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Disclaimer
“Medically Ready Force…Ready Medical Force”
AIM Form Training May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation
AIM Form Training May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation
TSWF Pulmonary CPG AIM Form Training May-Aug 2020 Form Version Medically Ready ForceReady Medical Force Disclaimer Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data. Medically Ready
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Recent Changes
The following group of slides reflect changes made to the form.
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CORE Compatible le Updates
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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.'
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CORE Compatible le Updates
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Updated the wording in the 'Self-Reported Level of Functioning' row on the PHQ-9 NEW OLD
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CORE Compatible le Updates
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Updated 'Pain Treatment history' section on the Exit CCP tab
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CORE Compatible le Updates
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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’
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Objectives
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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.)
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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
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Why The Training Materials?
- To interpret aspects of the TSWF Pulmonary CPG
AIM Form that can be incorporated to improve
- utcomes and prognoses
- To identify resources/materials to assist in the
evaluation and management of asthma and chronic
- bstructive pulmonary disease
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TSWF Pulmonary CPG AIM IM Form
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Asthma & COPD
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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 <5th percentile
- Repeat with bronchodilators to establish reversibility
DO NOT RELY ON SYMPTOMATOLOGY ALONE!
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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
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HPI/PFSH/CCP Tab
Document pulse oximetry
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HPI/PFSH/CCP Tab
Answering these six questions at each visit will help paint a clearer clinical picture of your patient
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HPI/PFSH/CCP Tab
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.
Text field to input name of patient’s Primary Opioid Provider
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HPI/PFSH/CCP Tab
Test for colorectal cancer screening HEDIS measure can be documented here
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HPI/PFSH/CCP Tab
Remember to document the date of completion for tracking purposes Access the Asthma Control Test thru this link when needed
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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
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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
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HPI/PFSH/CCP Tab
Preventive Se Services Recommendations
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If appropriate or according to local protocol, complete pre-travel counseling and Infectious Disease Travel Screen Note: blue clinical clues about various diseases
Screening Tab
Travel Sc Screening/Infectious Di Disease Travel l Sc Screen
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Screening Tab
Links to HHS and smokefree.gov next to Tobacco Questions
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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).
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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.
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Screening Tab
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BH/Other Screening Tab
De Depression Sc Screening Note clinical clue on the Depression Screening ribbon
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“Medically Ready Force…Ready Medical Force” Clues give instructions on how to ask the questions
BH/Other Screening Tab
C-SS SSRS (c (cont.)
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BH/Other Screening Tab
C-SS SSRS (c (cont.)
- Complete the summary
statement including actions taken
- Pre-positioned text is
included
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ROS Tab
Color-coded ROS items are taken directly from the VA/DoD CPGs Click to open the ribbon
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ROS Tab
Open ribbon shows Clinical Features Differentiating COPD and Asthma
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PE Tab
Color-coded PE items are taken directly from the VA/DoD CPGs
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PE Tab
Here are links to resources on the detection
- f cognitive impairment
Ribbon includes a place to document Pre & Post Bronchodilator Spirometry
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Exit/CCP Tab
This field includes several NCQA elements for Medical Home recognition. It can be adapted, but we recommend retaining the information listed. Document the patient’s understanding of their medication regimen and administration
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Exit/CCP Tab
- Patients who have multiple chronic conditions
may require additional documentation
- Document/update additional chronic care plans
(CCPs) here
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Exit/CCP Tab
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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.
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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
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In Initial Tab
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In Initial Tab
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In Initial Tab
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Potential Alt lternate Dia iagnoses Tab
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Potential Alt lternate Dia iagnoses Tab
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Potential Alt lternate Dia iagnoses Tab
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Severity Assessment Tab
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Severity Assessment Tab
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Severity Assessment Tab
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Severity Assessment Tab
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Follow Up Tab
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Follow Up Tab Asthma
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Follow Up Tab
Asthma Con
- ntrol
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Follow Up Tab
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Follow Up Tab
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Exacerbation Tab
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Exacerbation Tab
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Medications Tab
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Medications Tab
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Medications Tab
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TSWF Resource Material
The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/
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