“Medically Ready Force…Ready Medical Force” TSWF Nursing Services AIM Form Training 19 February 2015

“Medically Ready Force…Ready Medical Force” Welcome to the Nursing Services AIM Form Training Please sign in on the training roster Please log onto computer using your CAC Please open up ‘live’ AHLTA and sign in Please let one of the trainers know when you are signed in so your computer favorites can be configured

“Medically Ready Force…Ready Medical Force” Agenda Introduction/Overview Who can use this form? Discuss ideal integration and workflow Basic Reminders How to use the Nursing Services AIM Form

“Medically Ready Force…Ready Medical Force” Why Use a TSWF Nursing Services AIM Form? Creates clear clinical nursing notes Daily charting is easier and faster Provides patient education/counseling notes Air Force-Specific Notification: This form replaces the need to use the AFMOA-approved support staff protocol questionnaires

“Medically Ready Force…Ready Medical Force” Who should use the TSWF Nursing Services AIM Form? ALL services can use the Nursing Services AIM Form (Note: there are service-specific items within the form) Any clinic that gives medications or does routine procedures can benefit from the use of this form Nurses and Support Staff Providers Medication doses are written for ADULT patients only – the form is NOT intended for use with PEDIATRIC patients

“Medically Ready Force…Ready Medical Force” Integration and Workflow Methods of using the TSWF Nursing Services AIM form: Provider appointments In conjunction with most TSWF AIM forms Stand-alone form in Nurse or Tech clinics

“Medically Ready Force…Ready Medical Force” Integration and Workflow Example 1 Starting with the TSWF Core AIM form, the provider asks the nurse/technician to give the patient an injection of “Toradol”. The technician will pull up the TSWF Nursing Services AIM form to chart the administration of the Toradol injection. (Choose “Add Additional S/O Note” or “Edit Note” according to the provider’s preference as to where the documentation of the procedure will emit into the encounter)

“Medically Ready Force…Ready Medical Force” Integration and Workflow Example 2 During influenza season, the MTF has set up a nurse- facilitated FLU screening clinic. The nurse uses the Nursing Services form to screen the patient and treat the patient as needed Example 3 A patient comes in for a pregnancy test. The technician can use the form as a stand-alone form to chart the patient’s encounter (according to the MTF’s or Service’s protocol)

“Medically Ready Force…Ready Medical Force” Basic Reminders Never set a TSWF AIM form as a default Add yourself as an additional provider (paraprofessional/nurse) Create a favorites list using the diagnosis/procedure codes frequently used in the clinic Always screen for allergies: It pulls the information from CHCS into AHLTA:

“Medically Ready Force…Ready Medical Force” HPI Tab Click the ‘Nursing Services Form Used’ box

“Medically Ready Force…Ready Medical Force” HPI Tab Notify TSWF of any issues with or recommendations for this form Document Special Duty assignment if applicable

“Medically Ready Force…Ready Medical Force” Ebola Screening Questions Note the banner placed on the HPI tab indicating to see the Screening tab for Ebola screening, guidance and resource links. Refer to the Ebola Training for screening details.

“Medically Ready Force…Ready Medical Force” HPI Tab Highlights The pain assessment and reassessment annotation box is located on the HPI tab Click the small box in the lower right-hand corner to open the additional text box c c

“Medically Ready Force…Ready Medical Force” HPI Tab Highlights Document current medications to include dosage, route, and frequency Add any non-CHCS medications (including OTC meds) to the AHLTA module as well

“Medically Ready Force…Ready Medical Force” HPI Tab Highlights Document if the patient is taking his/her medications as prescribed in the Medication Compliance box on the first tab

“Medically Ready Force…Ready Medical Force” HPI Tab Highlights Chart the dates and the results, if applicable, the patient completed his/her clinical Preventive Service(s) If the patient is overdue for a service(s), follow approved MDG protocols for ordering preventive services

“Medically Ready Force…Ready Medical Force” Screening Tab Highlights: PHQ-2 and PHQ-9 Document a PHQ-2 during a face to face visit in the clinic. Be sure to add the score if it’s positive (3 or greater) If the PHQ-2 is positive, administer/document the PHQ-9 and notify the provider that it was done

“Medically Ready Force…Ready Medical Force” Screening Tab Highlights: Alcohol Screening If patients answer “No” to use of alcohol, click the “No” box and move on. A date is not needed. If they answer “Yes,” complete the Audit C and enter a date in the date box.

“Medically Ready Force…Ready Medical Force” Screening Tab Highlights: Alcohol Screening

“Medically Ready Force…Ready Medical Force” Exit/CCP Tab Medication Reconciliation is a provider function, and is documented here.

“Medically Ready Force…Ready Medical Force” Immunizations Tab Overview If not checked on the HPI tab, check the ‘Nursing SVC AIM Form Used’ box Document patient’s outcome and observation in the Outcome of Patient section

“Medically Ready Force…Ready Medical Force” Immunizations Tab General Vaccination All prepositioned text in the documentation boxes can be edited/deleted according to specific needs

“Medically Ready Force…Ready Medical Force” Immunizations Tab PPD Reading

“Medically Ready Force…Ready Medical Force” Meds 1 Tab Overview

“Medically Ready Force…Ready Medical Force” Meds 1 Tab Respiratory

“Medically Ready Force…Ready Medical Force” Meds 2 Tab Overview

“Medically Ready Force…Ready Medical Force” Meds 2 Tab Clonidine & Benadryl

“Medically Ready Force…Ready Medical Force” Procedures 1 Tab Overview A link to the TSWF Procedure AIM Form is available for access to other procedures

“Medically Ready Force…Ready Medical Force” Procedures 1 Tab Cardiovascular

“Medically Ready Force…Ready Medical Force” Procedures 2 Tab Overview

“Medically Ready Force…Ready Medical Force” Procedures 2 Tab Injury Care

“Medically Ready Force…Ready Medical Force” Procedures 2 Tab Wart Treatment

“Medically Ready Force…Ready Medical Force” Patient Education Tab Overview

“Medically Ready Force…Ready Medical Force” Patient Education Tab General Information

“Medically Ready Force…Ready Medical Force” Patient Education Tab Respiratory

“Medically Ready Force…Ready Medical Force” Obsolete Terms Tab The Obsolete Terms tab removes AHLTA past medical history MEDCIN terms which copy forward and are no longer used, or emit in different areas of the TSWF-AIM forms

“Medically Ready Force…Ready Medical Force” The TSWF repository for training/educational materials and updates The TSWF repository for training/educational materials and updates TSWF Resource Material

“Medically Ready Force…Ready Medical Force” Feedback & Resources Contact Form feedback / discussion forums: TSWF resources / educational materials: Local Clinical Systems Trainer (CST)

“Medically Ready Force…Ready Medical Force” TSWF Service Leads ARMY – Dr. Jones (Physician lead) NAVY – CDR George (Physician lead) AIR FORCE Col(s) Kaps & Maj Barnes (Physician leads) TSWF Feedback

“Medically Ready Force…Ready Medical Force” Air Force Specific Requirements Check this box if the AF SSP was used, and add the SSP score if applicable

“Medically Ready Force…Ready Medical Force” 1Q2015 Summary of Changes Specific Nursing Services Form Changes: Added Ebola travel screening questions to Screening tab Fixed multiple spelling errors/typos Added AF Throat Culture SSP grading scale Added “Time” into each medication area on the medication tabs to document actual time a medication is administered Added link to the TSWF Procedure AIM Form within both Procedure tabs

“Medically Ready Force…Ready Medical Force” 1Q2015 Summary of Changes General TSWF AIM Form Changes: Fixed multiple URL links Removed TSWF Twitter link (discontinued) Added Additional USPSTF A&B Recommendations ribbon to the HPI Tab Changed Chlamydia Screen to GC/Chlamydia Screen in Preventive Services Recommendations on the HPI tab Removed PTSD Checklist-PCL-C using 0-4 scale from BH/Other Screening tab