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

TSWF Mil ild Traumatic Brain In Injury ry (mTBI) AIM IM Form Training May May-Aug 2020 Form rm Version “Medically Ready Force…Ready Medical Force” 1

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”

mTBI Updates Changed the ‘Initial Visit’ tab to ‘NSI’ “Medically Ready Force…Ready Medical Force” 4

mTBI Updates Changed the ‘Follow Up Management’ tab to ‘PCM Follow Up’ “Medically Ready Force…Ready Medical Force” 5

Objectives Training Objective: Identify the clinical workflows, screeners and tools available in the TSWF mTBI Form Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Define mTBI and severity levels • Verbalize the workflow of the MACE 2 and its appropriateness only in initial visits • Summarize the elements on the Technician Tab including Management Notes, a Neurobehavioral Symptom Inventory (NSI) for every visit, and Exertional Testing • Differentiate the elements completed during an initial visit versus those done during follow-up management “Medically Ready Force…Ready Medical Force” “Medically Ready Force…Ready Medical Force”

mTBI Form His istory The mTBI form has been in development since 2014. In partnership with Defense and Veterans Brain Injury Center (DVBIC) and Quad-Services, this primary care form provides the appropriate guidance at the point of care. As awareness of TBI increases, primary care providers need a simple and standardized means of treating patients and documenting care. ❑ Form Elements ❑ Facilitate diagnosis, treatment, referral ❑ Facilitate use of required algorithms ❑ Align with and Complement TBI Education and Training Programs ❑ Documentation support ❑ Document elements required by CPG and Algorithms ❑ Make as much of this data mineable as possible (e.g. MACE 2) ❑ Outcomes collection ❑ Give providers an easy way to document required data (e.g. NSI) ❑ Make outcomes data elements mineable “Medically Ready Force…Ready Medical Force”

mTBI Screener – New Version Guided Yes/No questions prompt support staff Button opens the TSWF mTBI AIM form “Medically Ready Force…Ready Medical Force”

Navigating th the TSWF mTBI AIM IM Form Information carries over from the CORE form and is populated here A link is provided to download and print the MACE 2 card “Medically Ready Force…Ready Medical Force” 9

MACE 2 Tab MACE 2 2 Ass ssessment Questions The MACE 2 ribbon contains a place to document the results of all 17 assessment questions. Utilize the MACE 2 for the initial visit ONLY. “Medically Ready Force…Ready Medical Force” 10

MACE 2 Tab MACE 2 2 Ass ssessment Questions (c (cont.) MACE Question 3 describes common symptoms after a concussion. Question 4 looks at historical data. “Medically Ready Force…Ready Medical Force” 11

Sc Screening/Red Fl Flags/MACE 2 Tab MACE 2 2 Ass ssessment Questions (c (cont.) “Medically Ready Force…Ready Medical Force” 12

MACE 2 Tab Cog ognitiv ive Su Summary ry an and MACE 2 2 Resu sults Clinical clues are found throughout and give relevant information Here are MACE results by category. The staff should notify the provider immediately for any red flag items and to move ahead to the Tech tab. “Medically Ready Force…Ready Medical Force” 13

Tech Tab Medic Management Specific tab dedicated to notes and an NSI are Tech/Medic/Corpsman required at every visit workflow. Will be used for initial and follow-up appts. “Medically Ready Force…Ready Medical Force” 14

Tech Tab Perform exertional testing when ready to return to duty “Medically Ready Force…Ready Medical Force” 15

HPI/PFSH Tab • Defines mTBI • Provides for the PCM HPI • Outlines red flag items and items which should lead to an immediate CT scan “Medically Ready Force…Ready Medical Force” 16

HPI/PFSH Tab Copy forward areas (always in yellow) copy info forward from other TSWF forms and Med. Rec. “Medically Ready Force…Ready Medical Force” 17

ROS Tab A TBI ROS, saying the NSI has been completed can be checked “Medically Ready Force…Ready Medical Force” 18

PE Tab PE as seen in all TSWF forms “Medically Ready Force…Ready Medical Force” 19

NSI Tab Used by provider for initial visit and follow- up management. NSI is found here. “Medically Ready Force…Ready Medical Force” 20

NSI Tab Link to the mTBI CPG guidance Definition of the initial mTBI severity (may be different than later symptoms’ severity) “Medically Ready Force…Ready Medical Force” 21

PCM Follow Up Tab CPG’s algorithm for complete TBI care, including when to perform exertional testing for return to duty “Medically Ready Force…Ready Medical Force” 22

PCM Follow Up Tab NS NSI Since the NSI is done at each visit, it is included here “Medically Ready Force…Ready Medical Force” 23

PCM Follow Up Tab Pre-positioned text with suggested PCM management items and exertional testing “Medically Ready Force…Ready Medical Force” 24

PCM Follow UP Tab Stages for and guidance of progressive return to duty “Medically Ready Force…Ready Medical Force” 25

Education & Coding Tab • Assists in defining mTBI injury and AOC, LOC, or PTA • Defines initial mTBI severities, contrasting these severities with potential severities of later symptoms “Medically Ready Force…Ready Medical Force” 26

Education & Coding Tab Links to handouts “Medically Ready Force…Ready Medical Force” 27

Education and Coding Tab Cod odin ing In Instructions s & Workflows Coding of initial and follow-up visits with commonly-used and rehab codes “Medically Ready Force…Ready Medical Force” 28

Education and Coding Tab Cod odin ing In Instructions s & Workflows ELSE coding structure: Etiology, Location, Severity, Encounter “Medically Ready Force…Ready Medical Force” 29

Education and Coding Tab Cod odin ing In Instructions s & Workflows • DoD-unique TBI codes • TBI screening codes • Deployment status codes “Medically Ready Force…Ready Medical Force” 30

TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/ “Medically Ready Force…Ready Medical Force” 31

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”