TSWF Pediatric Nursing Services

AIM Form User Guide

May 2018

Form Version: May-Aug 2018

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Pediatric Nursing Services AIM form

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

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

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

Form Tabs dm

HPI/PMH/ROS……………………………………………………... 6

Behavioral Health………………………………………………… 7

Chronic Conditions…………..………………………………….. 8

Immunizations...………………………………………………….. 9

Meds 1…….………………………………………………………... 10

Meds 2……………………………………………………………… 11

Procedures 1……………………………………………………… 13

Procedures 2……………………………………………………… 14

Patient Education 1.…..…………………………………………. 15

Patient Education 2………………………………………………. 16

Adding Form to Favorites Instructions……………………………………….. 17

Copy Forward Instructions……………………………………………………… 20

AHLTA Options……………………………………………………………………. 24

Table of Contents

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Introduction to Pediatric Nursing Services 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. Who is this form made for? The TSWF Pediatric Nursing Services AIM form is recommended to be used to document clear nursing notes for PEDIATRIC patients within Patient-Centered Medical Home (PCMH) clinics. The Pediatric Nursing Services AIM form may be incorporated into scheduled Provider Visit workflows or stand-alone Nursing Visit workflows. Use this form to document administered immunizations, medications, nursing procedures, and patient education & counseling performed at the point-of-care during acute, routine, or other scheduled patient visits. This form is NOT intended to be utilized by Immunization clinics outside of the PCMH clinic. Air Force specific, this form also replaces the need to use the AFMOA-approved support staff protocols questionnaires as they have been incorporated into the TSWF Pediatric Nursing Services AIM form. Not all elements are completed at every visit or encounter…only document what is necessary. 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 p20 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 tabs on the TSWF Pediatric Nursing Services AIM form, primarily highlighting the differences between it and the CORE. For full details about the use of the CORE AIM form, please reference the CORE User Guide. 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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---------------------------- (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 information forward from one appointment to the next via 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!!)

Form Basics:

General Information on Form Use

“Helpful Tips” are found throughout and give relevant information.

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

Small boxes throughout the form allow additional free text entry.

Important information throughout the form is in red.

Access any TSWF form from the Navigator via this link.

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

The Change Log shows the updates made with each version.

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 (at the top of the page) can be clicked if this was done accidentally.

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There are two scenarios where the Pediatric Nursing Services AIM form can be used; either in conjunction with a provider’s visit or during a nursing-only encounter. The way this form is used will differ depending on which scenario is being used.

Best Practice Procedures and Workflows (Scenario 1: using the Pediatric Nursing Services AIM form in conjunction with a Provider’s visit)

Recommended Documentation Workflow for Scenario 1 a. Clinical support staff (CSS) copies forward previous essential encounter information

(highlighted in yellow on the AIM forms), preferably before the day of the visit via the “Open, not checked-in” option.

b. On the day of the visit the CSS checks the patient in, and reviews/updates all copy-forward information (e.g. past history, etc.) in the note with the patient.

c. The CSS also enters all required screening information on the screening tab (per MTF protocol), and enters a few details into the HPI section on the first tab of the AIM form.

d. The provider then takes “ownership” of the note (i.e. ‘edits’ S/O portion of the note) and reviews all copied forward information and everything entered by the CSS.

e. The provider documents encounter and orders point-of-care services as necessary. f. CSS adds an “additional S/O note” to document completed point-of-care services and notifies

provider when completed. g. Provider reviews documented services and signs note when completed.

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*per Service/MTF protocol

When using the form for stand-alone nursing procedures, the staff should change their role and add a supervising provider. To do this, from the Current Encounter module, choose “Providers” from the menu bar along the top of the screen and change the role to “Nurse” or “Paraprofessional.” Then add the provider, changing their role to “Supervising Provider”.

NOTE: Copy-forward is important even for nursing-only encounters where this form is used, since it is compatible with the rest of the CORE suite of forms. Remember, only elements placed in yellow fields will copy-forward.

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.

Best Practice Procedures and Workflows (Scenario 2: using the Pediatric Nursing Services AIM form for nursing only procedures)

The TSWF repository for training/educational materials and updates:

www.tswf-mhs.com

Clinical Support

Staff

Patient Patient Signs In

Patient Enters Data on Paper Intake

(if used)*

Completes and Signs Encounter

Note is Opened

Data Entered into AIM

form*

Adds a Supervising

Provider to the Encounter*

Documents Point-of-Care

Services Utilizing the

AIM form

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HPI/PMH/ROS Tab

The Pediatric Nursing Services 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.

Use the AHLTA allergies module to document pharmaceutical allergies.

All medication charting should include dosage, route and frequency.

2 contraceptive counseling links are included

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

Please note these tips.

The ROS contains highlighted boxes for pediatric patients presenting with specific types of complaints. Different ROS categories include: Quick, New Patients, Asthma, ADHD and Sports Participation.

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Elements on the Behavioral Health tab include PHQ-2, PHQ-9, PSC, C.R.A.F.F.T., SCARED, and the Vanderbilt scale.

Behavioral Health Tab

Clinical algorithm for administering and scoring the PSC.

Utilize the C.R.A.F.F.T. for drug and alcohol screening purposes.

The SCARED screening tool is used to identify and differentiate types of anxiety. Send home with the patient/parent and address during a follow-up visit.

This link is to PDF form fill documents that can be downloaded from the TSWF-MHS site and sent to patients via Secure Messaging.

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The Chronic Conditions tab supports PCMH recommendations and is used to document the management of frequent pediatric chronic conditions.

You’ll see several of these buttons in our forms. Clicking here will open up a “ribbon” to show more details (as shown below).

Chronic Conditions Tab

This field addresses the patient’s self-care management for their chronic conditions (what the patient’s management abilities are for themselves during the time they are not being seen in the clinic).

The Comprehensive Care Plans (CCP) ribbons for Asthma, ADHD and Diabetes document the actions, therapy, goals, barriers, and co-managing consultants for the patient’s diagnosis.

For example, the ADHD ribbon includes questions about behavior, personal and family cardiac history (for administration of medications), history of ADHD, the Vanderbilt and management goals.

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IMPORTANT: This tab is not intended for “stand alone” immunization clinics. It is intended to document immunizations performed in the normal workflow of a PCMH clinic that has point-of-care protocols for administering immunizations.

Users do not have to document this portion in the AP module any longer, but still must document the CPT code.

Make sure to complete the “Outcome of Patient” section. NOTE: once filled out, it will be greyed out on other tabs.

Be sure to annotate if the patient is pregnant and verify patient identification.

Each ribbon from this point on (until you get to the Pt Education tabs) includes prepositioned text written in S.O.A.P. note format for easy documentation. All prepositioned text in the documentation boxes can be edited/deleted according to specific needs.

Immunizations Tab

If needed, open the notepad to document additional vaccinations.

A link to CDC Vaccine Information is provided as well as links to immunization schedule and education.

ICD-10, CPT, and E&M codes are displayed in blue for easy reference and coding help.

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Next are two tabs for the documentation of medication administration. Medications are grouped together by class or how they are used.

It is very important to document everything in this section, especially the “Medication Verified by:” and “Time Administered:” portions.

To make a selection, place an “x” in between the brackets or simply delete the other options. You will find many “multiple choice” options such as this as well as “Y/N” questions that must be answered.

Meds 1 Tab

Adding yourself as a paraprofessional in

the beginning of documentation will

save you a step later on. See

instructions on p5 of this Guide.

Two medication dosage calculators are provided on both Meds tabs to quickly calculate pediatric medication dosages.

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This tab contains the remainder of the medications as well as an area for documentation of IV placements. There is also an “Other Meds” ribbon for you to add additional medications which may not be listed.

Every text box in AHLTA has a 2000 character limit. In boxes like this one with a lot of text, you may need to erase inapplicable content in order have space to add pertinent information.

Again, it is important for clinical support staff to document the “Outcome of Patient” after administering medications.

Meds 2 Tab

On some of the ribbons you will notice

a block annotated with “AF ___ SSP

used”. Check if an Air Force support

staff protocol (SSP) was used.

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This free text field is available to document additional nursing notes in regard to IV hydration.

Meds 2 Tab, cont.

CPT and coding blue clinical cues were added to assist the services that allow their clinical support staff to document in the A/P and Diagnosis areas of the encounter.

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Following the Medications tabs are two Procedures tabs, grouped by system. At the top of the Procedures 1 tab is a place to: 1) verify the patient’s identification and 2) verify that a consent form was signed. The next sections of blocks will provide you with the “Counseling and Education” and “Confirmation of patient, procedure and site.”

Procedures 1 Tab

Link to “iMedConsent” is a way to virtually sign a consent form.

Air Force MTFs are required to use the AF SSP scoring field. The throat culture questions will emit into the note as well as the score.

When this section is addressed, these items must be marked with a ‘Y’, ‘N’ or ‘n/a’.

Centor Scoring Criteria…

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Similar to Meds, the Procedures are divided into 2 separate tabs.

There is an Additional Procedures ribbon to document other procedures not found on the form. Also note the link to the TSWF Procedures AIM form provided along the top.

Procedures 2 Tab

Clicking the “x” at the very top of the field populates all the prepositioned text into the note. You must type an “x” within the brackets to denote specific selections.

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Use the Patient Education tabs to document items discussed with the patient and to utilize links to patient education materials. Each of these are designed in text box format so they can be easily modified to capture the specific counseling that took place. Patient Education should be documented whenever it is given.

Patient Education 1 Tab

Click the “X” for each field to indicate that the patient was counseled on the pre-populated text (which again, can be modified as needed).

The Respiratory (2-6 years) ribbon includes patient education for metered-dose inhalers, at-home-use peak flow meters, and additional items that are routinely discussed during respiratory counseling.

(Not shown, but also included: Family Education, Emergency Treatment Education, and “Also discussed” items.)

The Common Childhood Illnesses ribbon includes patient education on medications, fever, constipation, ear infection, nausea/vomiting/diarrhea, consult counseling, and follow-up counseling. Place an “X” in the bracket of any information that the patient is counseled on.

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There are 4 ribbons in this tab: Metabolic, Pregnancy, Urinary Tract Infections (UTI) and Sexually Transmitted Infections (STI). Each of these are also designed in text-box format so they can be easily modified to capture the counseling that took place with the patient.

Patient Education 2 Tab

The Sexually Transmitted Infections (STI) education and counseling ribbon includes patient education for STI causes and risks; education and counseling; STI prevention, and STI follow-up information. The clinical clue area contains links to STI Fact Sheets and Patient hand-outs.

UTI patient education including links to helpful information.

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TSWF Pediatric Nursing Services 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…

1. Open “Tools”

2. Select “Template Management”

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

6. Click “Search” button

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

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

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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.

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

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

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TSWF Pediatric Nursing Services 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

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

Copy-Forward Instructions

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

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.

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AHLTA returns to the “Current Encounter”

7. Click “AutoEnter.”

6. Select “PMH” tab to copy-forward.

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.

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”

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8. Select “TSWF- Peds Nursing” AIM form

9. Once in the encounter, go to the ‘Obsolete Terms’ tab. Utilize the “…uncheck ALL the items below” button to eliminate 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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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

AHLTA Options

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: Setting: Outpatient; Service Type: Outpatient Visit; Exam type: General Multi-System

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.