TSWF Procedures AIM Form Training May 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 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 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 Updates Updated 'Pain Treatment history' section on the Exit CCP tab “Medically Ready Force…Ready Medical Force” 6
CORE Compatible 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 Procedures Form Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • 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) • Understand how to correctly document Counseling & Consent elements, Common Procedures, etc. “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force”
HPI/PFSH & Additional Tabs Links to TSWF website, TSWF Navigator, MilSuite and Change Log An entire visit can be documented using the Procedures form, as the first six tabs mirror the CORE form “Medically Ready Force…Ready Medical Force”
HPI/PFSH 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 Tab Test for colorectal cancer screening HEDIS measure can be documented here “Medically Ready Force…Ready Medical Force”
HPI/PFSH Tab “Medically Ready Force…Ready Medical Force”
HPI/PFSH Tab continued “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 resources on tobacco cessation “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 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 ‘Performs Armed Duty’ question “Medically Ready Force…Ready Medical Force”
BH/Other Screening Tab Note clinical clue on the Depression Screening ribbon “Medically Ready Force…Ready Medical Force”
BH/Other Screening Tab C-SS SSRS 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”
PE Tab Links to resources on the detection of cognitive impairment “Medically Ready Force…Ready Medical Force”
Counseling and Consent Tab Top section can be used to document any procedure Form can be used for pediatric patients “Medically Ready Force…Ready Medical Force”
Counseling and Consent Tab Links are provided for iMedConsent and OF 522 (Request for Administration of Anesthesia and Performance of Operations and Other Procedures form) “Medically Ready Force…Ready Medical Force”
Counseling and Consent Tab Document chain of custody for tissue specimen handling “Medically Ready Force…Ready Medical Force”
Common Procedures Tab “Medically Ready Force…Ready Medical Force”
Common Procedures Tab Some common CPT codes for several procedures are listed Pre-positioned text should be edited to match what was done during the procedure “Medically Ready Force…Ready Medical Force”
Common Procedures Tab “Medically Ready Force…Ready Medical Force”
Female-Only Procedures Tab “Medically Ready Force…Ready Medical Force”
Female-Only Procedures Tab Additional text field within the COLPOSCOPY ribbon “Medically Ready Force…Ready Medical Force”
Female-Only Procedures Tab Example of a female-only procedure that can be quickly edited to complete documentation “Medically Ready Force…Ready Medical Force”
Female-Only Procedures Tab IUD COUNSELING ribbon available “Medically Ready Force…Ready Medical Force”
GXT/ECG/P /PFTs/Others Tab “Medically Ready Force…Ready Medical Force”
Cardiopulmonary ry Stu tudies ECG Ri Ribbon Open Clicking the down arrow to the right of a term will open the Medcin tree, displaying more specific related items “Medically Ready Force…Ready Medical Force”
Cardiopulmonary ry Stu tudies ECG Ri Ribbon Open (c (cont.) Close this view of trees Shift trees to opposite side of screen Document presence or absence of specific findings by clicking ‘+’ or ‘ - ’ “Medically Ready Force…Ready Medical Force”
Obsolete Terms Review the Obsolete Terms tab for elements that copy forward from previous encounters. This function is very important when performing Copy Forward! If obsolete terms are not deselected, providers may inadvertently sign encounter notes with erroneous past medical history terms. “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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