TSWF Pediatric Nursing Services AIM Form Training May May-Aug 2020 Form Version “Medically Ready Force…Ready Medical Force”
Dis isclaimer Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data. “Medically Ready Force…Ready Medical Force”
Recent Changes • The following group of slides reflect changes made to all CORE compatible forms. The specific training slides for this form follow the change slides. “Medically Ready Force…Ready Medical Force”
Peds General, Peds 7-18 and Peds Nursing Updates A score of 3 or greater on the PHQ-2 Adolescent screening is now considered as positive for all ages. These changes are reflected in the highlighted locations. Updated clinical clue to ‘If the PHQ -2 is positive (score of 3 or higher), complete the PHQ- 9A below and alert provider.’ “Medically Ready Force…Ready Medical Force” 4
Peds Nursing Updates Added the DVPRS elements on the ‘HPI/PMH/ROS’ tab “Medically Ready Force…Ready Medical Force” 5
Objectives Pediatric Nursing Services Training Objective: Identify the clinical workflows, screeners and tools available in the TSWF Pediatric Nursing Services form Pediatric Nursing Services Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Understand that the Pediatric Nursing Services AIM form may be incorporated into scheduled Provider Visit workflows or stand-alone Nursing Visit workflows and T-Cons • Understand the documentation requirements found on the HPI tab (patient intake/Med Rec/Preventive Services) • Verbalize the elements found on the Behavioral Health and Chronic Conditions tabs • Provide an overview on how this form is used to document immunizations, medications, nursing procedures, and patient education “Medically Ready Force…Ready Medical Force”
Agenda • Introduction/Overview • Who can use this form? • Discuss ideal integration and workflow • Basic Reminders • How to use the Peds Nursing AIM Form “Medically Ready Force…Ready Medical Force”
Why Use a TSWF Peds Nursing AIM IM Form? • Creates standardized clinical nursing notes • Daily charting is easier and faster • Provides patient education/counseling notes • Air Force-Specific Notification: This form replaces the need to use the AFMOA-approved support staff protocol questionnaires “Medically Ready Force…Ready Medical Force”
Who should use th the TSWF Peds Nursing AIM IM Form? • ALL services can use the Peds Nursing AIM Form, however there are some service-specific items within the form • Any clinic that administers medications or does routine procedures can benefit from the use of this form • Nurses and Clinical Support Staff • Providers “Medically Ready Force…Ready Medical Force”
In Integration and Workflow Methods of using the TSWF Peds Nursing AIM form: • Provider appointments • In conjunction with most TSWF AIM forms • Stand-alone form for clinical support staff and walk-in clinics “Medically Ready Force…Ready Medical Force”
In Integration and Workflow Example 1 • Starting with a TSWF Peds AIM form, the provider asks the clinical support staff to administer the patient an “Albuterol” treatment. The support staff will pull up the TSWF Peds Nursing AIM form to chart the administration of the treatment. • Proceed directly to the S/O Note when used in conjunction with a provider visit. (Next slide) “Medically Ready Force…Ready Medical Force”
Integration and Workflow In Choose “Add Additional S/O Note” to document the nursing procedure “Medically Ready Force…Ready Medical Force”
In Integration and Workflow Example 2 • A patient is being screened by a nurse or support staff for Thrush. The AIM form can be used to chart the stand- alone procedure in the patient’s encounter (according to the MTF’s or Service’s protocol). • When using for stand-alone nursing procedures, the staff should change their roles and add a supervising provider. “Medically Ready Force…Ready Medical Force”
Basic Reminders • Never set a TSWF AIM form as a default • Add yourself as an additional provider (paraprofessional/nurse) • Create a favorites list using the diagnosis/procedure codes frequently used in the clinic • Always screen for allergies: It pulls the information from CHCS into AHLTA: “Medically Ready Force…Ready Medical Force”
HPI/PMH/ROS Tab TSWF resource information, training request, and/or AIM form change request A summary of changes made to the AIM form “Medically Ready Force…Ready Medical Force”
HPI/PMH/ROS Tab • ‘How to Use FLACC’ link is provided • Complete the ‘Date List Updated’ in the Medicines field Medication Reconciliation: Clinical support staff can complete the field documenting “Medication list updated at the beginning of the visit.” The lower section is for provider use only . “Medically Ready Force…Ready Medical Force”
Behavioral Health Tab Elements on the BH tab include PSC, C.R.A.F.F.T., SCARED and the Vanderbilt scale “Medically Ready Force…Ready Medical Force”
Im Immunizations Tab Overview Document patient’s outcome and observation in the Outcome of Patient section. This section will gray out if completed on a different tab to prevent duplicate documentation. “Medically Ready Force…Ready Medical Force”
Im Immunizations Tab Pre-Vaccination Sc Screenin ing Checkli list All pre-positioned text in the documentation fields can be edited/deleted according to specific needs. “Medically Ready Force…Ready Medical Force”
Im Immunizations Tab Ge General l Vaccin ination Additional immunizations may be entered in the “Additional Vaccinations” text box. “Medically Ready Force…Ready Medical Force”
Immunizations Tab Im PPD Readin ing “Medically Ready Force…Ready Medical Force”
Meds 1 Tab Overview 2 dosage calculators are available to quickly calculate pediatric medication dosages “Medically Ready Force…Ready Medical Force”
Meds 1 Tab Respir iratory ry It’s very important to document everything in this section, especially “Medication Verified By” and “Time Administered” “Medically Ready Force…Ready Medical Force”
Meds 2 Tab Overview “Medically Ready Force…Ready Medical Force”
Meds 2 Tab De Depo Provera Additional notepad added for further documentation of Depo- Provera injection “Medically Ready Force…Ready Medical Force”
Meds 2 Tab IV IV Hydration The Additional IV Hydration text box allows for further IV hydration documentation. “Medically Ready Force…Ready Medical Force”
Meds 2 Tab Syn ynagis is In Injection “Medically Ready Force…Ready Medical Force”
Procedures 1 Tab Overview A link to the TSWF Procedures AIM form gives access to other procedures “Medically Ready Force…Ready Medical Force”
Procedures 1 Tab Respir iratory ry “Medically Ready Force…Ready Medical Force”
Procedures 1 Tab Heel Sti Stick “Medically Ready Force…Ready Medical Force”
Procedures 1 Tab Toe oenail il Removal “Medically Ready Force…Ready Medical Force”
Procedures 2 Tab Overview “Medically Ready Force…Ready Medical Force”
Procedures 2 Tab Thru rush “Medically Ready Force…Ready Medical Force”
Procedures 2 Tab In Inju jury ry Car are “Medically Ready Force…Ready Medical Force”
Procedures 2 Tab Ear ar Irr Irrig igation “Medically Ready Force…Ready Medical Force”
Patient Education 1 Tab Overview “Medically Ready Force…Ready Medical Force”
Patient Education 1 Tab Common Child ildhood Illn Illnesses “Medically Ready Force…Ready Medical Force”
Patient Education 1 Tab Respir iratory ry (2 (2-6 years) “Medically Ready Force…Ready Medical Force”
Patient Education 2 Tab Metaboli lic “Medically Ready Force…Ready Medical Force”
Patient Education 2 Tab Metaboli lic “Medically Ready Force…Ready Medical Force”
Patient Education 2 Tab Se Sexually ly Tran ansmit itted In Infections “Medically Ready Force…Ready Medical Force”
Obsolete Terms Tab *Complete this step at every visit* 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”
TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/ “Medically Ready Force…Ready Medical Force”
Pri rimary Care Clinical Community Content Working Group ▪ DHA - Maj Matthew J Royall ▪ ARMY - Dr. Robert Marshall ▪ AIR FORCE – Dr. Matthew Barnes TSWF Feedback https://www.milsuite.mil/book/groups/tswf TSWF Website http://www.tswf-mhs.com/ “Medically Ready Force…Ready Medical Force”
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