tech park clinic handbook - sbmedchiefs.com · tech park clinic handbook updated july 2018 stony...

Tech Park Clinic Handbook Updated July 2018

Stony Brook Primary Care 205 N. Belle Mead Road, East Setauket, NY 11733

Phone: 631-444-4630 Main fax: 631-444-4652

Front desk fax: 631-444-4617

Tech Park Clinic Handbook

UPDATED 7/2018 PAGE 2

Table of Contents Clinic Overview ........................................................................................................................................................................ 3

Clinic Expectations .................................................................................................................................................................. 5

Clinic Documentation ........................................................................................................................................................... 11

Notes ................................................................................................................................................................................. 11

Medication Reconciliation ................................................................................................................................................ 16

Updating Problem List/ICD Tips ........................................................................................................................................ 18

Health Maintenance Tab ................................................................................................................................................... 19

Immunization Tab ............................................................................................................................................................. 19

Message Center ................................................................................................................................................................ 21

Depart Instructions ........................................................................................................................................................... 24

Letters on Behalf of the Patient/To the Patient ............................................................................................................... 27

EMR Chart Tips .................................................................................................................................................................. 29

Common Orders ................................................................................................................................................................... 31

In Office Orders ................................................................................................................................................................. 31

Labs and Tests ................................................................................................................................................................... 34

Consults/Referrals ............................................................................................................................................................. 35

Medications ...................................................................................................................................................................... 36

Medical Supplies ............................................................................................................................................................... 38

Home Care Orders ............................................................................................................................................................ 40

Creating Favorites Folder .................................................................................................................................................. 41

Tech Park Controlled Substance Prescription Policy ........................................................................................................... 42

Coumadin Management & Guidelines ................................................................................................................................ 44

Enrolling a patient in Coumadin clinic .............................................................................................................................. 44

Coumadin dosing adjustments ......................................................................................................................................... 44

Callbacks ............................................................................................................................................................................... 45

Clinic Evaluations & Procedures .......................................................................................................................................... 48

Appendix ............................................................................................................................................................................... 49

Chronic Pain Template ...................................................................................................................................................... 49

Diabetes Management Template ..................................................................................................................................... 51

Health Care Maintenance Template ................................................................................................................................. 52

Pre-Visiting Planning Template ......................................................................................................................................... 53

Medical Clearance Template ............................................................................................................................................ 54

Call Back Documentation Template .................................................................................................................................. 56

Urine Toxicology Template ............................................................................................................................................... 57

Coumadin Template .......................................................................................................................................................... 58

Coumadin Clinic Sheets ..................................................................................................................................................... 59



Clinic Overview Clinic Info Stony Brook Primary Care 205 N. Belle Mead Road, East Setauket, NY 11733 Phone: 631-444-4630 ONLY number you should give to patients Main fax: 631-444-4652 Front desk fax: 631-444-4617 **Important when dialing numbers in SB system:

Many are 4-____. This is 444-____.

Any number that begins with 8-____ is dialed as 638-____.

Any number that begins with 2-____ is dialed as 632-____. Patient Centered Medical Home (PCMH): Our primary care clinic is a PCMH where we coordinate and track all patient care needs for our patients. We have systems to ensure that all orders and referrals are completed in a timely manner. Faculty

Bibi Zainul (IM, Residency Clinic Director)

Diana Nido (IM, primary resident preceptor)

Susan Lane (IM, primary resident preceptor, residency PD)

Kimberly Kranz (IM/Geriatrics, primary resident preceptor, residency APD)

Patricia Ng (IM, residency APD)

Rachel Wong (IM, QI/QA supervisor)

Catherine Nicastri (IM/Geriatrics, geriatric fellowship PD)

Suzanne Fields (IM/Geriatrics, Clinic Director, Division Chief-General IM/Geriatrics)

Jennifer Hensley (IM/Geriatrics)

Irene Hwu (Medicine/Pediatrics/Geriatrics)

Mandeep Patel (IM)

Tracey Spinnato (Medicine/Pediatrics)

Scott Stein (IM/Geriatrics)

David Goodrich (IM)

Susan Lee (IM)



Staff & Important Numbers (NOTE-only give out main number to patients 444-4630)

Name Role Phone

Clara Tachack Resident clinic Secretary - support with patient scheduling, processing forms, faxes and mail, help obtaining PA forms, PA for testing, setting up home care, authorization for radiology, transportation forms

444-4183

Alley (Alice) Fernan, RN Resident clinic RN -Triage phone messages, callback INR results to patients for Coumadin management, home draws, home care, follow up phone calls for patient between-visit care, proposal of medication renewals, helps oversee narcotic renewals for patients with attendings, care transitions and care coordination, patient education

444-5824

Evelyn Ferraro Resident Clinic Patient Care Coordinator Assists with urgent/stat referrals and obtaining medical records

638-3888

Doreen Diane Stacey Kim Marie

Front Desk Clerks -Check in and check out of patients, scheduling, IDX management, help with phone numbers and info for referrals and testing

444-4654

Nubia Calles Jackie Drake

Medical Assistants - Bringing in patients, vital signs, point of care testing (spirometry, EKG, FS, HbA1c, HIV, urinalysis)

444-0618

Patricia (Trish) Graziano Maria Scourbys Lori Sharif

Licensed Practitioner of Nursing -Bringing in patients, vital signs, point of care testing (spirometry, EKG, FS, HbA1c, HIV, urinalysis), counseling patients, patient teaching (injections eg. lovenox/insulin, smoking cessation and patient educational materials), immunization injections, blood draws and IVs

444-0618

Christine Pidgeon, RN Clinical Staff Director -Master scheduling, staff training, answering/triage of messages for the entire practice, patient education, QI staff coordination

444-5297

Awaiting new hire DSRIP/Medicaid Social Worker -Provides SW support for patients with Medicaid

Message in EMR

Jennifer Damato Geoffrey O’Connell

Social Workers Message in EMR

Erin Dainer, MD Psychiatrist/Internal Medicine In office referrals Office Hours: Tues PM, Thurs AM/PM, Fri AM

Message in EMR

Nursing Desk -If you are running late, please call and let them know at the nursing desk (also call conference room to let attendings know- or page attendings)

4-0618

Conference Room -To reach faculty at the main conference room in clinic 4-9842, 4-4944

SB ER Call this number if you are sending a patient to the ER for evaluation. Here you will give a brief signout and can request an ambulance

4-1911

SBUH Operator Physician line to hospital operator 4-1077



Clinic Expectations Resident Expectations

Hours o Monday, Tuesday, Thursday: Arrive by 8:30am to review chart and “previsit plan.” This also applies to

the call back resident. o Fridays: Arrive by 8am for Tech Park morning report. o Wednesday: HSC for grand rounds and Academic Wednesday activities o If you are running late, please call nursing station at 444-0618 and attendings (by page/phone/or in

conference room). Conference room numbers: 444-9842 and 444-4944. o Call back residents should check in with attendings and Alley before leaving for the day.

Dress Code o Professional Dress

Men: Collared shirt, tie, dress slacks, and dress shoes Women: Blouse, pants/skirt, closed-toe dress shoes

o White Coat o CANNOT wear Stony Brook fleeces as replacement for white coat

Patient Care o Prioritize continuity of care with patients (Ex. Label yourself as “PCP” in chart, give patient your business

card, let patient know when you are in clinic next and have them schedule at front desk, etc.) Have patient make appointment at front desk before they leave the building as appointments fill

quickly for each provider o Should review chart and be prepared o Willing to help with seeing an additional patient if a resident is running behind or there is a patient that

urgently needs to be seen o Notes must be completed within 24hours of patient encounter o Ensure that “histories” tab is updated and accurate (PMHx, SHx, and FHx shouldn’t just be free texted

into note) o Update medication history and reconcile outpatient list (2 check marks) o Update problem list o Update Health Care Maintenance Tab o Include details in any imaging or referral orders o Sign all reviewed documents

Yale Curriculum o Pay attention to when you are scheduled (Listed on monthly calendar, posted on chief’s site, and will

receive email from Dr. Kranz regarding topic files) o Come prepared and review teacher’s guide o Make session interactive- DO NOT just read off the teacher’s guide o Include visuals- ex. Pictures, videos, or demonstration

Tech Park Resident Report o Select an AMBULATORY case to review o Create 20-30 minute didactic that focuses on reviewing clinical presentation, work-up, or management o Include EBM and clinical guidelines when appropriate o Make session interactive o Include visuals- ex. Pictures, videos, or demonstration o Include 1-2 related MKSAP questions o Scheduled by chief residents, pay attention for when you are scheduled



Scheduling

All clinic scheduling is done by Dr. Kranz, please let her know if you have any questions or concerns. o *ANY SCHEDULE CHANGE MUST go through the chiefs and Dr. Kranz. Any issues that would cause you to

miss part of a session must also go through the chiefs and Dr. Kranz. (This includes subspecialty clinic!)

AMB Block Schedules: Denote when you are in your continuity clinic and when you are in a subspecialty clinic.

Monthly Tech Park schedule- **very important to look at this in addition to your block schedule. This schedule denotes your assignment for each continuity clinic session (i.e. callbacks, urgent care resident, QI resident) and lists who will be presenting one of our weekly clinic conferences.

o If you do not see any patients scheduled in PowerChart, DO NOT assume that you are not in clinic. You may be on urgents vs call backs

o FYI- PGY1 will start urgent care and call-backs in the Spring o Example schedule:

Subspecialty Clinics: Each year residents will experience different medicine subspecialty clinics during their ambulatory block.

o PGY1: Endocrine, Rheumatology o PGY2: ENT, Hospice, GI, Pulmonary o PGY3: Heme/Onc o You will go to subspecialty clinic based on the “A, B, C” Schedule. (Please note that you may be pulled

from subspecialty clinic if there is extra-help needed at Tech Park. You will be alerted of these changes via email and updated posted schedules)



All schedules are posted on SB IM- Chief’s Site

Types of Patient Visits:

AM Patients are scheduled for 9AM-12PM and PM Patients are scheduled for 1:30-5PM

Visit template-typically 2 FUV, 1 UCV, 1 NPV (if a patient cancels, another patient can be placed in that slot and that may be for a UVC/FUV/or HFU).

Visit Label Description

FUV/FTX Follow Up Visit

Established patient visits (X dependent on patient care team) Goals: follow up and management of chronic conditions and health maintenance (Example: review of diabetic and HTN control, review of medications, review of health screening and immunizations, counseling on chronic conditions)

UCV Urgent Care Visit

Established patient with urgent issue Goals: triage, care and management of acute patient issue (Example: acute URI or UTI, dizziness, rash)

NPV New Patient Visit

Patient encounter to establish care at the practice Goals: address patient concerns, enter medical history into EMR, medication review and reconciliation, obtain prior records, establish care plans for acute and chronic diseases, orient to the clinic

MCL Preoperative Medical Evaluation

Goal: consultation/medical optimization prior to surgery/procedure (Ex- Preoperative for knee replacement requiring risk stratification, adjustment of diabetic medications)



HFU Hospital Follow Up

Patient encounter after acute inpatient hospitalization (ideally within 7-14 days) Goals: ensure that acute issues have resolved and that ongoing care is continued, medication reconciliation, address modifiable risk factors for re-admission, ensure that appropriate consultative care is set up, assess functional status and additional home-based needs

AMW Annual Medicare Wellness Visit

Annual well visit for preventive measures and screening for Medicare patients Goals: review packet of health information, screening for vision, hearing, gait, dementia, ensuring documentation of health care proxy/advanced directives, functional status (ADLS/IADLs)

PAA Pain Management Visit

Visit to primarily assess pain management and renewal of controlled substances Goals: appropriately evaluate pain management (auto-text template), check PMP/ISTOP for consistency, ensure updated drug toxicology, pain contract, risk stratification and other important elements of pain management

Other visit types (do not require physician): Injections, BP check

Can write in depart when you want pt to return with this type of nursing visit These visits are usually scheduled as 6am or 9pm slots (You do not come in that those times, they just need to be placed on a schedule so an encounter can be billed for the service)

Clinic Schedule View

Gray = no show

Purple = in room

Green = seen by nurse/ready for physician

Orange = seen by resident/physician



Clinic Care Teams: All residents are divided into 4 care teams (red, blue, yellow, green). The front desk tries to schedule patients within the same care team if the primary care provider is not available. Example:

TEAM LETTER COLOR

Amb Group 1

Amb Group 2

Amb Group 3

Amb Group 4 Amb Group 5

TEAM A RED

Lo Park Predun Mei Weena

TEAM A RED

Abeles Andrews-Lum

Weinberg

Andrzejczyk Cheng (Shing Ben)

TEAM A RED

Sheikh

TEAM B BLUE

Quintero Garcia (Victor)

Zahra Ng, Brandon

Ciuffo

TEAM B BLUE

Malhotra Saif Antoine Aleem Lier

Team E YELLOW

K. Shah Shklar Odekon Winokur Gracia (Ely)

TEAM E YELLOW

Mizrahi Lum, Michael

Levit Ali Abraham

Team F GREEN

Sharon Wu Sosa Bhagat Kott

TEAM F GREEN

Schwartz Hurley Avvento Dufurrena Chatterjee

Workflow check list:

□ Review chart and pre-visit plan □ Update “Histories tab”(SHx, FHx, PSHx, PMHx) □ Reconcile medication history □ Update problem list □ Reconcile depart medications (Ex. what will the pt be sent home on?)—make sure there are “2 check marks” □ Add patient education into the depart (BEFORE PATIENT LEAVES) □ Print orders and give to patient □ Instruct patient to stop at front desk to schedule appt and receive information about referrals □ Complete progress note □ Update health maintenance tab □ Update immunizations

Reviewing tests/consults: We encourage all residents to call their own patients regarding test results if you are on your ambulatory block. However if you are not in clinic, all results will go to the “GM Resident Pool.” Medication Refills:

Usually completed at visits. Try to give 90 day supply and appropriate refills until next follow-up

If you receive a refill and you are not on ambulatory, you can forward the refill request to “GM Resident Pool” Consults: Stat/urgent consults should be made as “Consult/Referral Tracking (amb).” Please make sure you fill out details and notify Evelyn Ferraro to ensure that this is done.



Patient Care Documents: Sign and stamp all documents and make sure the patient’s name is on it (NPV forms, Pain Agreement, PHQ9s, GAD-7s, labs and test results, glucose logs, forms, etc.) Medical Record Requests: Have patient complete medical release form to get records from other hospitals/doctors and you can give these requests to Evelyn Ferraro. Inbox:

Please check your inbox multiple times throughout the day when on amb for updates on your patients.

Be aware that you may receive results from your inpatient rotations and these results should be forwarded to your inpatient attending.

Be aware that you may receive messages from other attendings or staff regarding patients that you will be seeing. Consider saving these messages to the chart if appropriate.

When not on amb, please check at least daily (except when on vacation) so as to not miss messages on your patients. If you receive a message that you cannot address because you are not on amb, it can be forwarded to the “GM Resident Pool”



Clinic Documentation

Notes Resident Expectations

Notes must be completed within 24-hours of patient encounter

Ensure that “histories” tab is updated and accurate (PMHx, SHx, and FHx shouldn’t just be free text into note)

Update medication history and reconcile outpatient list (2 check marks)

Update problem list

Update Health Care Maintenance Tab

Include details in any imaging or referral orders

Sign all reviewed documents Common notes that you will use

General Medicine Progress Note o Healthcare Maintenance Template o PAA Template o Diabetes Template

General Medicine Pre-Op Assessment o Pre-operative Template

General Medicine Preventative Visit Note

General Medicine Procedure Note

General Medicine Event Note o Pre-Visit Planning

Medicare Preventive Visit (go through each section)

You should save these note titles into your “Favorites”

See Appendix for Templates and Auto-Text How to Start, Sign, and Assign a Note

1. Click “+ Add” sign next to Documentation tab 2. Select which type of note you want to use (will come from list above). You need to either search for the note

title or find it in your “favorites”



3. Sign your note when you are done

4. Select “Request Endorsement” and search for your preceptor’s name into “Endorser” section



5. Select “Sign” in the “Type” section. 6. If you’d like other providers to “Review” your note, you can also add them to the list of “endorsement” to share

your note with them (Ex. Specialists, pt’s primary PCP (if not you), etc.)



How to Save a Template/Auto-Text: Method #1

1. Highlight text that you want to use as autotext 2. Right click and select “Save as Auto-Text” 3. Give autotext a title (Ex. “zzPrevisit”)—start title with letter or symbol you don’t type often such as “zz” so that

the prompt to include autotext doesn’t always come up as you are typing other things.

Method #2

1. Select “Manage Auto Text icon” text toolbar: 2. Click plus sign in left corner

3. Write and format your autotext 4. Save auto-text with a title/abbreviation that you will use to bring up autotext (Ex. “zzPrevisit”)



Tips on Viewing Notes in Chart

1. Select “Documentation” tab on left screen 2. Change “Display” to the following selection for the following views:

a. “All”- sees all types of notes written including phone messages, scanned files, nursing notes, “dynamic documentation” (which some providers use), etc.

b. “All Physicians” – filters notes only written by physicians c. Select a specialty (Ex. Primary care) to only see note from that department d. DO NOT use “All PowerNotes” because physician notes are not always categorized as a PowerNote.

How to Update “Histories” Tab

Make sure to review and update each section of the “Histories” Tab before you start your note. This section allows the SHx, FHx, Surgical Hx, and GYN Hx to auto-populate into your note

Use “Other” under Social History to list any important phone numbers for the patient (Ex. Social Worker, case manager, family member that needs to be contact, etc.)

It is NOT enough to only free text this information into your note



Medication Reconciliation Reconciling Medication History

1. Select Medication List on left menu and reconcile Meds History via Document Medication by Hx

2. Review each listed medication and ensure that the dose and frequency is correct. Also include compliance (Ex. Taking or Not Taking, etc)

a. +Add- allows you to add new medication to list b. Modify- allows you to edit the medication details c. Complete- select if pt is no longer taking medication or completed course d. Cancel/DC- if you added medication by mistake and would like to remove item e. External Rx History- allows you to review medication prescriptions received at patient’s pharmacy and

can be used to import to medication list f. Click “Done” when complete



Outpatient Medication Reconciliation (What meds are you sending the pt home with)

1. Select “Depart” in top menu bar: Select “Medication Reconciliation”

2. Add (top left)/ Continue (arrow) /Refill (prescription bottle) /Stop (square) listed. a. Use the “Acknowledge Remaining Home Meds” in bottom right area to quickly reconcile unchanged

meds

3. You can also add new medications in the “Orders” page but using the “Depart” is the easiest way to reconcile all

medications.



To ensure that you’ve reconciled both the medication history and outpatient reconciliation, you MUST get “2 check marks” in the Reconciliation Status:

Checking NYS I-STOP for Controlled Substances

1. Log onto: https://commerce.health.state.ny.us/public/hcs_login.html to review any controlled substance prescription

2. Include Reference Number and recent prescriptions into your note: 3. Look for dates to make sure not in habit of continually filling early; look at provider to make sure only our

practice is giving that medication.

Updating Problem List/ICD Tips Be as specific as possible in adding problems (ex- “Diabetes, controlled, with nephropathy” as opposed to just

selecting “Diabetes.” The detail helps show severity of your patient’s illness/overall condition.

Best practice is to add chronic problems to the “Diagnoses and Problems” section first and then convert over those issues you are addressing this visit. If patient has an acute issue, it should only be added to the section “Diagnosis (Problem) being addressed this visit” section.

1) Update “Diagnoses and Problems” first

2) Click “Dx” button to move problems addressed at this visit

https://commerce.health.state.ny.us/public/hcs_login.html



Health Maintenance Tab Be sure to update this tab each visit with dates of preventive measures such as HIV screening, Breast cancer screening, cervical cancer screening, colorectal cancer screening, Hep C screening. **Even if your visit note is updated, it must also be entered here (this is where information is pulled from when the clinic is checking how many of our patients are up to date on these quality measures!)**

Immunization Tab Labeled “Immunization Schedule.”

If a vaccination was given at Stony Brook hospital or in one of our Stony Brook clinics, it will be listed here once the staff charts off on it.

We can enter in vaccinations received outside of Stony Brook by clicking on “History” at the bottom right of the screen, choosing “Add to selections,” choosing the vaccine from the drop down menu and then completing the information on administration date/source of info (patient, prior health record, etc).

You can add commonly entered vaccines into our favorites when you right click the vaccine selected



Message Center Inbox Management

Please check your inbox multiple times throughout the day when on amb for updates on your patients.

Be aware that you may receive results from your inpatient rotations and these results should be forwarded to your inpatient attending.

Be aware that you may receive messages from other attendings or staff regarding patients that you will be seeing. Consider saving these messages to the chart if appropriate.

When not on amb, please check at least daily (except when on vacation) so as to not miss messages on your patients. If you receive a message that you cannot address because you are not on amb, it can be forwarded to the “GM Resident Pool”

How to Create and Send an EMR Message

1) Click the “Communicate button” in the Message Center bar or top tool bar:

2) Fill in appropriate sections: a) Patient: you can search for patient

names so that the message is associated with their chart

b) To/CC: Add who you would like to send the message to.

c) Include me: Select this if you would like to receive a copy of the message

d) To consumer: Check to send the message to the patient via patient portal

e) Subject: Please change the title to inform receiver what message is about (Ex. Coumadin management, Lab Results, Call Back Message, Transition of Care, etc)

f) Save to Chart: Check this in order to have your message seen within the chart. You should ALWAYS select this when creating messages about Coumadin management or Call Backs.

g) Remind on / Due on: You can select these feature to send a message to yourself on a certain date/time to follow up on various tasks

h) Message Journal: Can use to review any messages ever sent on a patient and may not have necessarily been saved to the chart



Adding an Addendum to a Phone Message

There will be times when you are simply addressing a phone message and you only need to document what you did as an addendum to the message.

Add your text via <Add Text> field

Be sure to select “Save to Chart” if you would like your message to be viewed by other providers in the chart.

Saving contacts to your favorites

1. Right click on recipient’s name and select “Add as Favorite.” Their name will featured in the “Personal Address List” above the message.

2. Clinic contacts that should be part of your favorites: a. Alice (Alley) Fernan b. Clara Tachack c. Evelyn Ferraro d. Each Social Worker: Jennifer Damato, Geoffrey O’Connell, and DSRIP Case manager (once hired) e. Preceptors: Bibi Zainul, Diana Nido, Kimberly Kranz, Rachel Wong, Susan Lane, Patricia Ng f. GM Resident Pool g. GM Fellows Pool (may need to forward message if Geri fellow patient and incorrectly routed to resident

pool)



Depart Instructions At the end of each patient visit, you should complete the “Depart” to provide:

Final Medication Reconciliation

Patient Education

Medication information

Invite patients to sign up for the patient portal

Follow-Up Visit Instructions

1. Click “Depart” Icon in your top tool bar:

2. Click to edit each section

3. Patient Education/Follow Up: a. You can add Patient Education Materials that have already been uploaded to the EMR. These will be

printed by the front desk if you select the items before the patient leaves. b. If you have already added appropriate ICD codes for the visit, there will be suggested patient education

materials. (Ex. ICD- pharyngitis “Self Care for Sore Throats”) c. You can also add medication information via the “Medication Leaflet” tab d. In the “Follow Up” tab, select when you would like the patient to return to clinic.

i. You should instruct f/u in 5-week intervals to optimize continuity with your ambulatory weeks (Ex. 5 weeks, 15 weeks, etc) Have the patient make an appointment at front desk before leaving to ensure that appointment is made with you and they receive the appropriate help for their referrals

ii. You can include instructions in “Edit Comments” to include nursing visit instructions or what the patient will be following up for at your next visit (Ex. Follow up in 2 weeks for BP check with RN and then 5 weeks with me for diabetes check-up)

e. See next page for screen shots:



4. You can add free text instructions in the “Addendum” tab. Please note that the addendum will erase every time you re-click the section, so you will not be able to go back to edit what was already written.

5. Once you’re done, click “Patient verbalizes and understands all instructions given” and click “Sign” at the bottom of the depart window.

FYI: You can enroll patients for the patient portal in the Depart by selecting the “Stony Brook Portal Registration” tab. You simply need to add their email and select “Yes, Generate Invite” under “Patient Portal Registration”



Letters on Behalf of the Patient/To the Patient

1. Make sure you’re in a GEN MED Encounter

2. Click small arrow to the right the Communicate Button Patient Letter

3. Select a letter template. You will often use: a. Excuse for Work/School b. Letter on behalf of Patient c. Letter- Normal Results d. Letter- Abnormal Results To use only after multiple attempts of trying to contact the patient via the

phone. Check with attending before sending. Verbal relay of abnormal results is ALWAYS preferred.



4. Write your text in the top text box.

a. If you are writing a letter informing a patient about lab results, you can include the lab tests by selecting “Add Results” and selecting the labs you’d like to include

5. Once you’re done, you can “Preview” your note before clicking “Ok” to “Print Now.”



EMR Chart Tips Below are helpful troubleshooting when you have having trouble finding information in the EMR:

Whenever creating orders, writing letters, writing notes, make sure you’re in a GEN MED encounter. If having trouble with doing any of these actions, the encounter you’re in may be the issue.

o Click “Loc” in top right of blue bar o In the pop-up window, select the most recent “General Medicine-Setauket” encounter



Lab/Test Results: Change the date range for what results are reported. Right click on the gray bar with the date and then change the date range in the Search Criteria.

Flowsheets: o Endoscopy View- EGD and colonoscopy reports o Pathology View- Pap smear results

Clinic Notes: Select this tab in the left menu to review scanned documents into the chart o Pain contracts: You will find in the “Controlled Substance” folder o Correspondence Communication of PHI: To get additional phone numbers if patient cannot be

reached by the number listed in the demographics tab

Chart Search: Select this tab in the left menu to search for specific text in notes

You can check additional doctor visits your patient has scheduled by checking: o Patient Schedule on the left menu o Demographics Visit List (sort by Future Arrival Date)



Common Orders

In Office Orders Where to look

o Quick Orders (make sure you add “General Medicine Quick Orders” Tab)

o Orders screen change to “In office”, not prescription



Example In-Office Orders: o Vaccinations

Influenza

Quad valent (Flucelvax)

High Dose (Fluzone) TDAP Tetanus Zostavax or Shingrix PCV13 and PCV23 Gardasil (HPV vaccine) HBV and HAV combination (Twinrix) HBV HAV MMR Meningoccocal

o PPD Placement o Medications

Albuterol nebulizer IV Fluids B12 shots Anti-hypertensives ASA

From Quick Orders Page



o Procedures/Tests Stool guaiac (Stool Occult Blood x1 82272

Charge) POCT U/A (Urinalysis, Automated Charge

81003 Charge) POCT Urine microalbumin (Microalbumin,

Urine 82044 Charge) POCT HgA1c (Hgb A1c POC 83036 Charge) POCT finger stick (Glucose by Glucose

Monitoring Device 82962 Charge)* POCT rapid flu (Rapid Influenza A &

B870502QW Charge) POCT rapid HIV screen (Rapid HIV-1 POC 86701

Charge) Collect urine tox screen (Urine tox screen-

amb) EKG (EKG 12 lead w/Interp 93000 Charge) Spirometry (Spirometry Including Graphic

Record) Pap smear (Cervical/Vaginal Screening w/

Breast Exam G0101 Charge)*

ThinPrep Pap and High Risk HPV

ThinPrep Pap w/ Reflex HPV and GC/C



Labs and Tests You can order lab or test prescriptions in either the Quick Orders or Orders tab. Makes sure you select “Prescriptions”

When ordering lab tests make sure that you select:

(amb) tests

Priority: Stat vs urgent vs routine

Fasting: Yes or No

Include the appropriate ICD10 diagnosis code o You can use diagnoses from an updated problem list o DO NOT USE Z-codes

TIP: Check out quick orders for lab care sets (ex. Annual exam care set includes CBC, BMP, LFT, TSH, Lipid)



Consults/Referrals You can order “Consult/Referral Tracking (amb)” orders in either the Quick Orders or Orders tab. When creating the consult, be sure to complete the following:

Select the requested service (If there is a specific provider you want the pt to see, you may type that in) o If you need a neuropsychiatry evaluation, select neurology and then add “neuropsychiatry” in special

instructions

Priority of consult: Urgent vs Stat vs Routine If the pt needs a stat or urgent consult, please inform Evelyn Ferraro aware so she can assist with arranging the appointment

Reason for referral: you MUST include why you are placing the referral and indicate your clinical question. If you don’t have a question, then you may not need that referral.

Appropriate ICD10 code



Medications There are 3 ways to send medication prescriptions for your patients: 1) Orders Tab:

a) Click “+Add” and search for your medication b) You can search by “Therapeutic class” to find folders of medication families (Ex. Inhaled corticosteroids, beta-

blockers cardio selective, etc.) c) Try to select medications that has next to it. This indicates that the medication is preferred and covered

by the pt’s insurance.

2) Quick Orders:

a) You can search for medications via the “New Order Entry+” Tab b) Try to select medications that has next to it. This indicates that the medication is preferred and covered

by the pt’s insurance.



3) Depart: Click next to the “Medication Reconciliation” tab a) Click the “+Add” to order new medications

b) Select the circle under the to refill home medications

Once you’ve selected the medication, make sure you complete each section correctly:

Dose

Route of administration (Ex. Oral vs topical?)

Frequency

Duration- if you are prescribing a long-term medication, please select 90 days

PRN- if applicable

Dispense- if you are filling a long-term medication, please prescribe a 90day supply and enough refills until the patient’s next visit

Send To: Make sure you select the right pharmacy



Medical Supplies Use the “DME” order to send medical supplies for patients.

Sometimes supplies may need Medicare/Medicaid numbers of attendings this can be found by Alley

For mobility devices, hospital beds, etc, you MUST justify in your note why your patient needs this equipment (i.e. Wheelchair- pt cannot ambulate but can self-propel)

Common medical supplies:

Mobility devices:

Compression Stockings – PRINT scripts instead of e-scribe (patient needs to go to medical supply store and get measured)

Diabetes Supplies: o Insulin syringe needles o Insulin Pen Needles o MUST include brand name for glucometer and associated test strips (Ex. One Touch, Bayer Contour,

Freestyle, Accu-check, etc)

*IMPORTANT* Do not forget to indicate the needle gauge and length when ordering syringe or pen needles. As seen in the image below, pen needles are usually 5/16” – ½” in length and 29-32G



Pulmonary supplies o Incentive spirometry o Peak flow meter

Others o Foley o Beds o Blood pressure cuff



Home Care Orders

We can ask a home care agency to go into a patient’s home for a certain “need.” This could be a skilled nursing need, PT/OT need, or SW need. Insurances play a part in what will be covered therefore when this is discussed in a patient plan, you should go speak with Alley and Clara to make sure we can send someone in and they will give you the form to complete. The form lists the reasons why you are requesting the home care service, but it must ALSO be in your note. Patients can also go home with home care after a hospitalization. We will get orders to sign to continue services if appropriate clinically. Examples of why we send in home care:

Monitoring VS: BP, HR, Weight, SpO2 (i.e. pt having BP meds adjusted or just hospitalized for Afib or CHF and we need close eyes on their BP/HR/weight/O2 sat)

PT/OT (i.e. pt can’t get to outpt PT, homebound, and needs gait training for unsteady gait and multiple falls)

Home safety evaluation

Med Rec (i.e. you are concerned about a patient having the correct meds, perhaps they didn’t know meds at visit or brought list of old meds a nurse can go in the home and rec all pill bottles in the home)

Wound care

Send in RN to figure out home services (see if a patient qualifies for more help at home, they assess the entire home environment/current family involvement)

Medical aide (help determine if qualifies for aide and perhaps hours needed)

Your note MUST explain why you are sending these services in



Creating Favorites Folder

1) To add an order to your favorites, right click the order and select “Add To Favorites”

2) You can view your favorites by selecting the icon 3) To organize your favorites, click the down arrow next to the star. This will bring you to the “Organize Favorites”

window and you can organize your favorites in various folders



Tech Park Controlled Substance Prescription Policy During your ambulatory experience, you may care for patients who require long-term prescriptions for controlled substances (ex. opiates or benzodiazepines). If these types of medications are appropriate for the management of the patient, you must do the following:

1) Review the Chronic Controlled Substance/Opiate Use Contract with the patient and have them sign the agreement

a. Per the contract, patients will be required to follow up every 5 or 15 weeks b. Patients who follow a 5-week follow up schedule are individuals who require medication titration or are

at risk of non-adherence c. Patients need to understand that they can ONLY obtain controlled substances prescriptions our office

and can only use ONE pharmacy for their medications d. Make sure that a copy of the signed contract goes to Clara and to the patient

2) Use the PAA Template in your progress note (See Appendix).

a. This template helps us keep track of how helpful the medication is, why the patient is on the medication, what work-up was completed, what other therapies he/she tried, and what risk factors patients may have for medication non-adherence.

b. We should use the PAA template to assess the efficacy of the controlled medications at least once a year.

c. Be sure to include the Opiate Risk Tool score in the note via the AdHoc button completing the ORT here allows it to automatically go into your note



d. Be sure to review imaging, alternative therapies, consult notes when you are completing the annual PAA i. This is a good opportunity to consider adjusting opiate dosing, alternative therapies or referrals

(pain management, orthopedics, etc.) e. The PAA is completed annually and is a good time to review the controlled substance contract with the

patient and do the toxicology screen at the same time i. Title annual note as “PAA”

ii. At 5 or 15 FUV, you only need to use the “assessment and plan” part of template in all your notes and the note can be titled as “FUV”

f. ALWAYS check ISTOP when you are prescribing opiates to make sure that they are compliant. Document the ISTOP number or screenshot the ISTOP into a note

3) Have the patient complete a urine toxicology screen in the office. a. Order Urine Tox (amb) and let the nurse know that you’ve ordered this test Patient completes Utox in

office and sheet goes to nurse. b. A urine tox should be done at least annually and can be done more frequently if we need to ensure

compliance c. If a patient is unable to provide urine during the office visit you can also do an oral swab to check for

compliance (use same order, in comments we list that it was an oral swab) i. FYI- oral swab does not check for ambien

d. Be sure to document in the comments section of the toxicology screen order what medications the patient was on and indicate the date and time when each substance was last taken (this information helps us figure out what should be positive and can check if the patient is adherent to the treatment plan)



Coumadin Management & Guidelines

Enrolling a patient in Coumadin clinic Inform Alley Fernan during the office visit that you would like to enroll someone in the Coumadin clinic. She will

typically come to the room, introduce herself and the Coumadin clinic to the patient and give them some information

o If you are discharging a patient in the hospital who will be following our clinic for Coumadin, you can send Alley a message via the EMR and call her on the phone.

INR orders o Alley will typically ask you to write an order for an INR – order INR’s once weekly AND PRN x 6 months

Coumadin orders o Patients will typically have fluctuating doses of Coumadin therefore you may be asked to prescribe

multiple doses of Coumadin so that patients will have several different dose tabs that they can use based on the MD’s recommendations for dosing (which is based on INR)

o Ex. You may be asked to prescribe 1 mg tabs, 5 mg tabs, 10 mg tabs so that they can alternate 6 mg and 7.5 mg dosing

Coumadin dosing adjustments During callbacks you will receive INR results as well as “purple sheets” which are a record of the patient’s recent

INR values as well as changes made to the dosing FIRST double check the indication for Coumadin as well as the target INR Review previous dosing the patient has been on in addition to the current INR If Alley is available she typically calls the patient and documents the phone call. If Alley is not in the office then

the resident on callbacks is responsible for calling the patient When calling the patient back make sure to ask:

o Any side effects? Bleeding? Missed doses? New medications? o Discuss any changes you would like to make to their INR dosing with the patient, consider using teach

back so that you make sure they understand the dosing o Ensure they have enough pills at the correct dosing to make the changes you are asking o Inform them when you would like the INR repeated

If you are changing Coumadin dosing, repeat INR in 1 week If INR dosing is stable and at goal, consider spacing out the next required INR

o Document the conversation in a saved phone message! (See Appendix for Coumadin Template) o If you cannot reach the patient ask them to call you back to discuss their Coumadin and try them at a

later point in the day. It is important that you discuss any changes to their Coumadin directly with the patient or

caretaker. *If you cannot reach a patient by the end of the day and a change must be made, you must let

the clinic on-call attending know and they will continue to call to reach the patient (clinic on-call attending is one of the attendings in the practice; Alley or the preceptors that day can let you know who the individual is for that given date).



Callbacks

Expectations o Complete all documents in folder o Check in with Alley and an attending before you leave for the day o Document what you did on the call via saved phone message and use the callback template (See

Appendix) o Stamp and sign all documents that you review

Parts to Callbacks o Phone calls (symptoms, refills, etc.) o Folders

Consults Results (Labs, imaging) Coumadin Prior Authorizations Medication Refills

1) Consult Folders

o Review consultant notes o Write a brief event note documenting pertinent findings or changes to management made during

appointment o Stamp and sign consult notes and put into appropriate bin based on what the folder says

2) Lab/Imaging Results

o Abnormal results Review previous notes to see if there was a plan for what to do based on results. Call the

patient and discuss with the patient the results, explain what these results mean in layman’s terms.

If you want to start a new medication, discuss your plan with an attending and consider following up testing for monitoring

Document what you did in a saved phone message template. You can also consider sending a message to the resident/attending who saw the patient at the last visit.

If the patient does not answer:

Try to contact the patient at least once more time

If it is necessary that the labs be discussed with the patient, consider giving it to Alley and come up with a plan to ensure that the next callbacks person tries to call the patient as well (consider making a message in the inbox).

As a last resort, check with an attending if you can mail a letter with abnormal results.

o Normal results You can leave a phone message stating that results are normal but you MUST confirm that we

have consent to leave a message on that phone number.

To check for consent: Clinical Notes Correspondence folder Communication of PHI forms Find “Communication Consent” form (see next page for screen shot)

This section is also where you can check if the patient has given us consent to share medical information with certain family members



Write a brief saved phone message documenting the conversation that you had with the patient (See Appendix for Callback template)

If the patient does not answer: You can print out a letter to the patient with the labs indicating that all the labs are normal and give the phone number to the office to call back in case they have questions

o If family member pick up the phone and wants to review results, make sure you confirm consent in our chart that you can share information with them (Look for Communication Consent form as detailed above)

o Toxicology Results Document results in a general medicine event note, entitled “utox,” with the following (See

Appendix):

Medications the patient was taking at the time of the test

Substances found in the utox screen

Indicate if this this is consistent or inconsistent with their prescribed medications

Inform Alley of the results. o If results are inconsistent, have patient schedule a follow up. DO NOT review

over phone and refills of controlled substances will not be given until patient comes in for visit

o At follow-up, results will be discussed and there should be plans if the medications should be continued or tapered

3) Prior Authorizations o Clara is your go-to person here and often she has a pre-filled out forms for you with the patient’s

information if it is a medication that needs frequent prior authorization



o Before starting to fill out a prior authorization request think: “Can I change this to another medication that will be covered by the patient’s formulary?”

If so, consider changing the medication to one covered by the formulary Pharmacists can help you find out which medications are covered so try calling their pharmacy

and ask to speak to a pharmacist. Sometimes this requires that you send the medication over to the pharmacy in order to check for coverage (and you can discuss with one of the precepting attendings, especially if the attending who saw the pt is present in clinic that day many times there is no reason why we wouldn’t switch to another med in formulary)

If you can’t find alternative therapy before filling out the prior authorization or making the phone call for the prior authorization make sure you know what other medications were tried by the patient, whether they were tolerated, and for how long they were trialed

4) Medication Refills o Check when the patient was last seen in clinic

If > 1 year, call the patient and ask them to set up a follow up visit (Clara or Alley can help coordinate this for you)

Only refill for 30 days with no refills until they are seen again in the clinic o Check that the medication being refilled is something that our clinic is actually managing

Ex. Pt’s coumadin is actually being managed by cardiology office. The pt should be informed to call that provider

Ex. Pt requests to refill bipolar medications, such as lithium. These are usually managed by a psychiatrist and should confirm who has been prescribing.

o If patient has been seen regularly and is requesting a refill for a medication that they have been on for an extended period of time and is not being titrated/does not require monitoring

Can refill for 90 days with 1 refill o Controlled substance refills

If Alley is in the office, forward these requests to her and she will discuss with the attendings if refill is appropriate

If Alley is not in the office, forward these to whichever attending is handling controlled substance refills for the day (ask whoever is in clinic)

5) Coumadin (See Coumadin Management section for more instructions) o Alley handles all Coumadin clinic patients o Double check the coumadin indication to see why the patient is on coumadin and what the target INR is o Review purple sheets to see trend for INRs and when the last level was checked/what dose they are on o Look to the back of the purple sheet for some suggestions for how you should adjust the Coumadin

dosing based on the INR o Document all management in the “Coumadin Management” Template

General rules for all callbacks o Check to make sure resident clinic patient

If it is a geriatrics patient, ensure it is not an urgent issue and then notify Alley that you are placing it into the geriatrics mailbox

If it is the patient of one of the private attendings, ask Alley which nurse works with that patient and she will help you find the appropriate way to communicate results with that attending and nurse

o Read last note for plan guidance (Ex. If A1c X then add Y medication…) o Always read the folders to find out where you should put the paper results once you have documented

your management plan o Always document everything you do during callbacks!



Clinic Evaluations & Procedures Evaluations: You will be evaluated twice a year by clinic preceptors, nursing, and patients. These evaluations will be in New Innovations and will be reviewed at your semi-annual reviews with program directors DOT: You are required to complete 2 outpatient DOTs per year in New Innovation. Procedure that we can perform in clinic:

POCT U/A

POCT Ur-microalbumin

POCT HgA1c

POCT fingerstick

POCT rapid flu

POCT rapid HIV screen

Collect urine tox screen

EKG

Spirometry

Incision & Drainage of abscesses

Shave biopsy

Suture and staple removal

Cerumen disimpaction

Stool guaiac

Give IV Fluids Outpatient procedures you need to log for graduation that you can do in clinic:

5 pap smears

5 breast exams FYI there is a New Innovations App for IPhones called “Armis,” where you can send evaluations and DOTs to attendings. Unfortunately procedure logging is not an available feature yet.



Appendix

Chronic Pain Template

***FYI- PAA note needs to occur annually. You only need assessment and plan portion of the template should be included in every FUV that addresses their pain.***

PROGRESS NOTE TITE: “PAA” History: Location === Duration === Radiation === Quality === Severity (1-10) === Exacerbating Factors === Alleviating Factors === PEG Score (average of 3 scores below): === -On scale of 0-10 (0= no pain, 10=severe pain), what best describes your average pain level in the past week? -On a scale of 0-10 (0=does not interfere, 10=severely interferes), what best describes how pain has interfered with your enjoyment of life over the past week? - On a scale of 0-10 (0=does not interfere, 10=severely interferes), what best describes how pain has interfered with your general activity over the past week? 1) Date of last refill of controlled substance: === 2) Prescription Monitoring Program (PMP) registry consistent: Reference # === 3) Last intake of controlled substance (Date/Time): === 4) Last urine drug testing (Date): === 5) Pain contract documented in the chart (Date): === 6) Functional treatment goal: Type of controlled substance: Opiates/Anxiolytics/Sedatives/Other === Opioid Risk Tool Score: Prior pharmacologic treatment: Prior non-pharmacologic interventions: Physical Therapy/steroid injections/trigger point injections/acupuncture/counseling Relevant Imaging: Symptoms: Controlled/Uncontrolled Compliance: Taking medications as prescribed/Not taking medications as prescribed Etiology of Pain: Musculoskeletal/Neuropathic/Inflammatory/Neoplasm/Trauma/Other Functional Status: Fully functional/Functional Limitations with extended activities/Functional with Assistive Devices/Functional Limitation with ADLs Red Flags: None/Persistently Increasing Pain/Fever/Confusion/Falls/Weight Loss Side Effects: None/Constipation/Nausea/Vomiting/Itching/Sedation High Risk: Failed urine drug screen in the past/Referred to Substance Abuse in the past/Hospitalized for overdose in the past/ORT score ≥8 Mental Health Disorders: None/Depression/Anxiety/SubstanceAbuse/BipolarDisorder/PTSD/Schizophrenia/ADHD



Assessment and Plan: Plan: Continue current regimen/Change medication regimen/Taper or discontinue controlled substance Advised that medications may impair ability to drive or operating heavy machinery Advised to avoid bed rest Counseled and provided educational materials and resources Follow up: Follow up in 5 weeks/ Follow up in 15 weeks Specialty Follow up: None/Requires Pain Management/Requires Substance Abuse Program/Other Recommended toxicology screen: Every 5 weeks/Biennial/Annual/Other=== Functional treatment goal:



Diabetes Management Template Diabetes Assessment and Plan Medication regimen: Continue *** / Change to *** HbA1c (date) : Next check on: BMI: ≤25 at goal/≥25 not at goal Blood Pressure (≤ 140/90 or ≥ 140/90) Date of Last foot exam: Date of last eye exam: Flu Shot: yes / no Pneumococcal 23-valent vaccine: yes / no Hepatitis B immunity: yes / no / titers? Urine microalbumin (date): Is this patient on an ACEi/ARB: yes / no Total Cholesterol: LDL: ≤ 100 at goal / ≥ 100 not at goal



Health Care Maintenance Template Healthcare Maintenance CARDIOVASCULAR [ ] ASA primary heart attack prevention [ ] Diabetes screening DATE: [ ] High cholesterol screening DATE: WOMAN’S HEALTH [ ] DEXA for osteoporosis DATE: [ ] Cervical cancer DATE: [ ] Mammography for breast cancer DATE: MEN’S HEALTH [ ] Discussion of PSA testing DATE: [ ] Abdominal Aortic Aneurysm DATE: GENERAL CANCER SCREENING [ ] Lung cancer screening for smokers DATE: [ ] Colorectal cancer screening DATE: HIGH RISK [ ] Smoking history documented in social history within 1 year [ ] Alcohol history documented in social history within 1 year [ ] HIV screening (offered each year) DATE: [ ] Hepatitis C (Born in 1945-1965) DATE: [ ] Additional STI Screening: syphilis, HBV, HCV, GC/Ch DATE: VACCINES [ ] Influenza DATE: [ ] Tetanus, diphtheria, pertussis (Td/Tdap) DATE: [ ] Shingles DATE: [ ] Pneumococcal-23 DATE: [ ] Prevnar-13 DATE: [ ] Gardasil/HPV DATE:



Pre-Visiting Planning Template

Pre-Visit Planning: What type of visit? Urgent / Routine Follow-up / Hospital follow-up / New Patient / Annual Medicare Wellness Diabetes: Y/N [ ] Care Plan Date: [ ] HbA1c Date: [ ] Microalbumin Date: [ ] LDL Date: [ ] Eye Exam Date: [ ] Foot Exam Date: (inspection, pulses, monofilament) Obesity: Y/N BMI: [ ] Individualized Care Plan Date: Tracking information -- Were tests ordered at last visit completed? Yes/No Were consults ordered at last visit completed? Yes/No Notes: Health Maintenance CARDIOVASCULAR [ ] ASA primary heart attack prevention [ ] Diabetes screening DATE: [ ] High cholesterol screening DATE: WOMAN’S HEALTH [ ] DEXA for osteoporosis DATE: [ ] Cervical cancer DATE: (21-29 q 3 yrs; 30-65 q 5yrs) [ ] Mammography for breast cancer DATE: MEN’S HEALTH [ ] Discussion of PSA testing DATE: [ ] Abdominal Aortic Aneurysm DATE: (Male 65-75, ever smoked) GENERAL CANCER SCREENING [ ] Lung cancer screening for smokers DATE: (55-80yo with 30pack year and smoked within 15 yrs) [ ] Colorectal cancer screening DATE: (50y/o +) HIGH RISK [ ] Smoking history documented in social history within 1 year [ ] Alcohol history documented in social history within 1 year [ ] HIV screening (offered each year) DATE: [ ] Hepatitis C (Born in 1945-1965) DATE: [ ] Additional STI Screening: syphilis, HBV, HCV, GC/Ch DATE: VACCINES [ ] Influenza DATE: [ ] Tetanus, diphtheria, pertussis (Td/Tdap) DATE: [ ] Shingles DATE: (Shingrix for 50 and older) [ ] Pneumococcal-23 DATE: [ ] Prevnar-13 DATE: [ ] Gardasil/HPV DATE: (Up to age 26 y/o)



Medical Clearance Template History:

Preoperative screening:

1. Do you usually get CP or breathlessness when climbing 2 flights of stairs at normal speed? 2. Do you have kidney disease?

3. Has anyone in family had problems with anesthesia?

4. Have you ever had a heart attack? 5. Have you been diagnosed with an irregular heartbeat?

6. Have you ever had a stroke? 7. Have you had problems with anesthesia?

8. Do you suffer from epilepsy or seizures? 9. Do you have any problems with pain, stiffness or arthritis in your neck or jaw?

10. Do you have thyroid disease?

11. Do you suffer from angina? 12. Do you have liver disease?

13. Have you ever been diagnosed with heart failure? 14. Do you suffer from asthma?

15. Do you have diabetes that requires insulin?

16. Do you have diabetes that requires tablets? 17. Do you suffer from bronchitis?

18. Steroids in past 6 months?

STOP BANG: (>3 yes = high risk for OSA)

1) Snore Loud enough to wake up your partner? 2) Do you feel Tired, fatigued, or sleepy during the day after a restful sleep?

3) Has anyone observed you stop breathing during your sleep? 4) Do you have or are you being treated for high blood pressure?

5) BMI more than 35? 6) Age > 50?

7) Neck circumference greater than 40cm?

8) Male Gender?

RISK SCORES

R Gupta Cardiac https://www.qxmd.com/calculate/calculator_245/gupta-perioperative-cardiac-risk RCRI cardiac score http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/ ARISCAT pulmonary score https://www.uptodate.com/contents/calculator-ariscat-canet-preoperative-pulmonary-risk-index?source=see_link Gupta respiratory failure http://www.surgicalriskcalculator.com/prf-risk-calculator Gupta pneumonia http://www.surgicalriskcalculator.com/postoperative-pneumonia-risk-calculator

Functional status: 1 MET = ADLs, walk 1-2 blocks 4 METs = climb 1 flight stairs, walk 4 mph, some heavy lifting >10 METs = sports Surgery specific risk



- Low risk (<1%) endoscopic, superficial, cataract, breast, ambulatory - Intermediate (<5%) CEA, endovascular AAA repair, head/neck, intraperitoneal, intrathoracic, orthopedic, prostate - High (>5%) vascular

Assessment, plan and Risk Stratification:

A:

This Patient is ____ Risk for ______ Risk Surgery

Plan:

-hold _____meds (ASA and NSAIDs held at least 7 days before)

-c/w _____ meds -NPO prior to procedure

-Perioperative pain management to be determined by surgical team -post operative incentive spirometry

-Blood products on hold



Call Back Documentation Template

(Complete as saved phone message) Title: Call Back Message Caller/Who You Called: Purpose of call: Plan:



Urine Toxicology Template General Medicine Event Note Title: “utox” Medication(s) patient is taking with date and time of last dose taken: UTox (Date, Result): Results are: Consistent/Inconsistent Plan: [ ] Schedule follow-up visit [ ] Continue current regimen



Coumadin Template

Create as saved phone message.

Title should be “Coumadin Template” and send to Alley Fernan

Delete parts of template not needed/used Phone message title: “Coumadin template” Indication: __ Atrial Fibrillation/CHADVASC2 score :_ __ DVT: Provoked/Unprovoked: Recurrent? Yes__ No__ Last ultrasound if known: __ __ Pulmonary Embolism (date and diagnosis): __ Other: Hypercoagulable Work-up (Date/Result): Date of Therapy Initiation: (month/year)__ Expected Duration: __ Anticipated End Date:__ *********************************************************************************** Dx: Goal: INR: Recommendations: _ Continue Current Dosage _ Hold Coumadin for _ days and restart _ _ Change Dose to: _mg/day SUN MON TUE WED THU FRI SAT _mg _mg _mg _mg _mg _mg _mg NEXT INR TO BE DRAWN: _ days _ weeks Comments: _



Coumadin Clinic Sheets