(CSSP) AIM Form Training May May-Aug 2020 Rev. 2 Form Version - - PowerPoint PPT Presentation

“Medically Ready Force…Ready Medical Force”

DHA Clinical Standard Staff Protocol (CSSP) AIM Form Training May May-Aug 2020 Rev. 2 Form Version

“Medically Ready Force…Ready Medical Force”

Disclaimer

“Medically Ready Force…Ready Medical Force”

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 slides reflect changes made to the

• form. The specific training slides for this form follow

the change slide.

“Medically Ready Force…Ready Medical Force”

Mid id cycle Rev. 1 changes to DHA CSSP forms and In Infectious Dis isease Travel Screening form (As

(As of

• f May 21

21)

4

Removed link to the ‘Infectious Disease Travel Screen’ form on the left-hand side menu of all the DHA CSSP forms

“Medically Ready Force…Ready Medical Force”

Mid id cycle Rev. 1 changes to DHA CSSP forms and In Infectious Dis isease Travel Sc Screening form (As

(As of

• f May 21

21)

5

On the ‘Infectious Disease Travel Screen’ form, links to all CSSPs except the ‘Adult Cold’ form were removed on the left-hand side. And ‘DHA-CSSP’ has been removed from the title of the form.

“Medically Ready Force…Ready Medical Force”

Objectives

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Training Objective: Identify Defense Health Agency (DHA) Clinical Standard Staff Protocol (CSSP) workflows and tools available in the DHA CSSP AIM forms. Learning Objectives: At the conclusion of today’s activity, the participant will be able to:

• Locate the AHLTA Options
• Identify where to find the Inclusion criteria for each CSSP
• Identify where to find the Exclusion criteria for each CSSP
• Find the clinical clue stating what to do if the patient answers ‘yes’ to any of the Exclusion

criteria

“Medically Ready Force…Ready Medical Force”

Who created the content for r the DHA CSSP’s?

• The content seen in the AIM forms was approved

by the Content Management Sub Working Group and PCMH Advisory Board.

• With recent DHA reorganization the Primary Care

Clinical Community (PCCC) now has content decision making authority and is actively reviewing these protocols.

“Medically Ready Force…Ready Medical Force”

Why were th these AIM IM form rms s created and who sh should ld approve the use se on sit site?

• DHA-IPM 18-001
• “MTFs will, at a minimum, implement CSSPs for: adult cold, adult sore

throat, urinary tract infection, pregnancy test, pediatric cold, and pediatric sore throat in those clinics with high incidence of these conditions. Standard CSSP guidelines will be provided by the DHA for approval at the local level. The direct care system will develop CSSP protocols based on industry-standard algorithms and embed the protocols in TSWF.”

• MTFs are advised to follow their Service guidance

regarding executive staff review and implementation requirements.

“Medically Ready Force…Ready Medical Force”

Where sh should ld I su I submit it content change requests?

• All content changes must be submitted through

the Remedy system.

• This will generate a Remedy Ticket for the Primary Care Clinical

Community Content Working Group (PCCCC WG) for review.

• You may submit directly through Remedy or the TSWF-MHS site

“contact us”. http://www.tswf-mhs.com/support/contact-us/

“Medically Ready Force…Ready Medical Force”

Who should use th these AIM IM forms?

• The DHA CSSP AIM forms are intended for nurses

and clinical support staff in PCMH clinics to document 6 protocols: Dysuria, Pregnancy Test, Pediatric Cold, Adult Cold, Pediatric Sore Throat and Adult Sore Throat.

“Medically Ready Force…Ready Medical Force”

Why would ld I I want to use se the AIM IM form rms? s?

• The forms are structured and follow a logical

workflow with embedded prompts and cues, the forms provide guided, standardized documentation

• f work-ups, dispositions, and treatments where

applicable.

“Medically Ready Force…Ready Medical Force”

Can I I use se the DHA CSS SSP AIM IM form rms s in in conju junctio ion with ith a Provid vider visit visit?

• While the CSSP forms are designed for stand-alone

encounters, the DHA CSSP forms can be used in conjunction with a Provider visit.

• Consider using the "Add an additional note" option

when opening the S/O section of AHLTA to clearly identify the support staff documentation if combined with a provider appointment.

“Medically Ready Force…Ready Medical Force”

Documentatio ion: : Keepin ing ROS S term rms together in in an encounter

• For proper formatting it is recommended that you

keep ROS and HPI terms standard.

• This will only need to be completed once.

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DHA CSSP

Ch Checkin ing Opti tions

To change your AHLTA Options, open any clinical encounter to this screen, and click on the Options icon.

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DHA CSSP

Ch Checkin ing Opti tions

Ensure that the ‘Automatically convert positive ROS findings to HPI’ selection under Options is NOT selected.

“Medically Ready Force…Ready Medical Force”

DHA CSSP

Work rkfl flow utili tilizin ing DHA CS CSSP SP

Recommended Documentation Workflow

• a. Nurse/Clinical support staff (CSS) opens the appropriate

Clinical Standard Staff Protocol (CSSP) based on the patient’s chief complaint.

• b. The Nurse/CSS follows the CSSP as it flows vertically from

top to bottom.

• When criteria are met (or if the Provider states to

continue with the CSSP when criteria are not met), complete Summary and A/P sections.

• If criteria are not met, document the plan according to

the Provider’s direction in the Summary section.

“Medically Ready Force…Ready Medical Force”

DHA CSSP - Dysuria

Use this CSSP to document an encounter for a patient presenting with dysuria symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Dysuria

Ch Chie ief f Co Compla lain int, , Revie view Vit ital l Sig Signs, , In Inclu lusio ion Cr Crit iteria ia

Select the symptoms for the Inclusion Criteria. For the Review Vital Signs fields of each CSSP, select whether or not they fall within the CSSP criteria. The chief complaint is pre-populated with information and simply needs to be checked. Additional Chief Complaint information can be free-texted if desired.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Dysuria

Exclu lusio ion Cr Crit iteri ria

Exclusion criteria is pre-populated with “Yes/No” replies that are specific for each CSSP. Any “yes” response requires provider notification for a plan of care.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Dysuria

Su Summary ry, Resu sult lts, Treatment

Select the appropriate

• ptions.

Free text space is available by clicking the small box to the right

• f each

statement.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Dysuria

Pati tient Educatio ion, , Follo llow-up up

Document that patient was given educational materials by clicking the box. The specific handout can be annotated in the free text box.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Use this CSSP to document an encounter for an adult patient 18-65 years old presenting with sore throat symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Ch Chie ief f Co Compla lain int, , Revie view vit vital l sig signs, In Inclu lusio ion Cr Crit iteria ia

For the Review Vital Signs fields of each CSSP, select whether or not they fall within the CSSP criteria. If they do, proceed to Inclusion

• criteria. Abnormal vital signs

should be repeated after 5 minutes and both sets reported to the provider for plan of care. Any patient not meeting one or more of the Adult Sore Throat Inclusion Criteria should be reported to the provider for plan of care. Document the number of days that the patient has had sore throat symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Exclu lusio ion Cr Crit iteri ria

If any Exclusion criteria is YES, the provider must be notified. Every question must be asked of the patient.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

St Strep Exp xposure, Observ rvatio ions, Dia iagnosis is Decisi ision Su Support rt

Field for documenting the score for Strep Pharyngitis is provided.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Su Summary ry, Resu sult lts

Each CSSP includes a section with options to document the patient’s summary of care.

Coding guidance is provided to be documented in the A/P module of AHLTA when appropriate.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Medic icatio ion Admin inis istratio ion (Bic Bicilli illin)

Open this ribbon for pre-populated text for Bicillin administration.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Sore Throat

Treatment, Pati tient Educatio ion, Foll llow-up up

A link to a patient OTC Medication handout is provided. Medication recommendations if the patient has a PCN allergy.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Cold

Use this CSSP to document an encounter for an adult patient 18-65 years old presenting with cold symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Cold

Ch Chie ief f Co Compla lain int, , Revie view vit vital l sig signs, In Inclu lusio ion Cr Crit iteria ia

Abnormal vital signs should be repeated after 5 minutes and both sets reported to the provider for plan of care. Any patient not meeting one or more of the Adult Sore Throat Inclusion Criteria should be reported to the provider for plan of care. Always take note of the clinical clues as they provide pertinent information specific to each CSSP.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Cold

Exclu lusio ion Cr Crit iteri ria

Every question must be asked of the patient. If any Exclusion criteria is YES, the provider must be notified. This is an area to document differential criteria for

• influenza. Ask the patient if

two or more of the Differential criteria have been present for less than 48 hours.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Cold

Su Summary ry, Resu sult lts, Treatment, Co Codin ing Guid idance

Editable free text box is provided in the Treatment section. If the provider made another plan of care, specify the plan in the free text box.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Adult Cold

Pati tient Educatio ion, , Follo llow-Up, OTC C Treatment, Treatment Opti tions

A listing of OTC treatments is provided. The Follow-Up free text box is editable.

“Medically Ready Force…Ready Medical Force”

DHA – In Infectious Dis isease Travel 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”

DHA CSSP – Pediatric Sore Throat

Use this CSSP to document an encounter for a pediatric patient presenting with sore throat symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Chie ief Compla lain int, , Revie view vit vital l sig signs, In Inclu lusio ion crit riteria ia

The chief complaint is pre-populated with information and simply needs to be checked. Additional Chief Complaint information can be free-texted if desired. If the patient does not meet the Inclusion Criteria with one or more symptoms, continue to the Summary section to document actions taken.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Exclu lusio ion Cr Crit iteri ria

If any Exclusion criteria is YES, the provider must be notified. Every question must be asked of the patient.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

St Strep Exp xposure, Observ rvatio ions, Dia iagnosis is Decisi ision Su Support rt

Field for documenting the score for Strep Pharyngitis is provided.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Su Summary ry, Resu sult lts

A pre-populated text field is provided to document a throat swab. ICD-10 and E&M Codes are provided in the Clinical Clues.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Treatment

Medication recommendations if the patient has a PCN allergy.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Pati tient Educatio ion, , Follo llow-Up Up

Document any patient education materials that were provided to the patient. Document patient follow-up, edit as needed.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Sore Throat

Medic icatio ion Admin inis istratio ion (Bic Bicilli illin)

Open the ribbon for a pre-populated S.O.A.P. note is provided for Bicillin administration.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Cold

Use this CSSP to document an encounter for a pediatric patient presenting with cold symptoms.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Cold

Ch Chief f Co Compla lain int, , Revie view vit vital l si signs, In Inclu lusio ion Cr Crit iteria ia

The chief complaint is pre-populated with information and simply needs to be checked. Additional Chief Complaint information can be free-texted if desired.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Cold

Exclu lusio ion Cr Crit iteri ria

Every question must be asked of the patient. This is an area to document differential criteria for

• influenza. Ask the patient if

two or more of the Differential criteria have been present for less than 48 hours.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Cold

Su Summary ry, Resu sult lts, Treatment

If the provider made another plan of care, specify the plan in the free text box. Editable free text box is provided in the Treatment section.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pediatric Cold

Patie ient Educatio ion, , Follo llow-Up, OTC Treatment, Add’l Treatment Opti tions

Each CSSP contains Patient Education and Handouts if available. If indicated,

• ver the

counter treatment information is provided.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pregnancy Test

Use this CSSP to document an encounter for a patient presenting for pregnancy test. Click on the link to view the Pregnancy DHA CSSP Algorithm.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pregnancy

Chie ief Compla lain int, , Revie view vit vital l sig signs, In Inclu lusio ion Cr Crit iteria ia, Exclu lusio ion Cr Crit iteria ia

The chief complaint is pre-populated with information and simply needs to be checked. Additional Chief Complaint information can be free-texted if desired. If any Exclusion criteria is YES, the provider must be notified.

“Medically Ready Force…Ready Medical Force”

DHA CSSP – Pregnancy

Su Summary ry, Resu sult lts, Treatment, Follo llow-Up, and Co Codin ing Guid idance

If the provider made another plan of care, specify the plan in the free text box.

“Medically Ready Force…Ready Medical Force”

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/