DHA Clinical Standard Staff Protocol (CSSP) AIM Form Training May May-Aug 2020 Rev. 2 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 slides reflect changes made to the form. The specific training slides for this form follow the change slide. “Medically Ready Force…Ready Medical Force”
Mid id cycle Rev. 1 changes to DHA CSSP forms and In Infectious Dis isease Travel Screening form (As (As of of May 21 21) Removed link to the ‘Infectious Disease Travel Screen’ form on the left-hand side menu of all the DHA CSSP forms “Medically Ready Force…Ready Medical Force” 4
Mid id cycle Rev. 1 changes to DHA CSSP forms and In Infectious Dis isease Travel Sc Screening form (As (As of of May 21 21) On the ‘Infectious Disease Travel Screen’ form, links to all CSSPs except the ‘Adult Cold’ form were removed on the left-hand side. And ‘DHA - CSSP’ has been removed from the title of the form. “Medically Ready Force…Ready Medical Force” 5
Objectives Training Objective: Identify Defense Health Agency (DHA) Clinical Standard Staff Protocol (CSSP) workflows and tools available in the DHA CSSP AIM forms. Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Locate the AHLTA Options • Identify where to find the Inclusion criteria for each CSSP • Identify where to find the Exclusion criteria for each CSSP • Find the clinical clue stating what to do if the patient answers ‘yes’ to any of the Exclusion criteria “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force”
Who created the content for r the DHA CSSP’s? • The content seen in the AIM forms was approved by the Content Management Sub Working Group and PCMH Advisory Board. • With recent DHA reorganization the Primary Care Clinical Community (PCCC) now has content decision making authority and is actively reviewing these protocols. “Medically Ready Force…Ready Medical Force”
Why were th these AIM IM form rms s created and who sh should ld approve the use se on sit site? • DHA-IPM 18-001 • “MTFs will, at a minimum, implement CSSPs for: adult cold, adult sore throat, urinary tract infection, pregnancy test, pediatric cold, and pediatric sore throat in those clinics with high incidence of these conditions. Standard CSSP guidelines will be provided by the DHA for approval at the local level. The direct care system will develop CSSP protocols based on industry- standard algorithms and embed the protocols in TSWF.” • MTFs are advised to follow their Service guidance regarding executive staff review and implementation requirements. “Medically Ready Force…Ready Medical Force”
Where sh should ld I su I submit it content change requests? • All content changes must be submitted through the Remedy system. • This will generate a Remedy Ticket for the Primary Care Clinical Community Content Working Group (PCCCC WG) for review. • You may submit directly through Remedy or the TSWF-MHS site “contact us”. http://www.tswf-mhs.com/support/contact-us/ “Medically Ready Force…Ready Medical Force”
Who should use th these AIM IM forms? • The DHA CSSP AIM forms are intended for nurses and clinical support staff in PCMH clinics to document 6 protocols: Dysuria, Pregnancy Test, Pediatric Cold, Adult Cold, Pediatric Sore Throat and Adult Sore Throat. “Medically Ready Force…Ready Medical Force”
Why would ld I I want to use se the AIM IM form rms? s? • The forms are structured and follow a logical workflow with embedded prompts and cues, the forms provide guided, standardized documentation of work-ups, dispositions, and treatments where applicable. “Medically Ready Force…Ready Medical Force”
Can I I use se the DHA CSS SSP AIM IM form rms s in in conju junctio ion with ith a Provid vider visit visit? • While the CSSP forms are designed for stand-alone encounters, the DHA CSSP forms can be used in conjunction with a Provider visit. • Consider using the "Add an additional note" option when opening the S/O section of AHLTA to clearly identify the support staff documentation if combined with a provider appointment. “Medically Ready Force…Ready Medical Force”
Documentatio ion: : Keepin ing ROS S term rms together in in an encounter • For proper formatting it is recommended that you keep ROS and HPI terms standard. • This will only need to be completed once. “Medically Ready Force…Ready Medical Force”
DHA CSSP Ch Checkin ing Opti tions To change your AHLTA Options, open any clinical encounter to this screen, and click on the Options icon. “Medically Ready Force…Ready Medical Force”
DHA CSSP Ch Checkin ing Opti tions Ensure that the ‘Automatically convert positive ROS findings to HPI’ selection under Options is NOT selected. “Medically Ready Force…Ready Medical Force”
DHA CSSP Work rkfl flow utili tilizin ing DHA CS CSSP SP Recommended Documentation Workflow a. Nurse/Clinical support staff (CSS) opens the appropriate Clinical Standard Staff Protocol (CSSP) based on the patient’s chief complaint. b. The Nurse/CSS follows the CSSP as it flows vertically from top to bottom. • When criteria are met (or if the Provider states to continue with the CSSP when criteria are not met), complete Summary and A/P sections. • If criteria are not met, document the plan according to the Provider’s direction in the Summary section. “Medically Ready Force…Ready Medical Force”
DHA CSSP - Dysuria Use this CSSP to document an encounter for a patient presenting with dysuria symptoms. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Dysuria Ch Chie ief f Co Compla lain int, , Revie view Vit ital l Sig Signs, , Inclu In lusio ion Cr Crit iteria ia The chief complaint is pre-populated with information and simply needs to be checked. Additional Chief Complaint information can be free-texted if desired. For the Review Vital Signs fields of each CSSP, select Select the symptoms for whether or not they fall the Inclusion Criteria. within the CSSP criteria. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Dysuria Exclu lusio ion Cr Crit iteri ria Exclusion criteria is pre-populated with “Yes/No” replies that are specific for each CSSP. Any “yes” response requires provider notification for a plan of care. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Dysuria Su Summary ry, Resu sult lts, Treatment Free text space is Select the available by appropriate clicking the small options. box to the right of each statement. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Dysuria Pati tient Educatio ion, , Follo llow-up up Document that patient was given educational materials by clicking the box. The specific handout can be annotated in the free text box. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Use this CSSP to document an encounter for an adult patient 18-65 years old presenting with sore throat symptoms. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Ch Chie ief f Co Compla lain int, , Revie view vit vital l sig signs, In Inclu lusio ion Cr Crit iteria ia For the Review Vital Signs fields of Document the number of each CSSP, select whether or not days that the patient has they fall within the CSSP criteria. had sore throat symptoms. If they do, proceed to Inclusion criteria . Abnormal vital signs should be repeated after 5 minutes and both sets reported to the provider for plan of care. Any patient not meeting one or more of the Adult Sore Throat Inclusion Criteria should be reported to the provider for plan of care. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Exclu lusio ion Cr Crit iteri ria Every question must be asked of the patient. If any Exclusion criteria is YES, the provider must be notified. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat St Strep Exp xposure, Observ rvatio ions, Dia iagnosis is Decisi ision Su Support rt Field for documenting the score for Strep Pharyngitis is provided. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Su Summary ry, Resu sult lts Each CSSP includes a section with options to document the patient’s Coding guidance is summary of care. provided to be documented in the A/P module of AHLTA when appropriate. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Medic icatio ion Admin inis istratio ion (Bic Bicilli illin) Open this ribbon for pre-populated text for Bicillin administration. “Medically Ready Force…Ready Medical Force”
DHA CSSP – Adult Sore Throat Treatment, Pati tient Educatio ion, Foll llow-up up Medication recommendations A link to a if the patient has patient OTC a PCN allergy. Medication handout is provided. “Medically Ready Force…Ready Medical Force”
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