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AIM Form Training May May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation
AIM Form Training May May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation
TSWF Low Back Pain CPG AIM Form Training May May-Aug 2020 Form Version Medically Ready ForceReady Medical Force Recent Changes The following group of slides reflect changes made to the form. Medically Ready ForceReady Medical
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CORE Compatible 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 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 Updates
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Updated 'Pain Treatment history' section on the Exit CCP tab
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CORE Compatible 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 Low Back Pain 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 documentation requirements found on the HPI tab (patient intake/Med
Rec/Preventive Services) as well as the importance of noting LBP Red Flags
- Demonstrate the purpose and use of the Low Back Pain Chronic Care Plan
- Understand the use of various screeners (Travel/Audit-C/Tobacco use/Annual
Questions/Learning Assessment/Military Specific Screening)
- Summarize the interventions and recommendations for initial and follow-up management
- f Low Back Pain
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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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Workflow Key Points
- Clinical Support Staff (CSS) completes TSWF LBP form
- r CORE form
- Provider takes “ownership” of the CSS note
- Provider loads TSWF LBP CPG AIM form
- Provider reviews information completed by CSS and
completes the note
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TSWF Navigator
TSWF Navigator takes you to the most current version of the forms
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HPI/PFSH Tab
Form version, links to MilSuite, TSWF Navigator, TSWF Website, and Change Log are listed at the top
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HPI/PFSH
Activ ivity Lim Limit its & Pri rior LB LBP His istory ry
VA/DoD LBP CPG recommends documentation of patient’s limitation of activity and any prior history of low back pain
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HPI/PFSH Tab
Red Flag Flags
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Negative Red Flags
(N (Note Vie iew) NOTE: When red “No” is selected for all the ‘Red Flags’, it will emit as negative or “NO” in Note View
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Positive Red Flags
NOTE:
If only a few positive ‘Red Flags’ are selected “Yes”, then the Note View will
- nly show those
selected
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Positive Red Flags
(N (Note Vie iew)
NOTE:
When red “Yes” is selected for all the ‘Red Flags’, it will emit as positive in Note View
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HPI/PFSH Tab
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HPI/PFSH Tab
Medication Reconcil ilia iation
Support staff updates medication list (and checks box verifying completion) 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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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
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) 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
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Screening Tab
Healt lth Lit Literacy/Mil ilit itary-Specific
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
Document if visit is deployment related here
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Screening Tab
Mili ilitary ry-Specific Sc Screenin ing ‘Performs Armed Duty’ question
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BH/Other Screening Tab
De Depression Sc Screening Note clinical clue on the Depression Screening ribbon
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BH/Other Screening Tab
C-SS SSRS
Clues give instructions on how to ask the questions
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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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BH/Other Screening Tab
PTSD Sc Screenin ing
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BH/Other Screening Tab
PTSD Checkli list-PCL-5
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LB LBP ROS/P /PE Tab
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LB LBP ROS/P /PE Tab
- LBP-Specific PE is helpful when you are referring to Neurology/
Orthopedics
- Spinal Levels on the left correlate with sensation, motor strength and
reflexes as you move to the right
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LB LBP ROS/P /PE Tab
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LB LBP ROS/P /PE Tab
Cervical l Sp Spin ine/Neck Ri Ribbon
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LB LBP ROS/P /PE Tab
Additional Ri Ribbons
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Additional ROS Tab
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Additional PE Tab
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Additional PE Tab
Psych Links to resources on the detection of cognitive impairment
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Exit/CCP Tab
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Exit/CCP Tab
CCP Ri Ribbons
- 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
CCP Ri Ribbons
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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.
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LB LBP In Initial Eval/Mgmt Tab
For non-specific and non-severe sciatic LBP, routine imaging and labs in the first four weeks and use of second line medications are not recommended
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In Initial Eval/Mgmt Tab
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Follow-Up/M /Management Tab
Sa Sample Alg lgorithm
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Follow-Up/M /Management Tab
CPG Recommendations
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TSWF Resource Material
The TSWF repository for training/educational materials and updates: www.tswf-mhs.com
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