TSWF Metabolic Disorders CPG AIM Form

User Guide May 2020

Form Version: May-Aug 2020

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Metabolic Disorders CPG AIM form

Introduction………………………………………………………………………… 2

General Information.………………….………………………………………...,,, 3

Best Practice Procedures and Workflows……………………………………. 4

Form Tabs dm

HPI/PFSH/CCP…………………………………………………….. 5

ROS…………………………………………………………............ 7

PE………………………………................................................... 7

Exit/CCP……………………………………………………………. 8

Diabetes ®………………………………………………………….. 9

HTN (VA/DoD) ®…………………………………………………... 10

HTN (JNC-8) ®……………………………………………………... 11

Dyslipidemia ®…………………………………………………….. 12

Obesity ®………………………………………………………….... 13

Adding Form to Favorites Instructions……………………………………….. 15

Copy Forward Instructions……………………………………………………… 18

AHLTA Options………………………………………………………................... 21

Table of Contents

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Introduction to Metabolic Disorders CPG AIM Form

Background/History: The Tri-Service Workflow (TSWF) Team has created AIM forms to bring team care to MTF workflow, save provider and staff time through standardization of AHLTA templates, and enhance documentation of the patient encounter. The focus of TSWF activities is to facilitate improvements by evaluating clinical workflows and creating standardized structured documentation tools that mirror clinical processes. This is done through the use of AIM (Alternate Input Method) forms with the goal of improving care and documentation in AHLTA and not just the use of a form for its own sake. The Metabolic Disorders CPG AIM form is used in Primary Care and can be used alone or in conjunction with the CORE form during an encounter. In fact, all of the TSWF CPG AIM forms are compatible with each other and the CORE form and can be used interchangeably, either within an encounter or for different encounters. Who is this form made for? This form specializes in targeted care for patients diagnosed with diabetes, hyperlipidemia, hypertension, and/or obesity and can be used for any encounter for these patients. These conditions are common and have several aspects of management in common. The Metabolic Disorders CPG AIM form can support your evaluation, documentation, and management of patients with these conditions. The form contains key elements of four VA/DoD Clinical Practice Guidelines, resulting in documentation that supports adherence to the guidelines. The form also contains and provides easy access to clinical decision-making resources. Like the other TSWF CPG AIM forms, the Metabolic Disorders CPG form is largely similar to the TSWF CORE form in layout, function, and appearance, and allows for documentation of accompanying issues without having to switch between them. Therefore, this guide will primarily highlight the differences between the two. For full details about the use of the CORE AIM form, please reference the CORE User Guide. Why would I want to use this form for my notes? This form and associated workflow was designed to standardize health documentation practices in the MHS. Standardization of documentation can result in the following:

• Integrating clinical support staff into the care of patients

• Obtaining more thorough and better documentation

• Guiding providers toward using evidence-based care

• Standardizing suicide and safety evaluations

• Improving the speed and efficiency of documentation

• Improving coding accuracy

• Building in items required for inspection Features of the Tri-Service Workflow AIM forms and associated workflows:

• The copy-forward process (see instructions on p18 of this Guide): o Maintains continuity of clinical information o Carries forward treatment planning and ongoing course of care o Improves note writing efficiency

• The forms include clinical clues and reminders

• VA/DoD CPG decision support is available right at the point of care This user guide is a comprehensive AIM form reference that walks through the tabs on the TSWF Metabolic Disorders CPG AIM form. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: www.tswf-mhs.com. If you have questions or feedback about this User Guide, please contact us via the following link on Milsuite: https://www.milsuite.mil/book/groups/tswf.

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General Information on Form Use

---------------------------- (Sequence of Clinical Workflow) --------------------------

Form Structure: - Mirrors clinical workflow (from left to right: intake, screening, ROS, PE, and care plan documentation) - Facilitates use of clinical support staff (technicians, medics, corpsman, etc.) for screening and intake documentation - Provides decision support from VA/DoD CPGs and other national level recommendations - Improves documentation efficiency - Carries important past medical history (PMH) information forward from one appointment to the next utilizing the copy-forward process. (REMINDER: any information you want carried into subsequent notes must be placed into the yellow fields as these are the only fields that copy-forward!!) - Contains reference only tabs (®) outlining reference material specific to the CPGs covered in the form

Form Basics:

Do NOT delete the TSWF AIM form identifier (integral to the copy-forward process). Start the note below this text.

Clinical clues are found throughout and give relevant information.

The Change Log shows the updates made with each version.

Access any TSWF form from the Navigator via this link.

MilSuite link – AHLTA users can ask questions, provide input, and obtain training materials.

Website for TSWF training, contacting the TSWF team, and many other resources.

A red “X” indicates this section will be included in the note. AHLTA automatically marks this “X” after text has been entered. Clicking on the “X” after typing in the box will reset the box to its default text by erasing what has been entered. The Undo button (see the top of the screenshot above) can be clicked if this was done accidentally.

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Best Practice Procedures and Workflows

Recommended Documentation Workflow a. Clinical support staff (CSS): copy-forward PMH from previous encounter (highlighted in yellow on the

AIM forms); consider “Open, Not Checked-In” up to a week before the encounter to copy-forward and enter information preparatory to the encounter. Consider use of the Comprehensive Care Plan (CCP) for patients diagnosed with CPG-relevant conditions.

b. CSS: at the time of the encounter, perform Screening (2nd tab on the form), Past History, etc. as directed by clinic leadership and workflow. The CSS should also verify all the copy-forward information with the patient. They then “close” (not sign) note.

c. Provider “takes ownership of the note”, i.e. “edits” S/O portion of note. Provider reviews the existing documentation, edits as needed, and proceeds with documentation of additional history, physical exam in the AIM form.

d. Provider reviews CPG AIM form reference material as desired. e. Provider updates the CCP as desired. f. Provider completes A/P, disposition, and signs the encounter note.

Why Copy-Forward? Copy-forward supports continuity of care by allowing staff to bring forward all of the past medical history and chronic care planning into the current encounter to be reviewed and updated (only elements placed in yellow fields will copy-forward). In addition to this being best practice, performing a copy- forward is a significant time-saver as well.

PLEASE NOTE:

• A comprehensive visual change log has been created to assist users in identifying the changes made with each version’s update. Click here to access this presentation.

• Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data.

The TSWF repository for training/educational

materials and updates:

www.tswf-mhs.com

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HPI/PFSH/CCP Tab

The Metabolic Disorders CPG AIM form is set up so that you can see most of the important details about the patient in one place, right on the front tab. Many of these pertinent details about the patient don’t change much from visit to visit, so our workflow has the Clinical Support Staff copy-forward (CF) these past medical history (PMHx) elements for review during the encounter. You can identify CF PMHx by the yellow highlighted elements on the form.

HPI box: for describing more detail about the presenting problem or reason for appointment.

Attending physician field is intended for use at training programs only.

Link that launches an external website.

These statements can be used as shortcuts for documenting steps associated with reconciling medications.

Use the AHLTA allergies module to document pharmaceutical allergies.

This box contains reminders of interventions that have a demonstrated positive impact on morbidity and mortality in patients with these four conditions.

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HPI/PFSH/CCP Tab, cont.

These 3 lifestyle questions are placed here because they are commonly a concern in patients with these conditions. They should be answered by the clinical support staff during the intake process in addition to the regular screening that’s done for these patients.

You’ll see several of these buttons in our forms. Clicking here will open a ribbon to show more details.

The CCPs for Obesity and for Metabolic Disorders are placed on the first tab to attract the staff’s attention. These comprehensive care plan fields are designed as a common documentation location for elements that are recognized by the CPGs as necessary for adequate continuity of care. This is an area for the support staff to gradually, visit by visit (preferably in an open-not-checked-in mode) fill in this information on the patient. These are copy-forward fields which can be customized to the provider’s or patient’s needs. They are pre-populated with information, but you can modify them if you wish.

The VA/DoD Dyslipidemia CPG recommends use of one of these risk tools. Providers are encouraged to become familiar with the tools and use the one that you are comfortable with.

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ROS Tab

These tabs are color-coded with colors corresponding to elements that are specifically addressed in the VA/DoD CPGs. Remember, the CPGs are not written to instruct on history and physical exam. There may be important ROS or PE items for a condition that are not color-coded.

PE Tab

Free-text boxes can be opened for additional documentation.

Italics is used for items not routinely performed; these are not selected when the Normal button is selected and must be marked manually.

All Normal button available for quick documentation of common ROS. Select All Normal and either deselect or change N to Y as appropriate.

Normal button for quick documentation of PE.

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Several accreditation agency expectations (such as patient handouts and self-management assessments) are on the Exit/CCP tab. This tab also contains comprehensive care plans that exist for a large number of chronic clinical conditions and help to document the kind of data that would have been in a coversheet of a paper record. These include many aspects of the patient’s care plan, like their goals, test results, etc. Although this is a lot of data, it only has to be filled out once. Once it’s been started, it’s relatively easy to keep up with. Clinical support staff can update a lot of this information when they do the “Open, Not Checked-In” scrub of the record.

Exit/CCP Tab

This copy-forward field documents important self-care management plans. As a text field, it can be adapted to fit your needs, but we recommend retaining the information listed.

Link to CPG guidelines.

Info from all yellow ribbons will copy-forward.

Remember, the Obesity and Metabolic Disorders CCPs are on the first tab of the form. All the other CCPs can be found here.

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The remainder of the tabs on the Metabolic Disorders CPG AIM form are for reference only- no patient data or information is recorded on them.

This tab contains algorithms, charts, and other reference materials for diagnosis, classification, and treatment of Diabetes.

Diabetes Reference Tab

View of open Diabetes Diagnosis and Classification ribbon.

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For example, when the first ribbon is expanded, a flow diagram is presented that describes a screening and diagnosis decision tree. The sidebars are taken directly from the CPG itself.

Hypertension (HTN VA/DoD) Reference Tab

The next reference tab covers Hypertension recommendations from the 2014 VA/DoD CPG. Like the Diabetes tab, there are a number of ribbons which can be opened to reveal different tables or algorithms from the CPG.

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In general, TSWF forms emphasize the VA/DoD CPGs as resource material. However, the decision was made to include reference material from JNC-8 since that reference might be more familiar to some users. While the two guidelines are very similar, there are some differences. Both the JNC-8 and the VA/DoD CPG are reference material for educating providers on medical evidence. The material is presented for handy reference, not to dictate a certain practice.

Hypertension (HTN JNC-8) Reference Tab

Clinical clues in blue offer additional help and recommendations for algorithms.

This button links to the JNC – 8 guidelines.

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The recommendations on the dyslipidemia reference tab are based primarily on the VA/DoD CPG. In addition, this tab includes a ribbon describing recommendations from the ACC (American College of Cardiology)/AHA (American Heart Association). Recommendations for initial labs are also noted at the top, and there are four ribbons with additional material.

Dyslipidemia Reference Tab

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This tab contains algorithms on treatment for weight loss and maintenance, a link to the Obesity CPG, as well as other reference materials.

Obesity Reference Tab

The bariatric surgery ribbon contains short excerpts from the VA/DoD Obesity and Overweight CPG.

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TSWF Metabolic Disorders CPG AIM Form:

Adding Form to Favorites Instructions

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The preferred method of accessing TSWF AIM forms is to have the Navigator in your Favorites. Loading from the Navigator will take you to the most current version of the form. Alternate Method: Add the specific TSWF AIM form to your Favorites…

5. From “Owner Type” dropdown list select “Enterprise”

1. Open “Tools” 2. Select “Template Management”

3. Click “Expanded Search” to locate TSWF– AIM forms

4. In “Template Name” line type “TSWF”

6. Click “Search” button

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8. Select “Add Favorite” (Do not use “Save As”, as the form will not get updated properly…see below)

Do not use ‘Save As’ when adding this template to your favorites list. Do not set this form as your default encounter template unless you have specific instructions on how to do it from your local clinical systems trainer. ‘Save As’ will break the link to the Enterprise and keep the form from updating properly; setting as a default will also break the link if not done properly. We suggest cleaning out old and un-used templates from your favorites to help you quickly find the ones you most often use.

7. In the “Search Results” list: Right click on the “TSWF Metabolic- CPG- Department of Defense” AIM form

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TSWF Metabolic Disorders CPG AIM Form:

Copy-Forward Instructions

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Consider including “cancelled/LWOBS” visits when reviewing this module.

1. In Appointments view; Double-Click on the Patient. (This takes you to this “Current Encounter” view.) DO NOT OPEN S/O

Copy-Forward Instructions

2. Select the “Previous Encounters” module from the Folder List.

The copy-forward process is integral to the Tri-Service Workflow. Following these steps will ensure that the appropriate data you enter in today gets reused as efficiently as possible. REMINDER: only information placed in the yellow fields throughout the form will copy-forward!!

4. Click the “Copy Forward“ icon on the tool bar.

3. Click on the most recent and compatible TSWF encounter listed (e.g., includes “<<Note accomplished in TSWF-_______>>” in the HPI section).

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AHLTA returns to the “Current Encounter”

7. Click “AutoEnter.”

TSWF Copy-Forward process All copy-forward items are located on the PMH tab in this view and are ONLY in the yellow colored fields throughout the AIM form. Critical Assumptions You MUST complete copy-forward and open the TSWF AIM form before editing the content. You MUST copy-forward from a TSWF “standard primary care” AIM form (CORE or any CPG AIM).

DO NOT MAKE ANY EDITS WITHIN THE COPY-FORWARD TEMPLATE! -If the Copy-Forward Template is not automatically loaded; select it from the Template drop down menu.

5. Select “S/O”

6. Select “PMH” tab to copy-forward.

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8. Select “TSWF-Metabolic CPG” AIM form

9. Once in the encounter, go to the ‘Obsolete Terms’ tab. Click the “…uncheck ALL the items below” button to remove any term found on this page as they are no longer used on TSWF forms. You will not see these terms in the form view, but they would show up on the Note View. This should be your final step in the copy-forward process.

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AHLTA Options

Line 1- will default to your name

Line 2- as directed by your MTF-in the LIVE system, AHLTA’s default is PHYSICIAN/WORKSTATION

Line 3- as directed by your MTF

Co-signer- as directed by your MTF

AUTO CITES- recommend checking Allergies and Questionnaires (if used). Uncheck anything else.

VITALS/LABS/RADS- this will automatically place ANY vitals/results in your note for the time period you selected- i.e. for the last 7 days. We recommend leaving all these unchecked. WARNING-THIS FUNCTION WILL AUTOMATICALLY PLACE INFORMATION IN YOUR NOTE REGARDLESS OF WHO ORDERS THE LABS. Individual labs/rads can be added to the encounter when viewing those results.

A/P Active Order Default: recommend checking all the boxes

Access by opening up any clinical encounter or tel-con to this screen. Click on the OPTIONS tab.

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S/O Default- We recommend unchecking both of these boxes. Having them checked can cause unexpected behavior in the forms.

Disposition Follow Up Discussed with Default: Defaults to Patient. Option to override for exceptions is located in the DISPOSITION tab

E&M Calculator Defaults: Recommend ‘Outpatient’ for Setting, ‘Outpatient Visit’ for Service Type, and ‘General Multi-System’ for Exam Type.

Do NOT check AUTO PRINT or SENSITIVE

Include ICDCM/DoD Unique/CPT4/HCPCS codes in encounter note- check this box. This will place the codes on the signed encounter. No action required by user. Warn me if no procedure documented- for primary care, do not check this box. Auto Save- recommend unchecking this box. This used to be helpful, but auto-saving freezes up AHLTA for a moment and it’s really just not needed.