“Medically Ready Force…Ready Medical Force” CORE AIM Form Training January 2016 Jan-Apr 2016 Form Version

“Medically Ready Force…Ready Medical Force” Why Use the TSWF CORE AIM Form? Serves as a “one-stop shop,” standardizes care and simplifies documentation. Provides easy access to clinical-decision making resources. Provides legible notes in shortest amount of time. Includes many NCQA, HSI and JC requirements.

“Medically Ready Force…Ready Medical Force” Changes With This Release Updates will now be made every 4 months instead of every 3. This release will be valid from January – April of Updated PTSD Screening adding to Screening Tab Added Breast Cancer Risk Assessment tool to Well Female tab Changed “Desires to Quit” Tobacco question to no longer copy forward Full list of changes available from “Change Log” tab

“Medically Ready Force…Ready Medical Force” HPI/PFSH Tab At the top of this tab you will find the form version as well as links to MilSuite, As-U-Type-Tool, TSWF Navigator and TSWF Resources.

“Medically Ready Force…Ready Medical Force” HPI/PFSH Tab Include all medical conditions/problems. Document all current meds/OTCs/herbals. Recommend documenting dosage, route, and frequency. Fill in dates as services are completed. Can use 3G or other tools to access data. Fill in dates as services are completed. Can use 3G or other tools to access data.

“Medically Ready Force…Ready Medical Force” HPI/PFSH Tab Support staff updates medication list (and checks box verifying that they did it) Provider completes red section

“Medically Ready Force…Ready Medical Force” HPI/PFSH Tab You’ll see several double arrows in our forms. Clicking here will open up a “ribbon” to show more details.

“Medically Ready Force…Ready Medical Force” Screening Tab Review the dates of all routine screenings to ensure they are current. Complete if necessary.

“Medically Ready Force…Ready Medical Force” PHQ-2 Use this specific verbiage to ask the questions in order to maintain the validity of the screening tool. Screener enters PHQ-2 score here. If positive, continue assessment and notify provider.

“Medically Ready Force…Ready Medical Force” PHQ-2/PHQ-9 Document the PHQ-2 at every visit. Ensure documentation of scores in the appropriate boxes. If the PHQ-2 is positive complete the PHQ-9 and follow local protocols. ALWAYS NOTIFY the provider. Note: If the patient is on an antidepressant and/or has a diagnosis of depression, automatically complete the PHQ-9 (PHQ-2 does not have to be separately documented).

“Medically Ready Force…Ready Medical Force” PTSD Screening (new) Two different screenings are available for PTSD. Make sure you use the correct one per local policy.

“Medically Ready Force…Ready Medical Force” Verbal/Physical Abuse If the patient answers “yes,” the ribbon will expand prompting you to ask two additional questions. A link to the Domestic Violence Questionnaire is included here for use as needed. If the patient declines to answer, NOTIFY PROVIDER. If the patient answers “yes,” the ribbon will expand prompting you to ask two additional questions. A link to the Domestic Violence Questionnaire is included here for use as needed. If the patient declines to answer, NOTIFY PROVIDER.

“Medically Ready Force…Ready Medical Force” Screening Tab Joint Commission questions need to be asked on an annual basis. If more than 12 months have elapsed since they were last updated, uncheck the red “X” to reset the questions to the current requirements. If yes, it expands. It is expected that the Service-specific system will be consulted to see if the patient is on a profile or not.

“Medically Ready Force…Ready Medical Force” BH/Other Screening Tools Additional screening tools are available on the BH/Other Screening tab. Use these according to provider-specific protocol.

“Medically Ready Force…Ready Medical Force” BH/Other Screening Tab Suicide Risk Assessment Click-button risk categories added Clinical guidance updated for the different possible scores

“Medically Ready Force…Ready Medical Force” BH/Other Screening Tab PTSD Screening Tab Open This tab includes several BH screenings (E.g. GAD-7, DVBIC tool) as well as a place to document a health literacy assessment

“Medically Ready Force…Ready Medical Force” ROS Tab A comprehensive review of systems covering the majority of systems is found in the top left grey box. Select “All Normal” and document positive items by exception.

“Medically Ready Force…Ready Medical Force” ROS Tab Free-text option for documenting ROS. Add free-text here to expound upon an entry if needed. The box will change in appearance once text is entered.

“Medically Ready Force…Ready Medical Force” PE Tab The auto-normal button selects those elements to the left of the bold black bar that are not gold. Gold font is used to represent items not routinely performed; these are not selected when the "Normal" button is used, and must be marked manually.

“Medically Ready Force…Ready Medical Force” PE Tab Click to see additional MEDCIN tree terms available for that system. (Click “Close Trees” to exit).

“Medically Ready Force…Ready Medical Force” Well Female Tab Female-specific details and the entire PE can be entered here. This pelvic exam is more comprehensive than what’s found on the PE tab.

“Medically Ready Force…Ready Medical Force” Well Female Tab - Breast Cancer Risk Assessment Clues are offered for assessing risk, and several helpful links are provided

“Medically Ready Force…Ready Medical Force” MSK (up) Tab Upper and lower musculoskeletal exams have their own tabs. Each individual area is in its own ribbon.

“Medically Ready Force…Ready Medical Force” MSK (up) Tab Shoulder Ribbon Open Divided into bilateral sections, the ribbon contains two “All Normal” buttons for quick documentation of normal exams.

“Medically Ready Force…Ready Medical Force” MSK (low) Tab Design and layout are the same as MSK Upper tab

“Medically Ready Force…Ready Medical Force” Spine Tab Be sure to document presence or absence of red flags. Designate an item as positive by deleting the ‘-’ sign and entering a ‘+’ sign.

“Medically Ready Force…Ready Medical Force” Exit/CCP Tab Many items that are required to meet NCQA PCMH standards are included in aspects of the patient care plan. This only has to be filled out once and then it is relatively easy to maintain. Many items that are required to meet NCQA PCMH standards are included in aspects of the patient care plan. This only has to be filled out once and then it is relatively easy to maintain.

“Medically Ready Force…Ready Medical Force” Links to CPGs and Relay Health Exit/CCP Tab

“Medically Ready Force…Ready Medical Force” Exit/CCP Tab Metabolic Disorders Ribbon Contains pre- populated text that can be edited/modified as desired Will copy-forward from visit to visit Includes a ‘Date last updated’ area Contains pre- populated text that can be edited/modified as desired Will copy-forward from visit to visit Includes a ‘Date last updated’ area

“Medically Ready Force…Ready Medical Force” Procedures Tab ECGs and Spirometry are included here. For documentation of many other common procedures, use the link to the TSWF Procedures AIM Form.

“Medically Ready Force…Ready Medical Force” Obsolete Terms Tab *Complete this step at every visit. 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. *Complete this step at every visit. 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” Change Log This tab shows a summary of changes made to the AIM form

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

“Medically Ready Force…Ready Medical Force” Comments or Feedback 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. Brian Jones & MAJ James Phillips  NAVY – CDR Anja Dabelic  AIR FORCE –Maj Matthew Barnes & Maj Thomas Mahoney TSWF Feedback