tri-service workflow (tswf)€¦ · web viewt2 fpma stg autotext. page 21 of 54. military health...

MHS GenesisT2 FPMA AutoText Phrases

Instructions for use:To create new AutoText Phrases:

1. From the Home screen, click Messages within the Inbox Summary panel on the left side of the screen.

2. Click the Communicate button.3. On the Message toolbar, click the Manage AutoText button. 4. Click the Add New Phrase button . 5. Copy and Paste the phrase Abbreviation into the Abbreviation field.6. Copy and Paste the phrase text into the text field.7. Highlighted text indicates a drop-down list of selections. Select the entire highlighted

area and click the Create Drop List button. 8. Each item of varying color should be converted to a drop-down item by copying the

item, clicking the Add List Item button, then pasting the new item.9. Click the Create button when all drop-down items have been created. All highlighting

will disappear after the items are converted to a list.10. When finished creating all drop downs, review the AutoText phrase, then click the

Save button.

11.

MILITARY HEALTH SYSTEM

T2 FPMA STG AutoText

Abbreviation: 2tfpma-hpi-cv-hypertensionDescription:

Hypertension Specific HPI:Pt presents for HTN F/U Pt presents for initial HTN evaluation appointmentPatient adherent with the DASH diet plan. Patient adherent with Mediterranean diet Patient is NOT adherent with Dash or Mediterranean diet plan. Patient engages in 150 minutes of moderate intensity exercise per week. Patient does NOT engage in 150 minutes of moderate intensity exercise per week.Patient uses self-monitoring device to track exercise. Pt does NOT use self-monitoring device to track exercise.

Abbreviation: 2tfpma-hpi-derm-acneDescription:

Acne Specific HPI:Pt presents with _ day week month year history of acne symptoms which include the following:Patient description of primary lesions:_, Initial site of rash:_, Current distribution:_, Factors that correlate with onset:_, What makes it better:_, What makes it worse:_- Any treatments attempted: No YES:- Response to any treatments: No YES: - Drug/medication exposure: No YES:- Caused by shaving: No YES:

Abbreviation: 2tfpma-hpi-endo-hypothyroidDescription:

Hypothyroid HPIPt presents with _ day week month year history of symptoms which include the following:

- Fatigue/tiredness: No YES:- Lethargy: No YES:- Proximal muscle weakness: No YES:- Weight gain: No YES:- Poor concentration: No YES:- Constipation: No YES:- Cold intolerance: No YES:- Dry skin: No YES:- Hair loss or thinning: No YES:

Abbreviation: 2tfpma-hpi-gi-abdominalpainDescription:

Abdominal Pain Specific HPI:Pt presents with _ day week month year history of abdominal pain symptoms which include the following:

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Location: Diffuse Localized:__ Quality: sharp dull aching cramping other: , constant intermittent migrates other: Frequency: constant intermittent other: What makes it better:_What makes it worse:_History: - Abdominal surgery: No YES: - Recent travel: No YES: - Alcohol use: No YES:Symptoms:- Nausea: No YES:- Vomiting: No YES: - Anorexia: No YES:- Constipation: No YES:- Diarrhea: No YES:- Pain radiates to the back: No YES: - Flank pain: No YES:- Blood in stool: No YES:- Black tarry stools: No YES:

Abbreviation: 2tfpma-hpi-gi-ageDescription:

AGE HPIPt presents with _ day week month year history of gastrointestinal symptoms which include the following:-Vomiting: YES: No vomiting BILIOUS VOMITING: VOMITING WITH BLOOD: , able to keep down fluids UNABLE TO KEEP DOWN FLUIDS: , -Diarrhea: YES: NO diarrhea DIARRHEA WITH MUCOUS: DIARRHEA WITH BLOOD: DIARRHEA WITH BLOOD AND MUCOUS: -Abdominal pain: No YES: , Decreased urine output: No YES: , Decreased tearing: No YES: , Sunken Eyes: No YES: , Dry appearing lips and mouth: No YES: , Fever: No YES:

Abbreviation: 2tfpma-hpi-met-diabetesDescription:

Diabetes Specific HPI:Patient is on a reduced calorie diet plan: Yes NO:Patient is engaged in a behavioral modification plan: Yes NO: Patient engages in 150 minutes of moderate intensity exercise per week AND muscle strengthening activities 2 or more days per week: Yes NO: Home glucose monitoring records (Not required if stable on oral meds):_- Episodes with symptoms of hypoglycemia (shakiness, anxiety, sweating, irritability, etc.): No YES:- Episodes with symptoms of hyperglycemia (frequent urination, thirst, blurred vision, etc.): No YES:- Episodes with symptoms of ketoacidosis (confusion, abdominal pain, fruity breath, etc.): No YES:

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Abbreviation: 2tfpma-hpi-met-obesityDescription:

Obesity Specific HPI: Assessment of patient’s readiness to change: precontemplation contemplation preparation action maintenancePatient is on a reduced calorie diet plan: Yes NO:Patient is engaged in a behavioral modification plan: Yes NO: Patient engages in 150 minutes of moderate intensity exercise per week AND muscle strengthening activities 2 or more days per week: Yes NO: Patient has had previous episodes of weight loss and gain: No YES:

Abbreviation: 2tfpma-hpi-msk-ankleDescription:

Ankle Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/ )Pt presents with _ day week month year history of ankle pain symptoms which include the following: Location:_, Quality:_, Factors that correlate with onset:_, What makes it better:_, What makes it worse:_Due to Injury: No YES:- Position at time of injury: not applicable inversion eversion plantarflexion dorsiflexion rotation- Was able to bear weight for at least 4 steps immediately after injury: not applicable No YES:- Popping or snapping sound: No YES: - Swelling: No YES:- Bruising: No YES:

- History of previous ankle injuries: No YES:- Patient participates in sports: No YES:

Abbreviation: 2tfpma-hpi-msk-kneeDescription:

Knee Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/47 )Pt presents with Left Right Bilateral knee injury, which began __hours days weeks ago.Location:_, Quality:_, What makes it better:_, What makes it worse:_- Mechanism of Injury:- Was able to bear weight and continue activity immediately after injury: No YES: - Knee swelling/effusion: No YES, within 2 hours of injury YES, after 2 hours or more- Recurrent effusion after activity: No YES:- Pain worse with activity: No YES:- Improves with rest: No YES:- Pain going up and down stairs: No YES:- Feeling of locking: No YES:- Feeling of popping/snapping: No YES:- Feeling of giving way: No YES:

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James Neville, 08/09/18,

Maybe below here we should list the abbreviations for other knee HPI options?

http://tswf-mhs.com/stg/cds/47

http://tswf-mhs.com/stg/cds/


Abbreviation: 2tfpma-hpi-msk-lbpDescription:

LBP Specific HPI:Pt presents with _ day week month year history of lower back pain symptoms which include the following:Location:_, Quality:_, Distribution of symptoms:_ When do symptoms occur:_ Factors that correlate with onset:_,Pain: Average Level:_, Worst Level:_, Lowest Level:_What makes it better:_, What makes it worse:_- Sensory or motor deficit: No YES:- Functional deficit(s): No YES:- History of previous episodes of back pain: No YES:- History of previous treatments: No YES:- Response to previous treatments: No YES:

Abbreviation: 2tfpma-hpi-rtiDescription:

RTI HPI:Pt presents with _ day history of respiratory tract symptoms which include the following: Fever: No YES: , Sore throat: No YES:, Nasal discharge: No YES:, Nasal blockage(stuffiness): No YES:, Sinus pressure: No YES:, Sinus pain: No YES:, Ear pain: No YES:, Shortness of breath: No YES:, NO cough DRY COUGH PRODUCTIVE COUGHPt has had sick contacts: No YES: Pt has had recent exposure to strep: No YES: Pt has had a recent course of antibiotics: No YES: Pt has recently taken OTC medications No YES:

Abbreviation: 2tfpma-hpi-msk-shoulderDescription:

Shoulder Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/ )Pt presents with _ day week month year history of shoulder pain symptoms which include the following:

Location:_, Quality:_, What makes it better:_, What makes it worse:_- Numbness, tingling, pain radiating past elbow: No YES: - Mechanism of injury: no trauma trauma: fall fall on outstretched arm other:- Pain causes functional impact: No YES:- Pain at rest: No YES:- Pain present during activities: No YES:- Does pain affect sleeping position: No YES:- Pain present at night: No YES:- Loss of motion/stiffness: No YES:- Weakness: No YES:- Symptoms of instability/ joint laxity: No YES:- Crepitus with motion: No YES:- Past history of shoulder pain: No YES:

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http://tswf-mhs.com/stg/cds/


- Previous treatment; corticosteroid injections: No YES:

Abbreviation: 2tfpma-ros-commonDescription:

Core ROS: Systemic: Fever: No YES:, Chills: No YES: , Recent weight loss: No YES: Head: Headache: No YES: Otolaryngeal: Earache: No YES:, Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: Pulmonary: Dyspnea: No YES: , Cough: No YES: Gastrointestinal: Nausea: No YES: , Vomiting: No YES: , Abdominal pain: No YES:, Bright red blood per rectum: No YES: , Diarrhea: No YES: , Constipation: No YES: Genitourinary: Urinary frequency: No YES:, Urinary urgency: No YES:, Dysuria: No YES: Musculoskeletal: Back pain: No YES: Neurological: Lightheadedness: No YES:Systemic: No fever, No chills, and No recent weight loss.Head: No headache.Otolaryngeal: No earache, No nasal discharge, No nasal passage blockage (stuffiness), and No sore throat.Cardiovascular: No chest pain and No discomfort.Pulmonary: No dyspnea and No cough.Gastrointestinal: No nausea, No vomiting, No abdominal pain, No bright red blood per rectum, No diarrhea, and No constipation.Genitourinary: No change in urinary frequency and No feelings of urinary urgency. No dysuria.Musculoskeletal: No back pain.Neurological: No lightheadedness.

Abbreviation: 2tfpma-ros-derm-acneDescription:

Acne Specific ROS/Red Flags: Systemic: Fever: No YES: Musculoskeletal Polyarthritis: No YES: Skin: Flushing: No YES:

Abbreviation: 2tfpma-ros-derm-rash Description:

Rash Specific ROS/Red Flags: Systemic: Fever: No YES: , Recent infection: No YES: , Recent weight loss: No YES: , Fatigue: No YES: Other: History of cancer: No YES: , Chronic corticosteroid use: No YES:

Abbreviation: 2tfpma-ros-cv-hypertension

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Description:

Hypertension Specific ROS: Systemic: Fatigue: No YES:, Lightheadedness: No YES: , Daytime somnolence: No YES: , No change in weight RECENT WEIGHT LOSS: RECENT WEIGHT GAIN: Eyes: Change in vision: No YES: , Transient blindness: No YES: Head: Headache: No YES: Otolaryngeal: Snoring: No YES: Cardiovascular: Chest pain: No YES: , Claudication: No YES: , Tachycardia: No YES: Pulmonary: Cough: No YES: , Dyspnea: No YES: Gastrointestinal: Flank pain: No YES: Genitourinary: Sexual dysfunction: No YES: Musculoskeletal: Proximal weakness: No YES: Skin: Bruising: No YES: , Skin thinning: No YES:

Abbreviation: 2tfpma-ros-met-diabetesDescription:

Diabetes Specific ROS: Eyes: Worsening vision: No YES: Otolaryngeal: Oral mucosa complaints: No YES: , Dental complaints: No YES: Cardiovascular: Intermittent leg claudication: No YES: , Leg is cold: No YES: , Foot is cold: No YES: Endocrine: Hair loss from lower limbs: No YES: Genitourinary: Change in urinary frequency: No YES: Musculoskeletal: Foot abnormality or sores : No YES: , Sexual dysfunction: No YES: Neurological: Leg weakness: No YES: , Tingling of the hands: No YES: ,Tingling of the feet: No YES: , Leg numbness: No YES: Skin: Lesions: No YES: , Bruising: No YES:, Skin thinning: No YES:

Abbreviation: 2tfpma-ros-gi-abdominalpainDescription:

Abdominal Pain ROS: ( CDS //Coding: meets requirement for 99214, 99204// ) Systemic: Fever: No YES: , Chills: No YES: , Recent weight loss: No YES: Head: Headache: No YES: , Sore throat: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: Pulmonary: Dyspnea: No YES: , Cough: No YES: Genitourinary: Change in urinary frequency: No YES: , Feelings of urinary urgency: No YES: , Dysuria: No YES: , Hematuria: No YES: Musculoskeletal: Back pain: No YES: Neurological: Lightheadedness: No YES: Skin: Jaundice: No YES: Female Only: Vaginal discharge: No YES:

Abbreviation: 2tfpma-ros-gi-ageDescription:

AGE ROS:Systemic: Chills: No YES: , Malaise: No YES: , Normal weight: Yes NO:Pulmonary: Dyspnea: No YES:Neurological: Change in alertness level: No YES:Musculoskeletal: Joint pain: No YES:

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Skin: Jaundice No YES:

Abbreviation: 2tfpma-ros-met-obesityDescription:

Obesity Specific ROS: Eyes: Worsening vision: No YES: Otolaryngeal: Oral mucosa complaints: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: , Intermittent leg claudication: No YES: , Leg is cold: No YES: , Foot is Not cold: No YES: Pulmonary: Dyspnea No YES: Endocrine: Hair loss from lower limbs: No YES: Genitourinary: Change in urinary frequency: No YES: Musculoskeletal: Foot abnormality or deformity : No YES: Neurological: Leg weakness: No YES: , Tingling of the hands: No YES: ,Tingling of the feet: No YES: , Leg numbness: No YES:

Abbreviation: 2tfpma-ros-msk-lbpDescription:

Ankle Specific ROS: Systemic: Fever: No YES: , Chills: No YES: , Night Sweats: No YES: , Unexplained weight loss: No YES: SKIN: Skin changes: No YES:


Knee Specific ROS: Systemic: Fever: No YES: , Chills: No YES: , Night sweats: No YES: , Unexplained weight loss: No YES: , Overweight adolescent: No YES: SKIN: Skin changes: No YES:


LBP Specific ROS/Red Flags:

ROS: - Psychological factors/stress present: No YES:

LBP Red FlagsFever: No YES:Recent infection: No YES:IV drug use: No YES:Fatigue: No YES:Immunosuppression: No YES:Loss of bowel or bladder control: No YES:

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Osteoporosis: No YES:Wide based gait: No YES:Saddle anesthesia: No YES:Focal neurological deficit: No YES:Recent significant trauma: No YES:History of cancer: No YES:Recent weight loss: No YES:Chronic corticosteroid use: No YES:AGE >70: No YES:Duration >1 month despite appropriate treatment: No YES:

Abbreviation: 2tfpma-ros-pulm-asthma-initialDescription:

Asthma ROS: Systemic: Fever: No YES: Otolaryngeal: Earache: No YES:, Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Skin: Rash: No YES: Neurological: Lightheadedness: No YES: , Syncope: No YES:

Abbreviation: 2tfpma-ros-pulm-asthma-initialDescription:

Asthma Follow-up ROS: Systemic: Fever: No YES: Otolaryngeal: Earache: No YES: , Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Skin: Rash: No YES: Neurological: Lightheadedness: No YES: , Syncope: No YES:

Abbreviation: 2tfpma-ros-rtiDescription:

RTI Review of systems (ROS) Head: Headache: No YES:Eyes: Eye discharge: No YES: Gastrointestinal: Vomiting: No YES: , Diarrhea: No YES: , Abdominal pain: No YES: , Normal appetite: Yes NO:Skin: Rash: No YES:

Abbreviation: 2tfpma-ros-wh-wellwomanDescription:

Well Woman ROS:

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- Severe menstrual pain: No YES:- Less menstrual bleeding: No YES:- Excess menstrual bleeding: No YES:- Bleeding between periods: No YES:- Urinary loss of control: No YES:- Breast symptoms: No YES:- Vaginal discharge: No YES:- Hematochezia: No YES:- Pelvic pain: No YES:- Pain with intercourse: No YES:

Abbreviation: 2tfpma-screen-annualquestionsDescription:

Annual Questions:Preferred language (written or spoken): English Other:_Preferred method of Learning? Verbal Written Other:_Learning disability, language barrier, hearing/vision deficit? No Yes(SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Never Rarely Sometimes Often AlwaysAdvance directive completed? No YesIs a copy of the Advance directive in the record? No YesDo you have any cultural or religious beliefs that may affect your care? No YesAre you enrolled in EMFP? No YesContact Preference:_PCM:_

Abbreviation: 2tfpma-screen-domesticviolenceDescription:

Has patient ever been forced / pressured to engage in any sexual activity or touched in a way that made you feel uncomfortable? No **Yes** Declined to answer. Notify provider Has patient ever been hit, kicked, slapped, pushed or shoved by your partner or someone important to you? No **Yes** Declined to answer. Notify provider

Abbreviation: 2tfpma-screen-auditcDescription:

AUDIT-C (CDS http://tswf-mhs.com/stg/cds/309) How often did you have a drink containing alcohol in the past year? 0=Never 1=Monthly or less 2=Two to four times a month 3=Two to three times a week 4=Four or more times a week How many drinks did you have on a typical day when you were drinking in the past year? 0=1 to 2 or does not drink 1=3 to 4 2=5 to 6 3=7 to 9 4=10 or more How often did you have six or more drinks on one occasion in the past year? 0=Never 1=Less than monthly 2=Monthly 3=Weekly 4=Daily or almost daily AUDIT-C result: negative (men<4, women <3) **positive** Alcohol use does NOT exceed maximum recommended limits, pt told to stay within recommended limits: Men < 14

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drinks/week or <4 drinks/occasion; Women < 7 drinks/week or <3 drinks/occasion) **positive** Alcohol use exceeds maximum recommended limits, (Conduct BRIEF counseling and consider referral to specialty care) Men > 14 drinks/week or >4 drinks/occasion Women > 7 drinks/week or >3 drinks/occasion **positive** Past history of alcohol related treatment or counseling. (Consider Specialty Care if patient unable to abstain/reduce alcohol use after counseling OR AUDIT-C >= 8)

Abbreviation: 2tfpma-screen-c-ssrsDescription:

C-SSRS (CDS http://tswf-mhs.com/stg/cds/181 )In the past month have you?1: Have you wished you were dead or wished you could go to sleep and not wake up? No **Yes**2: Have you had any actual thoughts of killing yourself? No (skip to question #6) **Yes**3: Have you been thinking about how you might do this? No **Yes** 4: Have you had these thoughts and had some intention of acting on them? No **Yes** 5: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? No **Yes**In your lifetime have you?6a: Have you ever done anything, started to do anything, or prepared to do anything to end your life? No **Yes**6b: Within the last three months? No **Yes** C-SSRS Summary:The patient's suicide risk level was evaluated with the Columbia Suicide Severity Rating Scale. No suicide risk items were endorsed Minimal Suicide Risk Level according to patient responses. **Moderate** Suicide Risk Level according to patient responses. Actions taken:_ **High** Suicide Risk Level according to patient responses. Actions taken:_

Abbreviation: 2tfpma-screen-dvprsDoD/Veterans Pain Rating Scale (0-10 scale) ( CDS http://www.tswf-mhs.com/stg/cds/426 )Current Pain: 0 1 2 3 4 5 6 7 8 9 10

Over last 24 HOURS, how much has your pain: ( CDS 0=Does not interfere 10 = completely interferes )Interfered with your usual ACTIVITY? 0 1 2 3 4 5 6 7 8 9 10Interfered with your SLEEP? 0 1 2 3 4 5 6 7 8 9 10Affected your MOOD? 0 1 2 3 4 5 6 7 8 9 10Contributed to your STRESS? 0 1 2 3 4 5 6 7 8 9 10

Abbreviation: 2tfpma-screen-tobaccocessationDescription:

Tobacco Cessation Counseling: (3-10 min): discussed impact of tobacco use on health, benefits of tobacco cessation, support resources to include 1800-QUIT-NOW, web-based resources, MTF Tobacco Cessation Program, medication options and quit strategies w/pt CPT

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http://tswf-mhs.com/stg/cds/181


code 99406 (>10min): discussed impact of tobacco use on health, benefits of tobacco cessation, support resources to include 1800-QUIT-NOW, web-based resources, MTF Tobacco Cessation Program, medication options and quit strategies w/pt CPT code 99407

Abbreviation: 2tfpma-screen-coreDescription:

Ambulatory Core Screening:

2tfpma-screen-dvprsMA HPI:_

Screening:Has the patient traveled outside the local area in the past 90 days? No Yes //Instruction// 2tfpma-screen-travelhistory //Instruction//2tfpma-screen-zika //Instruction//2tfpma-screen-pretravelcounselingIs the patient's BMI > or = 30? No Yes //Instruction// Behavior modification available by IBHC //Instruction// Add DX E66.09 for Obesity, or E66.01 for Morbid ObesityHas patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Other screening:2tfpma-screen-auditc2tfpma-screen-femaleonly2tfpma-screen-militaryspecific2tfpma-screen-annualquestions2tfpma-screen-healthliteracy2tfpma-screen-tobaccocessation2tfpma-screen-zika

PHQ-2:Over the last 2 weeks, how often have you been bothered by any of the following problems? 0-not at all 1-several days 2-more than half the days 3-nearly every day 1) Little Interest or pleasure in doing things 0-not at all 1-several days 2-more than half the days 3-nearly every day 2) Feeling down, depressed or hopeless.PHQ-2 score: _ Interpretation: Negative - combined score of 0-2 **Positive** combined score of 3 or higher //Instruction//if Positive perform PHQ-9 by using auto-text:2tfpma-screen-phq9 and alert provider.

Other screening:2tfpma-screen-c-ssrs2tfpma-screen-4questionptsd2tfpma-screen-gad22tfpma-screen-pcl52tfpma-screen-gad72tfpma-screen-tbi2tfpma-screen-insomnia

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ROS:2tfpma-ros-common

Abbreviation: 2tfpma-screen-femaleonlyDescription:

Female Only Screening: Could you be pregnant? No Yes Pt is pregnant, Pregnant for _ weeks based on LMP Hysterectomy: No Yes Menopause: No Yes

Abbreviation: 2tfpma-screen-gad2Description:

GAD 2: 0-not at all 1-several days 2-more than half the days 3-nearly every day 1. Feeling nervous, anxious, or on edge0-not at all 1-several days 2-more than half the days 3-nearly every day 2. Worrying too much about different thingsGAD-2 result: negative (score <3) **positive**, //Instructions//if Positive use auto-text template 2tfpma-screen-pcl5 for PTSD screening, or 2tfpma-screen-gad7 for generalized anxiety disorder screening

Abbreviation: 2tfpma-screen-gad7 Description:

Generalized Anxiety Disorder Screening: ( CDS http://www.tswf-mhs.com/stg/cds/308 )(0-not at all, 1-several days, 2-more than half the days, 3-nearly every day)0 1 2 3 1. Feeling nervous, anxious, or on edge0 1 2 3 2. Not being able to stop or control worrying0 1 2 3 3. Worrying too much about different things0 1 2 3 4. Trouble relaxing0 1 2 3 5. Being so restless that it’s hard to sit still0 1 2 3 6. Becoming easily annoyed or irritable0 1 2 3 7. Feeling afraid as if something awful might happen Add point values from each response, GAD-7 SCORE: [_] If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or getting along with other people? Not at all Somewhat Very Extremely

Abbreviation: 2tfpma-screen-healthliteracyDescription:

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Health Literacy: (CDS http://tswf-mhs.com/stg/cds/421 REALM-SF needed only when SILS question in annual questions is “often” or “always”)Administered health literacy deficit assessment.

REALM-SF Reading Assessment: Number of words pronounced correctly: [_] (Menopause, Antibiotics, Exercise, Jaundice, Rectal, Anemia, Behavior)

Other Assessment tool: _

Health literacy response care plan:[_] Referral to special needs care coordinator[_] Other: _

Abbreviation: 2tfpma-screen-insomniaDescription:

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the follwoing situations, in contracst to just feeling tired? 0=would never doze, 1=slight chance of dozing, 2=moderate chance of dozing, 3=high chance of dozing0 1 2 3 1. Sitting and reading0 1 2 3 2. Watching TV0 1 2 3 3. Sitting, inactive in a public place (e.g. a theatre or meeting)0 1 2 3 4. As a passenger in a car for an hour without a break0 1 2 3 5. Lying down to rest in the afternoon when circumstances permit0 1 2 3 6. Sitting and talking to someone0 1 2 3 7. Sitting quietly after a lunch without alcohol0 1 2 3 8. In a car, while stopped for a few minutes in trafficEpworth Sleepiness Scale Score:_Interpretation: 0-5 Lower Normal 6-10 Higher normal 11-12 Mild Excessive **13-15 Moderate Excessive** **16-24 Severe Excessive**

Abbreviation: 2tfpma-screen-militaryspecificDescription:

Military Specific Screening: Is the patient currently on a profile/limited duty chit? No Yes, patient profile reviewed Is the patient deployable? Yes No PHA Status: A PHA has been completed in the past year A PHA has been NOT completed in the past year

Abbreviation: 2tfpma-screen-pcl5Description:

PTSD CHECKLIST - PCL-5: (CDS https://sstg.ditaeon.com/cds/14)(0-not at all, 1-a little bit, 2-moderately, 3-quite a bit, 4-extremely)

0 1 2 3 4 Repeated, disturbing, and unwanted memories of the stressful experience?0 1 2 3 4 Repeated, disturbing dreams of the stressful experience?

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0 1 2 3 4 Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?0 1 2 3 4 Feeling very upset when something reminded you of the stressful experience?0 1 2 3 4 Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?0 1 2 3 4 Avoiding memories, thoughts, or feelings related to the stressful experience?0 1 2 3 4 Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?0 1 2 3 4 Trouble remembering important parts of the stressful experience?0 1 2 3 4 Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?0 1 2 3 4 Blaming yourself or someone else for the stressful experience or what happened after it?0 1 2 3 4 Having strong negative feelings such as fear, horror, anger, guilt, or shame?0 1 2 3 4 Loss of interest in activities that you used to enjoy?0 1 2 3 4 Feeling distant or cut off from other people?0 1 2 3 4 Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?0 1 2 3 4 Irritable behavior, angry outbursts, or acting aggressively?0 1 2 3 4 Taking too many risks or doing things that could cause you harm?0 1 2 3 4 Being 'super alert' or watchful or on guard?0 1 2 3 4 Feeling jumpy or easily startled?0 1 2 3 4 Having difficulty concentrating?0 1 2 3 4 Trouble falling or staying asleep?

Add point values from each response, PCL-5 SCORE: [_]

Abbreviation: 2tfpma-screen-phq9Description:

DEPRESSION SCREENING / MONITORING (PHQ-9): ( CDS http://www.tswf-mhs.com/stg/cds/306 )(0-not at all, 1-several days, 2-more than half the days, 3-nearly every day)0 1 2 3 Little Interest or pleasure in doing things0 1 2 3 Feeling down depressed or hopeless0 1 2 3 Trouble falling or staying asleep, or sleeping too much0 1 2 3 Feeling tired or little energy0 1 2 3 Poor appetite or overeating0 1 2 3 Feeling bad about yourself - or that you are a failure or have let yourself or your family down0 1 2 3 Trouble concentrating on things, such as reading the newspaper or watching television0 1 2 3 Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual0 1 2 3 Thoughts that you would be better off dead or of hurting yourself in some way

Add point values from each response:PHQ-9 score: [_]

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If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult **Very difficult** **Extremely difficult**

Abbreviation: 2tfpma-screen-pretravelcounselDescription:

Pre-travel counseling (CDS CDC Pre-Travel Information: https://www.cdc.gov/travel/page/traveler-information-center CDC Travel Health Notices: https://www.cdc.gov/travel/notices )Patient is traveling to _ on _.Discussed the following health/safety risks and recommended precautions:- Current CDC travel advisories- Following specific disease(s); _- Immunizations- Food and drink safety- Bug bite prevention- Caution around animals- Climate and outdoor precautions- Transportation and personal safety- Avoiding bodily fluid- Importance of knowing how to get medical care while traveling:

Abbreviation: 2tfpma-screen-tbiDescription:

TBI screening:Within the past 30 days, have you: been in a vehicle crash, nearby when a blast ocurred, fallen, or injured you head or neck? No Yes, patient has already been evaluated or treated for this issue. Yes, patient has not had evaluation or treatment for this issue //Instructions// If Yes, use 2tfpma-screen-mace

Abbreviation: 2tfpma-screen-travelhistoryDescription:

Travel history (CDS http://wwwnc.cdc.gov/travel/diseases/ http://wwwnc.cdc.gov/travel/notices/ http://wwwnc.cdc.gov/travel/page/in-clinic-quick-links/ http://wwwnc.cdc.gov/travel/page/travel-medicine-references/ )Travel from _on _ mon/day/yr_ to _ Return on_Travel from _on _ mon/day/yr_ to _ Return on_Did the patient experience illness during the trip? No **Yes** (details):

Abbreviation: 2tfpma-screen-zikaDescription:

Zika Risk Assessment: (CDS https://wwwnc.cdc.gov/travel/page/world-map-areas-with-zika https://www.cdc.gov/zika/prevention/transmission-methods.html) 1. Have you or your sexual partner traveled to or live in a Zika affected area in the past 6 months or are any of you planning to in the future? No **Yes**

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2. Are you pregnant or do you plan to conceive in the next 6 months? No **Yes**

Abbreviation: 2tfpma-ssp-b12Description:

Vitamin B12:S: - Yes No Written order verified from provider to administer Vitamin B12 IM injection. - Yes No 2 patient identifiers verified - Yes No Patient has picked up current B-12 prescription from pharmacy Exclusion criteria - Yes No Patient does NOT have excessive fatigue (Symptoms worse than initial assessment)? - Yes No Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)O: - Yes No Current allergy status shows no contraindications, no prior history of adverse reaction to Vitamin B12 injections.

[ Insert Labs Last 6 Months 2012 Smart Template] Procedure: Vitamin B12 IMPlease refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions.2. Next date due for injection: [_]

Abbreviation: 2tfpma-ssp-depoproveraDescription:

Depo-Provera:S: - Yes No Provider has prescribed Depo-Provera birth control for patient, current order validated - Yes No Pap smear is current is not current, patient was scheduled an appointment to obtain

//Instructions// Choose an option below: Within 5 days of onset of normal menses. First day of LMP: _ Neg HCG today; States been abstinent for 2 weeks. Repeat injection. Presents within window Date of last injection: _ Date injection due: _ Presents outside injection window; not given today.

Exclusion criteria: - No **Yes** Pregnancy or pregnancy symptoms - No **Yes** Prolonged/ongoing headaches - No **Yes** Heavy vaginal bleeding - No **Yes** Depression symptoms - No **Yes** New diagnosis of thrombophlebitis or thromboembolic disease (blood clots, stroke, heart attack) - Yes **No** Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)No exclusion criteria met **exclusion criteria present** provider notified

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O: - Yes No 2 patient identifiers met Procedure: Depo-Provera injectionPlease refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions. 2. Next date due for injection: [_] (CDS //Instructions// update in Diagnoses and Problem List in "dark menu", "contraception care", change title to Depo-provera next shot due (date).)

Abbreviation: 2tfpma-ssp-testosteroneDescription:

Testosterone:S: -Yes No Provider has prescribed testosterone injection for patient, current order validated Exclusion criteria: - No **Yes** Hypersensitivity to testosterone - No **Yes** History of male breast or prostate cancer - No **Yes** Women who are breast-feeding, pregnant or may become pregnant - No **Yes** New coumadin therapy (excessive edema. Excessive bleeding or bruising) - Yes **No** Liver function tests performed in the last 12 months - Yes **No** Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)No exclusion criteria met **exclusion criteria present** provider notified

O: - Yes No 2 patient identifiers met

[ Insert Labs Last 12 Months 2012 Smart Template] Procedure: Testosterone injectionPlease refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions.2. Next date due for injection: [_] (CDS //Instructions// update in Diagnoses and Problem List in "dark menu", "testosterone deficiency", change title to testosterone next shot due (date).)

Abbreviation: 2tfpma-ssp-synagisDescription:

Synagis:S: -Yes No Provider has prescribed Synagis injection for patient (2years of age and below), current order validated Exclusion criteria: - No **Yes** Hypersensitivity (allergic reaction) to palivizumab or murine antibody - No **Yes** Acute bronchospasm - No **Yes** Hypotension

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- No **Yes** Thrombocytopenia, hemophilia, or anticoagulation therapy - Yes **No** Patient has normal vital signs (Temp <101.5 premature: P 120-170, BP 65-85/45-55, RR 40-70 0-3 months P 100-150, BP 70-90/50-65, RR 30-45 3-6 months 100-150, BP 70-90/50-65, RR 30-45, 6-12 months P 90-130, BP 80-100/55-65, RR 25-40 1-3 years P 80-125, BP 90-105/55-70, RR 20-30)

No exclusion criteria met **exclusion criteria present** provider notified

O: - Yes No 2 patient identifiers met

Procedure: Synagis injectionPlease refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions.2. Follow up: PRN For booster within:_

Abbreviation: 2tfpma-ssp-dysuriaDescription:

Dysuria SSP: S: _ - Yes No Dysuria (pain/burning) - No Yes Frequent urination - No Yes Urinary urgency Exclusion Criteria: -No **Yes** Is the patient < 18 or > 64 years old? -No **Yes** Is this the patient’s first time experiencing UTI-like symptoms? -No **Yes** Has the patient been treated for 3 or more UTIs in the past 12 months? -No **Yes** Is the patient pregnant or possibly pregnant (e.g. late/missed menstrual cycle)? -No **Yes** Is the patient in a perioperative (pre or post-operative) status, been hospitalized or received a urinary catheter within the last 7 days? -No **Yes** Is the patient complaining of vaginal discharge and/or itching? -No **Yes** Is the patient complaining of ulcers, rashes or blisters in the genital area? -No **Yes** Does the patient experience pain with intercourse? -No **Yes** Does the patient have a history of kidney or urological diseases (e.g. kidney transplants, stones or procedures; urinary obstruction, abnormalities or urologic anatomic defects)? -No **Yes** Does the patient have severe abdominal, pelvic or flank pain? -No **Yes** Does the patient have nausea or vomiting? -No **Yes** Has the patient measured a fever at home of greater than 100.4o F/38oC? -No **Yes** Does the patient have a decreased immune system due to either medications (e.g. steroids or immunosuppressive agents for Rheumatoid Arthritis) or diseases (e.g. cancer or HIV)? -No **Yes** Does the patient have Diabetes Mellitus?

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Patient responded "No" to all questions above "Yes" to one or more of the questions above, provider alerted Allergies/Sensitivities: All other allergies verified: Y Nitrofurantoin: No Yes Trimethoprim/Sulfamethoxazole and/or does the MTF have >20% antibiotic resistance data? No Yes Fosfomycin Trometamol: No Yes

O: Vital signs noted as below:

Pt vital signs: WNL Abnormal after repeat, provider alerted P:Care Transferred: N/A other: Labs to be ordered:

Urinalysis No Yes Urine Culture No Yes Urine HC: No Yes GC/Chlamydia: No Yes

Medications to be ordered: Nitrofurantoin: No Yes Trimethoprim/Sulfamethoxazole: No Yes Fosfomycin Trometamol: No Yes

Patient education, counseling and follow-up care instructions were discussed with the patient and the patient conveyed understanding. Annotate instructions below (e.g. patient to follow-up with PCM if not responsive to medication regime within 2-3 days).

Abbreviation: 2tfpma-ssp-sorethroatDescription:

Sore Throat:S: Patient with a history of sore throat for # [_] days; presents to the clinic for throat swab per clinic protocol. -No Yes //Instructions// If Yes, then obtain strep and/or culture, notify provider Patient had recent exposure to strep and has symptoms -No Yes Decreased food intake -No Yes Decreased fluid intake Exclusion criteria: -No **Yes** Symptoms (sore throat or fever) more than 10 days? -No **Yes** Accompanying complaints or Chronic conditions: Earache, COPD, Diabetes, Chemotherapy, Immunosuppressive drugs, Significant cough, Asthma, HIV/AIDS, or Pregnancy? -No **Yes** More than 2 Strep infections within the last 12 months? -No **Yes** Sat % less than 95% with distress? -No **Yes** Any shortness of breath, or wheezing? -No **Yes** Any drooling, difficulty swallowing, or uvular deviation? - Pediatric patient with normal vital signs Temp <101.5, RR<25, P (age 3-6 yrs 70-115) (age 7-18 yrs 60-10) Pediatric patient with abnormal vital signs after repeat, provider alerted

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Adult Patient with normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5) Adult Patient with abnormal vital signs after repeat, provider alertedO: No Yes Throat erythema No Yes Exudate present No Yes Excess salivation No Yes Difficulty Opening Mouth No Yes Severe and/or one sided Tonsillar swelling No Yes Marked Swelling and Tenderness of Cervical Lymph Nodes No Yes Rash No Yes Foul smelling breath

SSP SCORING:0=No 1=Yes Is cough absent?0=No 1=Yes Is there a history of fever > 100.4F?0=No 1=Yes Is there tonsillar swelling or exudate?0=No 1=Yes Are there swollen tender anterior nodes?0=No 1=Yes Is patient age 3-14 years?0=No -1=Yes (Adult patients) Is pt age >44 years? (subtracts from score)

[_] Centor Score

A: Probable strep pharyngitis (recent exposure and has symptoms, or score >3) Possible strep pharyngitis (score 2-3) Viral pharyngitis (score 0-1)

P: Rapid strep or culture obtained, provider to assess pt and order treatment, home care instructions and medication education given Rapid strep or culture obtained, home care instructions given, results will be reported to provider No antibiotics or throat swab performed, home care instructions given, pt to F/U if symptoms persist or worsen

Abbreviation: 2tfpma-ssp-wartDescription:

Wart treatment: S: Patient presents at follow up visit with for new complaint of warts on [_]. No redness or swelling at the site is noted. Exclusion criteria: -No **Yes** Does the patient have a fever? -No **Yes** Does the patient have any redness at the wart site or treatment site? -No **Yes** Does the patient have any swelling at the wart site or treatment site? Patient answered "No" to all questions above "Yes" to one or more of the questions above, provider alerted Warts are treated per: Clinic protocol Provider instruction O:

Adult Patient with normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)Adult Patient with abnormal vital signs after repeat, provider alerted Pediatric patient with normal vital signs Temp <101.5, RR<25, P (age 3-6 yrs 70-115) (age 7-18 yrs 60-110) Pediatric patient with abnormal vital signs after repeat, provider alerted

A: Wart/s is noticeably smaller in size measuring is noticeably larger in size measuring measure at: [_] cm

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P: The wart/s was treated with: Cryotherapy: Nozzle was positioned 1-1.5cm above skin surface, aimed at center of wart. Liquid Nitrogen applied until ice field encompassed wart and margin (2-3mm). Freeze thaw technique performed with 2-3 minutes between cycles. Topical agent. Salicylic acid. Procedure completed by: [ Username ], Medical Technician Time of procedure: _- Yes No Treatment options and side effects discussed with patient- Yes No Verbal/written informed consent (as per local MTF policy) obtained from patient or parent/guardian- Yes No Universal precaution and time out procedures were initiated- Yes No Pt given home care instructions and educational materials - Yes No Pt scheduled a follow up appointment per physician orders

Abbreviation: 2tfpma-ssp-pregnancytestDescription:

Pregnancy Test:S: Pregnancy test is requested: Patient denies complaints of cramping, illness and severe nausea.Exclusion criteria -No **Yes** Does the patient have fever or chills? -No **Yes** Does the patient have moderate or severe abdominal pain? -No **Yes** Does the patient have heavy vaginal bleeding (more than the normal menstrual cycle)? Patient answered "No" to all questions above "Yes" to one or more of the questions above, provider alerted - Yes No Patient menstrual cycle is over 5 days late - Yes No Home pregnancy test completed and was positive Patient answered "Yes" to either/both questions above: HCG ordered as per clinic protocol "No" to both questions, patient instructed to return for testing at least 5 days after missed period.

-Is patient between 16 and 24? Yes No --If Yes, has chlamydia screening been completed in the past 12months? Yes - Date: _ No --If not done in 12 months, or overdue, discussed the importance of chlamydia screening and procedure for testing with the patient? Yes No ---Patient consented, test ordered and patient sent to laboratory declined testing First day of last menstrual period: _ [Gravida] _ //Instructions// Update in Histories: Pregnancy as needed O:

Procedure completed by: [Username] Time of procedure: [_] A: Unconfirmed pregnancy P: -Serum qualitative beta HCG ordered per clinical protocol provider order. Patient sent to lab. -Patient contact information has been verified. -Pt instructions given as follows: PCMH Team will contact patient with pregnancy test results and further instructions within 24 hrs. Positive results: Referral to obstetrical care has been placed, Pre-natal vitamins ordered (no contraindications noted), Active duty referred to Public health for workplace eval/counseling and profile

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Abbreviation: 2tfpma-ssp-pseudofolliculitisbarbaeDescription:

Pseudofolliculitis Barbae Clinic:Phase #: III Clinic visit: F/U #: Initial S: [Age], nationality _ , ADAF with c/o shaving bumps/ingrown beard. Length of condition: _ Age that first started to shave: _ The method used to shave the first time was: razor electric razor scissor hair clippers depilatory Current shaving method: _ Current problems with method: [_] papules, [_] pustules, [_] in grown hairs, [_] keloid, [_] lesions, [_] scarring, [_] none. Has patient been in the PFB program in the past? Yes, where and when: No O:

PFB Status: number and status of lesions: NONE- No lesions MILD- 20 or less papules/pustules MODERATE- 20-40 papules/pustules AND/OR one to three nodules SEVERE- More than 40 papules/pustules AND/OR more than three nodules Present Beard Status: SLIGHT (peach fuzz) Moderate HeavyA: Pseudofolliculitis Barbae Phase: IIIP: -PFB Educational Hadnout Given: Yes No -AF 469 given to Patient: Yes, expiration: No -Phase III- not to exceed 1/8 of an inch in growth. NOT TO BE SHAPED OR STYLED. -Follow up appointment: Yes, when: No -Duty phone number: _

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