Narrative Summary Basics Major Jared Brandt, MPAS, PA-C 152 MDG NVANG July 2016

Always On Mission Overview What is a NARSUM??? Purpose Requirements Where to Begin??? FORMAT USAF Specific Deployment Standards

Always On Mission What is a NARSUM (or AMS) It is YOUR Recommendation to the Waiver Authority It is a complex SOAP note, similar to a hospital discharge summary that may include: Special studies (labs, ECG’s, x- rays, MRI) Consultations (cardiology, neurology, etc.)

Always On Mission Purpose Purpose of the NARSUM: …..to convey to the MAJCOM a complete picture and recommendation to help waiver authority make decisions regarding the member’s ability to perform their military duty and make the best, safest decision for the ANG.

Always On Mission Purpose Cont….. Purpose of the NARSUM: “Stand Alone” narrative of the disqualifying condition – must convince the waiver authority that …* There is no unacceptable risk to the individual or to safety and mission accomplishment Specific requirements of MSD and Waiver Guide are met It is in the best interests of the USAF * If you want waiver submission to be considered favorably.

Always On Mission Requirements Two different templates – Medical and Mental Health Must use the correct template For MH NARSUM- DPHs are authorized to write (depending on their credentials) paragraph formatWill be written in paragraph format and comply with the NARSUM template. List/Bullet format is not acceptable. Effective NARSUM will convey a clear picture of condition(s) Needs to clearly state whether or not the member is unable to reasonably perform his/her duties*** Needs to clearly state whether or not the member is expected to be able to perform his/her duties within the next 12 months*** ***(bullets are directly from the DAWG checklist) The Conditions and Restrictions should match the 469!!!!

Always On Mission Requirements Cont…. Must include all conditions in NARSUM. Use the “whole person” concept Example 1: Member has an ALC code for diabetes and recently diagnosed with OSA. NARSUM will include information regarding OSA and diabetes. Example 2: Member has one duty related condition and one non duty related condition. Member will be processed using IRILO, but NARSUM will include both duty and non duty related conditions and will indicate which conditions are ILOD and NILOD

Always On Mission Requirements Cont… Will describe the condition(s), how it occurred, how it affects his/her duty, how it will affect deployability and prognosis Explain if member should be returned to duty with (or without) an ALC code or if member should be found unfit for military duty Annotate anticipated future care and treatment Example: Member recovering from cancer-will have follow up with oncologist every 6 months for next three years.

Always On Mission WHERE TO BEGIN?????? Run, don’t WALK to the - Medical Standards Directory (MSD) Look up the condition and VERIFY the NARSUM is even required!!!! VERIFY that you are holding the member to the correct STANDARD!!!!!! Aerospace Medicine Waiver Guide (AMWG) “This document primarily provides guidance for waivers on trained flying class II and III personnel, and where specifically stated applies to flying class I/IA applicants and other special duty personnel.” Simply a GUIDE and REFERENCE to know what is needed to get a favorable outcome (NOT JUST FOR FLYERS!!!)

Always On Mission NARSUM Format (1) Demographics: (2) History: (3) Current Medications: (4) HPI - Potentially Unfitting Diagnos(es): (5) Targeted Physical Exam: (6) Ancillary Study Summary: (7) Consult Summary: (8) Current Profile Restrictions: (9) Occupational Impact: (10) Prognosis/Recommendation:

Always On Mission Demographics (a) Full Name, Rank, and SS# (b) # years in service (TAMS and/or Total Guard Time) (c) Duty AFSC (Current duty title and brief (sentence or two) synopsis of primary duties), Unit and state (i.e. 193 SOS-PA, 201 RHS-PA, etc.) (d) List whether or not member has approved retirement or separation date and give the date. (e) Is this Duty Related or Non-Duty Related? Must have a completed LOD if duty related.

Always On Mission History (a) Pertinent Past Medical History: In “list” format: condition, year of onset, and state whether “resolved” or “active”. Only list major diagnos(es) which would be a factor in determining a member’s overall health for a “fitness for duty” decision. (Most “resolved” conditions aren’t applicable). (b) Pertinent Past Surgical History: In “list” format, give name and year of procedure. (c) Pertinent Family History: List ONLY genetic, heritable disorders related to any condition for which the patient carries a related diagnos(es).

Always On Mission Current Medications List both medications taken, and medications that have been prescribed and/or recommended that patient is not taking due to “noncompliance” or optional nature. Include dose/freq.

Always On Mission HPI (4) HPI - Potentially Unfitting Diagnos(es): For each potentially unfitting diagnosis as per MSD & AFI , Chapter 5 (or any other diagnosis which affects the member’s ability to perform duties, deploy and/or places a significant burden on the government to either protect or maintain the member), include the following: (a ) Diagnosis (b) Month/year of initial onset (c) What was member doing when injury or symptoms of illness occurred for the first time? (d) Where was the member (geographical location name) when injury or symptoms of illness first occurred?

Always On Mission HPI Cont… (e) Was this condition ever treated during a deployment and did it require an early return from deployment? (f) Month/year of any hospitalization, ER, or acute care visit, in the last 24 months, related to this condition. (g) Current medications and/or other treatment modalities used to treat this or related conditions (h) Prior medications and/or treatment modalities tried, for this condition, and reason for discontinuation. (i) If narcotics used, give dose, frequency, level of pain control, and history of narcotic use. (j) Include pertinent positive and negative ROS for this condition/related conditions. (k) If any condition existed prior to service, please list and tell if/how service has aggravated the condition

Always On Mission Targeted Physical Exam Note the table (attached) for specific exam elements. (a) Vital signs to include measured height and weight, with calculated BMI. (b) Exam should not be lengthy—give a relevant exam that documents the pertinent positive and negative exam findings related to each potentially unfitting condition. (c) If the member falls under a category in section (1)e above (for example, a Basic Military Trainee), make sure that orthopedic exams include range of motion studies (in degrees), strength, and function. For active duty, these studies will be conducted by the VA if DPAMM directs a full MEB.

Always On Mission Ancillary Study Summary Note the table (attached) for ancillary requirements. (a) Pertinent Labs: List pertinent positive and negative labs ONLY. Do not cut/paste groups of labs unless you delete those that are not directly applicable. Provide values over a continuum of time if they pattern a picture of decline or improvement, or unpredictable nature of condition. (b) Pertinent Rads: Do not copy and paste the entire study. Give the name of study, the date, and a clear picture of the results (impression). (c) Pertinent Other: refer to attached table for “other” requirements

Always On Mission Consult Summary Note the attached table. Provide a short, succinct summary of (a) pertinent findings, (b) diagnosis (c) prognosis and (d) recommended frequency of specialty follow-up for each consult. Since the consults will be attached to this NARSUM, only provide (a)-(d) for each consult in this NARSUM.

Always On Mission Current Profile Restrictions Review AF 469 (must be reviewed as current during NARSUM completion) and list any specific duty restriction, list the diagnos(es) to which the restriction is linked, and the release date of each restriction. We must know when you anticipate that the restriction will be removed, or if it is expected to be a long term and/or permanent restriction. Note: The AF 469 review of restrictions should not be older than 30 days. Please reflect your review in the “Restriction section” of the AF 469 and/or in the NARSUM via the following statement: “Provider reviewed restrictions and they are deemed accurate and appropriate on (date).” Signature required after the statement.

Always On Mission Line of Duty Determination (LOD): Reference AFI for (a) whether or not this is an Administrative LOD determination or (b) if this requires an AF Form 348 LOD determination. If AF Form 348 is required, ensure it is included with Initial RILO package.

Always On Mission Occupational Impact For each potentially unfitting condition, succinctly summarize: (a) whether or not condition limits the ability to perform duties and/or deploy, (b) the extent of the limitation(s) and (c) Admin LOD determination required or for injury, AF Form 348 needs to be included with IRILO?

Always On Mission Occupational Impact Cont.… USAF Specific Deployment Standards In addition to the general DoD deployment criteria listed in DoDI , Deployment- Limiting Medical Conditions for Service Members and DoD Civilian Employees, the following criteria must be met in order for USAF members to be considered deployable. Please refer to AFI , Chapter 11 prior to reviewing the additional criteria below. Additional requirements may be required for specific deployments; See COCOM reporting instructions. V1. Must be able to perform duties of AFSC for a prolonged period (at least 12 hours). V2. Must have adequate night vision to be able to travel unassisted at night. V3. At a minimum must be able to carry all required deployment baggage (at least 40 lbs) and additional requirements for duty or deployment AFSC. V4. Must be able to run at least 100 yards to take cover. V5. Must be able to subsist on field rations for up to 179 days. V6. Must be able to perform duties in hot and cold environments, without any known predisposition to heat or cold injury. Note: DoDI E3.a.(2) states “Conditions that prohibit immunizations” is a medical condition precluding deployment and requires a waiver.

Always On Mission Prognosis/Recommendations For each potentially unfitting condition, state the prognosis for: (a) full or partial (if partial, state to what degree) recovery, or stabilized maintenance of chronic condition (b) timeline for recovery or stabilized maintenance of chronic condition (c) future treatments (surgeries, procedures, studies, etc.) and duration of expected requirements. (d) list the anticipated annual frequency for each specialty requirement, and expected duration required.

Always On Mission Prognosis/Recommendations Example Recommendations 1. Capt X is a talented and respected fighter pilot with 15 years of experience and is an invaluable asset to both his squadron and the USAF. His mitral valve prolapse is completely asymptomatic and does not pose a risk to his personal safety, the safety of others, or mission accomplishment. I highly recommend that he be granted a waiver without restrictions. 2. Lt Col X is an experienced navigator but his Parkinson’s disease has become increasingly symptomatic over the past 2 months. His hands now shake too much to operate a computer. His neurologist has started him on immune modulating therapy which may be incompatible with flying. Moreover, he will be unable to deploy in the foreseeable future. Therefore, waiver can NOT be recommended at this time.

Always On Mission Summary What is a NARSUM??? Purpose Requirements Where to Begin??? FORMAT USAF Specific Deployment Standards

Always On Mission Resources Ch. 5, Ch. 10 and Ch. 11 MSD AMWG Flightlines: “Back to Basics: Writing AMS” by Douglas “X” Files

Always On Mission Additional Questions? Please contact: Major Jared Brandt 152 MDG (775) – office