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 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”
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 Patient Enters Data in Patient Patient Signs In BHDP/Paper Intake Transfers text Clinical support staff data to specified Note is Opened box in AIM Form (if available) Provider Reviews Documents Provider Completes Provider Patient Entered Provider Input and Signs Note Data into AIM Form 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. “Medically Ready Force…Ready Medical Force”
Screening The upper part of the Screening tab is designed so that all or part of it can be completed each visit Open the BHDP Data Ribbon to paste text from note output in BHDP Chief Complaint box for presenting problem Patient Demographic Information and Occupational History will copy forward from appointment to appointment “Medically Ready Force…Ready Medical Force”
Screening AUDIT-C Sc Score Links to external Important information is in red websites throughout the form “Medically Ready Force…Ready Medical Force”
Screening The lower part of the Screening tab has questions usually completed at the initial visit Small boxes throughout the form allow free text entry Some textboxes contain prepositioned text. Typing an ‘x’ within brackets denotes a selection “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 Adult screenings available Pediatric 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 Arrow Individual questions can be buttons will completed if the provider expand and desires this level of detail collapse ribbons Blue text contains helpful tips “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 on 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 Open ribbon to access assessment COMPREHENSIVE SUICIDE ASSESSMENT consistent with VA/DoD CPG guidelines “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!! Although copying forward items outside of Don’t delete or type PMH is not recommended, several BH clinics below the four dots ‘….’ 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 Free text option for documenting ROS Additional ROS can be located by opening this ribbon “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 option 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”
Treatment Pla lan & Care Notes Medication Reconciliation and Compliance is broken out into three separate check boxes “Medically Ready Force…Ready Medical Force”
Treatment Pla lan & Care Notes Treatment Team Information Defines Treatment plan terms and always copies forward, lists items which increases continuity to Include in of care in f/u notes treatment plan “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 CPG links • Substance Use • Bipolar Disorder • PTSD • Suicide Assessment “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/ “Medically Ready Force…Ready Medical Force”
Recommend
More recommend
