January Jan-Apr 2020 Form Version These slides were not updated - - PowerPoint PPT Presentation

“Medically Ready Force…Ready Medical Force”

TSWF Behavioral Health Specialty AIM Form January Jan-Apr 2020 Form Version

These slides were not updated during the May-Aug 2020 release but are still relevant

“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”

Objectives

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

• Recognize where BHDP data entry can be utilized (Slide 9)
• Understand the use of the various screeners available and the value of using the Score

Tracker on the Measures tab (Slides 9-15)

• Demonstrate the purpose and use of the following: Treatment Plan and Care Notes: CPG

Decision Support and Patient Resources (Slides 31-38)

“Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force”

General In Information

This form is intended for:

• Behavioral Health Clinics (not for primary care

clinics)

• Adult patients
• Initial Evaluation (full form)
• Follow-up appointments (most of note on last tab)
• Prescribers and therapists

“Medically Ready Force…Ready Medical Force”

General In Information

Form structure:

• Mirrors clinical workflow
• Facilitates use of technicians for screening and intake

documentation (if desired)

• Allows for BHDP data entry
• Provides decision support from VA/DoD CPGs
• Option of limited parallel charting serves as a failsafe measure

for when BHDP latency occurs

“Medically Ready Force…Ready Medical Force”

Best Practice Procedures and Workflows

One of the benefits of this form is that it helps get the clinical support staff involved in patient care. The recommendation is for the support staff to perform the screening and intake documentation.

Patient Enters Data in BHDP/Paper Intake Transfers text data to specified box in AIM Form Provider Reviews Patient Entered Data Documents Provider Input into AIM Form Patient Signs In Note is Opened Provider Completes and Signs Note

Patient Clinical support staff (if available) Provider

“Medically Ready Force…Ready Medical Force”

Screening

Patient Demographic Information and Occupational History will copy forward from appointment to appointment Open the BHDP Data Ribbon to paste text from note output in BHDP The upper part of the Screening tab is designed so that all or part of it can be completed each visit Chief Complaint box for presenting problem

“Medically Ready Force…Ready Medical Force”

Screening

AUDIT-C Sc Score

Links to external websites Important information is in red throughout the form

“Medically Ready Force…Ready Medical Force”

Screening

Some textboxes contain prepositioned text. Typing an ‘x’ within brackets denotes a selection Small boxes throughout the form allow free text entry The lower part of the Screening tab has questions usually completed at the initial visit

“Medically Ready Force…Ready Medical Force”

Measures

For each sequential visit, add a line with the updated scores to keep a running log (may not be needed if BHDP is used) Individual scores need to be filled out in addition to the BH Score Tracker

“Medically Ready Force…Ready Medical Force”

Measures

Pediatric screenings available Adult screenings available

“Medically Ready Force…Ready Medical Force”

Measures

Order of the adult screenings on the Measures tab now matches what’s found in BHDP

“Medically Ready Force…Ready Medical Force”

Measures

Blue text contains helpful tips Individual questions can be completed if the provider desires this level of detail Arrow buttons will expand and collapse ribbons

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

• Both the C-SSRS, Columbia Suicide Severity Rating

Scale, screener and a comprehensive assessment consistent with VA/DoD CPG guidelines are included

• Extensive clinical clues allow for easy reference

when completing the C-SSRS

• Completion of only one screening tool is necessary

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

C-SS SSRS

Clues give instructions

• n how to ask the

questions

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

C-SS SSRS (c (cont.)

Check box added to document patients who do not endorse any items (i.e. answer “No” to items 1,2, and 6)

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

C-SS SSRS (c (cont.)

• Complete the summary

statement including actions taken

• Pre-positioned text for

your convenience

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

C-SS SSRS (c (cont.)

Clear decision matrix for actionable items

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

Risk Assessment and Actions from DoD CPGs

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

COMPREHENSIVE SUICIDE ASSESSMENT consistent with VA/DoD CPG guidelines Open ribbon to access assessment

“Medically Ready Force…Ready Medical Force”

Suicide/Risk Assessment

Comparison of AF Suicide Levels and VA/DoD CPG Risk Levels

“Medically Ready Force…Ready Medical Force”

HPI

Don’t delete the TSWF AIM form identifier!! Don’t delete or type below the four dots ‘….’ Although copying forward items outside of PMH is not recommended, several BH clinics have optimized their documentation by copying forward HPI, serving as a narrative function (does not change from visit to visit in BH setting)

“Medically Ready Force…Ready Medical Force”

Past His istory ry

• For Initial Encounter: Enter Full Past

History

• For first Follow-Up Encounter: delete any

text you do not want to appear in subsequent encounters (click the red ‘X’)

“Medically Ready Force…Ready Medical Force”

ROS

Select ‘All Normal’ and document specifics by exception

“Medically Ready Force…Ready Medical Force”

ROS

Additional ROS can be located by opening this ribbon Free text option for documenting ROS

“Medically Ready Force…Ready Medical Force”

Mental Status & Physical Exam

Safety Questions must be documented here even if free-texting MSE

“Medically Ready Force…Ready Medical Force”

Mental Status & Physical Exam

Optional free text box for MSE documentation This ribbon is closed by default

“Medically Ready Force…Ready Medical Force”

Mental Status & Physical Exam

More common physical exam elements in psychiatry. Note: look for these items in medical/psychiatric patients. Free-text

• ption for

Physical Exam Additional Physical Exam Findings

“Medically Ready Force…Ready Medical Force”

Treatment Pla lan & Care Notes

Document treatments here Document follow up notes with the treatment plan in view

“Medically Ready Force…Ready Medical Force”

Treatment Pla lan & Care Notes

Document additional details in the free text box (REVIEW BOX CONTENTS)

“Medically Ready Force…Ready Medical Force”

Treatment Pla lan & Care Notes

PRESCRIBERS ONLY (Close ribbon after use) Document medications by opening the Medication Ribbon Medication Tracker is helpful when dispensing controlled medications (e.g. add meds)

“Medically Ready Force…Ready Medical Force” Medication Reconciliation and Compliance is broken out into three separate check boxes

Treatment Pla lan & Care Notes

“Medically Ready Force…Ready Medical Force”

Treatment Pla lan & Care Notes

Treatment plan always copies forward, which increases continuity

• f care in f/u notes

Defines terms and lists items to Include in treatment plan Treatment Team Information

“Medically Ready Force…Ready Medical Force”

Treatment Pla lan & Care Notes

Military and Occupational Actions Required

“Medically Ready Force…Ready Medical Force”

CPG Decision Support

CPG Decision Support

• Depression
• Substance Use
• Bipolar Disorder
• PTSD
• Suicide Assessment

CPG links

“Medically Ready Force…Ready Medical Force”

Patient Resources

Links to Patient Resources Click to link to T2 site for BH apps

“Medically Ready Force…Ready Medical Force”

Using This Form

Multiple ribbons with additional form use information

“Medically Ready Force…Ready Medical Force”

TSWF Resource Material

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

“Medically Ready Force…Ready Medical Force”

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/