OB AIM Form Training May May-Aug 2020 Form Version Medically Ready - - PowerPoint PPT Presentation

“Medically Ready Force…Ready Medical Force”

OB AIM Form Training May May-Aug 2020 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”

Objectives

“Medically Ready Force…Ready Medical Force”

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

• Understand the documentation requirements found on the History tab (patient intake/Med

Rec/Preventive Services) as well as the integral copy-forward fields available (Active Problems List/Care Plan/FH/FHT, etc.)

• Understand the use of the various screeners (Travel/Audit-C/Tobacco use/Annual

Questions/Learning Assessment/Military Specific Screening) as well as the Edinburgh Postnatal Depression Scale

• Understand the specific differences between the Intake, Acute, Routine and Postpartum

visit elements

• Understand the use of other tabs on the form (i.e.Tests/OB/Ultrasound/Lactation/Centering

Visit, etc.)

“Medically Ready Force…Ready Medical Force”

Why Use th the OB AIM IM Form?

• Continuity of care and a copy forward process that builds on all

antepartum care

• Follows CPG for depression and domestic violence where previously

many MTFs had no easy way of verifying documentation of this

• Summary of problems list
• Centering visits and pre-positioned text for documentation of

patient involvement

• Easy references for hand out or as information such as bottle

feeding and breast feeding

“Medically Ready Force…Ready Medical Force”

TSWF Navigator

Accessin ing th the OB Form

Select TSWF Navigator

“Medically Ready Force…Ready Medical Force”

TSWF Navigator

Accessin ing th the OB Form

TSWF Navigator takes you to the most current version of the TSWF form Select the TSWF Obstetrics form

“Medically Ready Force…Ready Medical Force”

Accessing Patient’s Health His istory

In the Current Encounter view, select Health History from the left side Folder List, or hover over the Health History tab at the bottom left of the screen

“Medically Ready Force…Ready Medical Force”

Accessing Patient’s Health His istory

This will display the patient’s health history across the bottom portion of the screen, as seen below

“Medically Ready Force…Ready Medical Force”

His istory Tab

In Intake, Pain ain Ass ssessment

Form name and version are listed at the top of each tab Complete the History tab first at every visit

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His istory Tab

In Intake, Pain ain Ass ssessment

Select which visit you are documenting from the available tabs External links are grouped for convenience

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His istory Tab

In Intake

The Intake box includes documentation of visit type: NOB, ROB, Acute, Post-partum, Lactation Consult, or RN Intake Typing above the ‘…..’ helps these data stand

• ut from the next section
• f the note

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His istory Tab

Pain ain Ass ssessment

Pain Assessment includes links to DVPRS

Assess and document pain according to local policy

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His istory Tab

Pregnancy His istory

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His istory Tab

Medical l Con

• ndit

itions, Act ctive OB Problems

Providers who want to populate their problem list at the top of the note should document their problems list here An active problem list is included for issues that may affect GYN health

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His istory Tab

Famil ily, So Socia ial Hx Hx, , Im Imms

If initial visit has been copied forward from CORE AIM form, click

• n red ‘X’ to reset items

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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

Alc lcohol, Tob

• bacco, De

Depression

VA/DoD guidelines recommend screening at wks 6-8, wk 28, and post-partum using either PHQ2 or EPDS VA/DoD recommends routine screening at weeks 6-8, week 28, and post-partum (The AAP recommends EPDS screening at Well Child visits 1, 2, 4, and 6 months)

“Medically Ready Force…Ready Medical Force”

Screening Tab

PHQ-9

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Following the intimate partner violence question are three OB- specific domestic violence questions. VA/DoD recommends routine screening at weeks 6-8, week 28, and post-partum

Screening Tab

Personal l Safety /Jo Joint Commissi sion Questions

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Screening Tab

Annual l Questions/SILS

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)

“Medically Ready Force…Ready Medical Force”

Screening Tab

Healt lth Lit Literacy Ass ssessment

If the SILS response is either “often” or “always,” further assessment of the patient’s health literacy is documented here, with an action plan if indicated. A link to REALM-SF is provided, but any appropriate assessment can be used.

“Medically Ready Force…Ready Medical Force”

Screening Tab

Mili ilitary ry-Specific Sc Screenin ing ‘Performs Armed Duty’ question

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In Intake/New OB Vis isit Tab

A free-text box and a pre-populated template are included on Intake, Routine, and Postpartum Visit tabs. Use only one of these, according to provider preference.

“Medically Ready Force…Ready Medical Force”

In Intake/New OB Vis isit Tab

Red text provides specific documentation instructions

“Medically Ready Force…Ready Medical Force”

In Intake/New OB Vis isit Tab

Clicking the ‘X’ in the upper left corner of the PMH, Surgical hx, Infection Disease hx, and Infection Disease Exposure hx sections will display documentation of negative history for all elements in that section. By doing this, the user can then document individual positive findings.

“Medically Ready Force…Ready Medical Force”

In Intake/New OB Vis isit Tab

Genetic Screening/Teratology

“Medically Ready Force…Ready Medical Force”

In Intake/New OB Vis isit Tab

Accuracy of Pregnancy Dating table is included

“Medically Ready Force…Ready Medical Force”

In Intake/New OB Vis isit Tab

The Physical Exam behaves like the PE on the CORE AIM form

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Routine Provider Vis isits Tab

A free-text box and a pre-populated template are included on Intake, Routine, and Post-partum Visit tabs. Use only one of these, according to provider preference.

“Medically Ready Force…Ready Medical Force”

Routine Provider Vis isits Tab

Select ‘all conditions are negative’ and document positive specifics by exception

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Routine Provider Vis isits Tab

Physical l Exam

Items in the Physical Exam will appear on the Intake/New OB Visit tab under Physical Exam if the encounter is closed and reopened

“Medically Ready Force…Ready Medical Force”

Routine Provider Vis isits Tab

PE fr from CORE AIM IM Form

These items appear on the Intake/New OB Visit tab under ‘PE from CORE AIM Form’ ribbon if the encounter is closed and reopened

“Medically Ready Force…Ready Medical Force”

Tests/OB Ult ltrasound Tab

Users can copy/paste labs into this section

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Tests/OB Ult ltrasound Tab

Quad & CF F Cou

• unseli

ling

Pre-positioned text is provided for efficient documentation

• f Quad and CF counseling

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Tests/OB Ult ltrasound Tab

Each subsequent section lists elements to be addressed at those visits Initial tests can be entered here

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Tests/OB Ult ltrasound Tab

Subsequent ultrasounds can be documented here (only the initial ultrasound will copy forward)

“Medically Ready Force…Ready Medical Force”

Postpartum Vis isit Tab

A free-text box and a pre-populated template are included on Intake, Routine, and Post-partum Visit tabs. Use according to provider preference.

“Medically Ready Force…Ready Medical Force”

Postpartum Vis isit Tab

If the encounter is closed & reopened, these items will appear

• n the Routine Visits tab

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Postpartum Vis isit Tab

De Depression Sc Screen

A scoring box is included for documenting results of the Edinburgh Questionnaire The questionnaire can be completed either here or on the front tab, but not in both locations

“Medically Ready Force…Ready Medical Force”

Postpartum Vis isit Tab

Physical l Exam

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La Lactation Tab

Ribbons provide documentation for elements important for establishing successful breastfeeding habits

“Medically Ready Force…Ready Medical Force”

La Lactation Tab

Breast Ass ssessment

Breast assessment ribbon open includes breast symptoms and hx

• f breast surgery

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La Lactation Tab

In Infant Ass ssessment

Infant assessment ribbon open; Weight history copies forward

“Medically Ready Force…Ready Medical Force”

La Lactation Tab

Cou

• unselin

ling an and Education

Counseling & Education ribbon includes helpful discussion items and recommendations for the breastfeeding mother

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Patient Education Tab

A free text box is provided for a counseling plan

“Medically Ready Force…Ready Medical Force”

Patient Education Tab

Items to address at each visit are listed accordingly

“Medically Ready Force…Ready Medical Force”

Patient Education Tab

**Note: some links are blocked at AF sites

Prenatal information sheets can be printed and given to patients Additional resource links are also provided

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Patient Education Tab

These resources may also be located within RelayHealth Patient Information

“Medically Ready Force…Ready Medical Force”

Centering Vis isit Tab

Ten centering visit ribbons are included

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Procedure Counseling Tab

Document procedures here. The TSWF Procedures AIM form can also be used for these & other ‘female only’ procedures.

“Medically Ready Force…Ready Medical Force”

Procedure Counseling Tab

TOLAC

TOLAC ribbon open; Pre-positioned text is included to be used/modified as needed

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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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DoD/V /VA CPG for Management of f Pregnancy

“Medically Ready Force…Ready Medical Force”

DoD/V /VA CPG for Management of f Pregnancy

http://www.healthquality.va.gov/guidelines/WH/up/

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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/