AIM Form Training May May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation

“Medically Ready Force…Ready Medical Force”

TSWF CORE

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 recent changes

made to CORE and all CORE Compatible forms. The specific training slides for this form follow the change slides.

“Medically Ready Force…Ready Medical Force”

CORE Compatible Updates

4

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”

CORE Compatible Updates

5

Updated the wording in the 'Self-Reported Level of Functioning' row on the PHQ-9 NEW OLD

“Medically Ready Force…Ready Medical Force”

CORE Compatible Updates

6

Updated 'Pain Treatment history' section on the Exit CCP tab

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CORE Compatible Updates

7

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”

CORE Compatible Updates

8

Updated the ‘The following procedures are available on the TSWF- Procedures AIM form:’ list to match what is on the Procedures AIM form

“Medically Ready Force…Ready Medical Force”

Objectives

CORE Training Objective: Identify the clinical workflows, screeners and tools available in the TSWF CORE form CORE Learning Objectives: At the conclusion of today’s activity, the participant will be able to:

• Understand the purpose and application of the DVPRS tool for pain screening
• 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 the use of other tabs on the form (i.e. BH/Other Screening, Well

Female/MSK/Spine/Procedures)

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Overv rview

Benefits of TSWF AIM Forms

• Improve continuity of care and healthcare outcomes
• Provide links to references for patient education
• Reduced unwanted variation by standardized documentation

and streamlined workflows

• Provide clinical cues
• Mandated: DHA Procedural Instruction 6025.06 May 16, 2018

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Why Use th the TSWF CORE AIM IM Form?

• Serves as a “one-stop shop,” standardizing care and

simplifying documentation

• Provides easy access to clinical-decision making

resources

• Provides legible notes in shortest amount of time
• Includes many DoD and TJC requirements

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HPI/PFSH Tab

Form version, links to MilSuite, TSWF Navigator, TSWF Website, and Change Log are listed at the top of form

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13

DHA pain assessment includes patient’s report of current pain and pain

• ver the past week. Complete other assessment items as appropriate.

HPI/PFSH Tab

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HPI/PFSH Tab

Include all medical conditions/problems Note the check box if meds not currently taken Document all current meds including OTCs and herbals. Document dosage, route, and frequency.

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HPI/PFSH Tab

Medication Reconcil ilia iation

Support staff updates medication list (and checks box verifying completion) Provider completes “provider use only” section Text field to document patient’s Primary Opioid Provider, if one exists.

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HPI/PFSH Tab

Alle llergie ies

Use the AHLTA allergies module to document pharmaceutical

• allergies. The allergy text field found on previous AIM forms has been

deleted to remove pt. safety risks and ensure allergy related info is properly documented in decision support systems (i.e. Pharmacy) Other allergy-related conditions that are not considered true allergies can be documented in “Medical Conditions” text field.

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HPI/PFSH Tab

Preventive Se Services

Record status of patient’s preventive services here; remove unnecessary lines The Clinical Registries Health Maintenance Report (CRHMR) In the MHS Pop Health Portal consolidates the Patient's preventive services results for easier copying into the TSWF AIM form's Preventive Service field. Training on how to access CarePoint is at http://www.tswf-mhs.com/core-forms/core/.

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HPI/PFSH Tab

Open the ribbon to show more details

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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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For patients who drink alcohol, complete an AUDIT-C if more than a year has passed since the last AUDIT-C or when clinically indicated. Place the score and date of completion in the ‘AUDIT-C’ field.

Screening Tab

Alc lcohol l an and Tob

• bacco

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Clinical clues for reference

Screening Tab

Alc lcohol

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Screening Tab

Verbal/ l/Physical Abuse

If the patient answers “yes,” the ribbon will expand prompting you to ask two additional questions. A link to the Domestic Violence Questionnaire is included here for use as needed. If the patient declines to answer, NOTIFY PROVIDER.

“Medically Ready Force…Ready Medical Force” 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.

Screening Tab

Annual l Questions/Health Lit Literacy

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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If the SILS response is either “often” or “always,” further assessment

• f 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.

Screening Tab

Healt lth Lit Literacy/Mil ilit itary-Specific

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BH/Other Screening Tab

This tab is used to screen for depression, suicidality, PTSD, anxiety, TBI, and sleepiness. Follow Service or local guidance.

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BH/Other Screening Tab

PHQ-2/PHQ-9

If the PHQ-2 is positive, complete the full PHQ-9 and NOTIFY the provider.

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BH/Other Screening Tab

C-SS SSRS

Cues give instructions on how to ask the questions

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BH/Other Screening Tab

C-SS SSRS

• Open the text box to

complete the summary statement

• Pre-positioned text is

provided, add actions taken

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BH/Other Screening Tab

PTSD Sc Screenin ing

Place the date the screener was completed in the copy forward field

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BH/Other Screening Tab

PTSD PTSD

DoD requires PTSD screening. Document the SIPS-B result and score here. Ensure documentation of scores in the appropriate boxes. If the SIPS-B is positive (score > 3) complete the PCL-5 and follow local protocols. ALWAYS NOTIFY the provider.

“Medically Ready Force…Ready Medical Force”

BH Screening Tab PTSD Checklist-PCL-5

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ROS Tab

A comprehensive review of systems is included if indicated. Select ‘All Normal’ and document positive items by exception.

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ROS Tab

Click the little box to add free- text to expound upon a specific entry if needed. The box icon will change in appearance after text is entered. Free-text option for documenting ROS

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PE Tab

The auto-normal button selects elements to the left

• f the bold black bar.

Italic font indicates items not routinely performed; these are not selected when the "Normal" button is used, and must be marked manually if examined.

“Medically Ready Force…Ready Medical Force”

PE Tab

Click to see additional MEDCIN tree terms available for each

• system. (Click “Close

Trees” to exit).

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Well Female Tab

Breast Can ancer Ri Risk sk Ass ssessment

Scrolling down on the ‘Well Female’ tab, be sure to open the ribbon to see breast cancer assessment algorithm. A link is provided to the TSWF breast cancer risk assessment form.

“Medically Ready Force…Ready Medical Force”

Well Female Tab

Physical l Exam

Well Female Physical Exam area includes some duplicate items from PE tab, for convenience when documenting these exams.

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MSK Tab

(U (Upper an and Lo Lower Extr xtremit ities)

Upper and lower musculoskeletal exams are combined in this tab, with anatomic areas designated by ribbon labels.

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MSK

Sh Should lder Ri Ribbon Open

Divided into bilateral sections, the ribbon contains two ‘All Normal’ buttons for quick documentation of normal exams

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Spine Tab

RE RED FL FLAGS

For patients with low back pain, be sure to document presence or absence of red flags. Designate an item as positive by clicking the ‘x’ next to yes. An all- negative button is available to document everything as negative.

“Medically Ready Force…Ready Medical Force”

Document self-care management and goals for patients with chronic conditions. This field copies forward to support continuity of care.

Exit/CCP Tab

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Exit/CCP Tab

Lifestyle Questions are on this tab Links to VA/DoD Evidence-Based Clinical Practice Guidelines

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Exit/CCP Tab

Comprehensive Care Plans (CCPs) include pre-populated text designed to help create evidence-based care plans for patients with chronic conditions. Info entered will copy forward into future encounters.

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Exit/CCP Tab

Metaboli lic Di Disorders as as an an example le

• Contains pre-

populated text that can be edited/modified as desired

• Will copy-forward

from visit to visit Enter date when the CCP is updated

“Medically Ready Force…Ready Medical Force”

Procedures Tab

For documentation of many

• ther common procedures,

use the link to the TSWF Procedures AIM Form.

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Obsolete Terms Tab

*Complete this step at every visit at the end of the copy forward process*

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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TSWF Resource Material

The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/

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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/