TSWF Nursing Services AIM Form Training May May-Aug 2020 Form - - PowerPoint PPT Presentation

“Medically Ready Force…Ready Medical Force”

TSWF Nursing Services AIM Form Training May May-Aug 2020 Form Version

“Medically Ready Force…Ready Medical Force”

Dis isclaimer

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 group of slides reflect changes made

to all CORE compatible forms. The specific training slides for this form follow the change slides.

“Medically Ready Force…Ready Medical Force”

CORE Compatible Updates

4

Updated the Hepatitis C screening recommendation on the 'Preventive Services Recommendations-All Patients' Ribbon. The new recommendation: 'The USPSTF recommends screening for hepatitis C virus infection in adults aged 18 to 79 years.'

“Medically Ready Force…Ready Medical Force”

CORE Compatible Updates

5

Updated the wording in the 'Self-Reported Level of Functioning' row on the PHQ-9 NEW OLD

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CORE Compatible Updates

6

Updated 'Pain Treatment history' section on the Exit CCP tab

“Medically Ready Force…Ready Medical Force”

CORE Compatible Updates

7

Updated 'Chronic Pain' ribbon label to say 'Pain Management Care Plan' and verbiage updated within section. Also changed the 'Pain care agreement on file’ to 'Pain Care Informed Consent on File’

“Medically Ready Force…Ready Medical Force”

Objectives

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

• Understand that the Nursing Services AIM form may be incorporated into scheduled

Provider Visit workflows or stand-alone Nursing Visit workflows and T-Cons

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

Rec/Preventive Services)

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

Questions/Learning Assessment/Military Specific Screening)

• Provide an overview on how this form is used to document immunizations, medications,

nursing procedures, and patient education

“Medically Ready Force…Ready Medical Force”

Agenda

• Introduction/Overview
• Who can use this form?
• Discuss ideal integration and workflow
• Basic Reminders
• How to use the Nursing Services AIM Form

“Medically Ready Force…Ready Medical Force”

Why Use a TSWF Nursing Services AIM IM Form?

• Creates standardized clinical nursing notes
• Daily charting is easier and faster
• Provides patient education/counseling notes
• Air Force-Specific Notification: This form replaces the

need to use the AFMOA-approved support staff protocol questionnaires

“Medically Ready Force…Ready Medical Force”

Who Should Use th the TSWF Nursing Services AIM IM Form?

• ALL services can use the Nursing Services AIM Form

(Note: there are service-specific items within the form)

• Any clinic that gives medications or does routine

procedures can benefit from the use of this form

• Nurses and Clinical Support Staff
• Providers

Medication doses are written for ADULT patients only – the form is NOT intended for use with PEDIATRIC patients

“Medically Ready Force…Ready Medical Force”

In Integration and Workflow

• Methods of using the TSWF Nursing Services

AIM form:

• Provider appointments
• In conjunction with most TSWF AIM forms
• Stand-alone form for clinical support staff and

walk-in clinics

“Medically Ready Force…Ready Medical Force”

In Integration and Workflow

• Example 1
• Starting with the TSWF CORE AIM form, the

provider asks the clinical support staff to give the patient an injection of “Toradol”. The technician will pull up the TSWF Nursing Services AIM form to chart the administration of the Toradol injection.

• Proceed directly to the S/O Note when used in

conjunction with a provider visit. (Next slide)

“Medically Ready Force…Ready Medical Force”

In Integration and Workflow

Choose “Add Additional S/O Note” to document the nursing procedure

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In Integration and Workflow

• Example 2
• A patient comes in for a pregnancy test. The clinical

support staff can use the form as a stand-alone form to chart the patient’s encounter (according to the MTF’s or Service’s protocol)

• When using for stand-alone nursing procedures, the

staff should change their roles and add a supervising provider.

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Basic Reminders

• Never set a TSWF AIM form as a default
• Add yourself as an additional provider

(paraprofessional/nurse)

• Create a favorites list using the diagnosis/procedure

codes frequently used in the clinic

• Always screen for allergies: It pulls the information

from CHCS into AHLTA:

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HPI/PFSH/ROS Tab

Form version, links to MilSuite, TSWF Navigator, TSWF Resources, and Change Log are listed at the top

Document Special Duty assignment if applicable

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HPI/PFSH/ROS Tab

‘Performs Armed Duty’ question

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HPI/PFSH/ROS Tab

Hig ighlig lights Pain assessment and reassessment annotation is located on the HPI tab

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HPI/PFSH/ROS Tab

Hig ighlig lights

Use the AHLTA allergies module to document pharmaceutical

• allergies. The allergy text field found on previous AIM forms has been

deleted to remove patient safety risks and ensure allergy related info is properly documented in decision support systems (i.e. Pharmacy) Other allergy-related conditions that are not considered true allergies can be documented in “Medical Conditions” text field.

“Medically Ready Force…Ready Medical Force”

HPI/PFSH/ROS Tab

Hig ighlig lights

Providers complete the Medication Reconciliation process Clinical support staff document that the medication list is updated

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HPI/PFSH/ROS Tab

Hig ighlig lights

Text field to input name of Primary Opioid Provider *Primary Opioid Provider means that a patient has an agreement in place that authorizes a single provider to write or renew prescriptions for opioid medications.

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HPI/PFSH/ROS Tab

Hig ighlig lights

Chart the dates and the results, if applicable, the patient completed his/her clinical Preventive Service(s) If the patient is overdue on any service, follow approved MDG protocols for ordering Preventive Services

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Screening Tab

AUDIT-C

If patient answers “yes,” complete the Audit C and enter the date and score in the text field. If patient answers “no” to use of alcohol, click the “No” box and move on. A date is not needed.

“Medically Ready Force…Ready Medical Force”

Screening Tab

Tob

• bacco Sc

Screening

‘Desire to Quit’ does not copy forward

Links to resources on tobacco cessation

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Screening Tab

Annual l Questions/Health Lit Literacy

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). These questions need to be completed annually. If more than 12 months have elapsed since last updated, uncheck the red ‘X’ to reset the questions to current requirements.

“Medically Ready Force…Ready Medical Force”

Screening Tab

Healt lth Lit Literacy

If the SILS response is either “often” or “always,” further assessment

• f the patient’s health literacy is documented here along 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”

BH/Other Screening Tab

PHQ-2 an and PHQ-9 PHQ-9 is separate ribbon from PHQ-2 PHQ-9 opens by selecting ‘Yes’ to PHQ-2 or by opening the PHQ-9 ribbon

“Medically Ready Force…Ready Medical Force”

BH/Other Screening Tab

PHQ-2 an and PHQ-9

Document a PHQ-2 during a face-to-face visit in the clinic. Be sure to add the score. If the PHQ-2 is positive, administer/document the PHQ-9 and notify the provider that it was done.

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BH/Other Screening Tab

C-SS SSRS

Cues give instructions on how to ask the questions

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BH/Other Screening Tab

C-SS SSRS (c (cont. t.)

• Complete the summary

statement including actions taken

• Pre-positioned text is

provided

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BH/Other Screening Tab

PTSD Sc Screenin ing

Place the date the screening was completed in the copy forward field

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Exit/CCP Tab

Lif Lifestyle le Questions Lifestyle Questions can be found in this tab

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Im Immunizations Tab

Overview

Document patient’s outcome and observation in the ‘Outcome

• f Patient’ section. This section will gray out if completed on a

different tab to prevent duplicate documentation.

“Medically Ready Force…Ready Medical Force”

Im Immunizations Tab

Ge General l Vaccin ination

Additional immunizations may be entered in the “Additional Vaccinations” text box. Links to CDC Vaccine Information Statements and Immunization Schedules added

“Medically Ready Force…Ready Medical Force”

Im Immunizations Tab

PPD Pla lacement

All pre-positioned text in the documentation fields can be edited/deleted according to specific needs.

“Medically Ready Force…Ready Medical Force”

Im Immunizations Tab

PPD Readin ing

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Meds 1 Tab

Overview

Document Patient Education if needed

“Medically Ready Force…Ready Medical Force”

Meds 1 Tab

Respir iratory ry

Document everything in this section, to include: ‘Medication Verified by:’ ‘Given by:’ ‘Time administered:’ found in each separate medication field.

“Medically Ready Force…Ready Medical Force”

Meds 2 Tab

Overview

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Meds 2 Tab

De Depo Provera

Additional notepad for further documentation of Depo-Provera injection

“Medically Ready Force…Ready Medical Force”

Meds 2 Tab

IV IV Hydration/Lab Dr Draw

The “Additional IV Hydration” text box allows for further IV hydration documentation

“Medically Ready Force…Ready Medical Force”

Meds 2 Tab

IV IV Hydration/Lab Dr Draw

Free text content can be used to document blood collection as a venipuncture

• r associated with IV

insertion. See coding clues below.

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Meds 2 Tab

Clon lonid idin ine & Di Diphenhydramin ine

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Procedures 1 Tab

Overview

A link to the TSWF Procedures AIM form is available for access to other procedures

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Procedures 1 Tab

Car ardiovascula lar

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Procedures 1 Tab

Toe

• enail

il Removal

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Procedures 1 Tab

Wart Treatment

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Procedures 2 Tab

Overview

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Procedures 2 Tab

Urin rinary ry I/O I/O Catheter

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Procedures 2 Tab

In Inju jury ry Car are

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Procedures 2 Tab

Ear ar Irr Irrig igation

“Medically Ready Force…Ready Medical Force”

Patient Education 1 Tab

Overview

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Patient Education Tab

Ge General l In Information

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Patient Education Tab

Respir iratory ry

“Medically Ready Force…Ready Medical Force”

Patient Education Tab

Metaboli lic

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Patient Education 2 Tab

Se Sexually ly Tran ansmit itted In Infections

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Obsolete Terms Tab

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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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/