Printing JUST a medication list

It IS possible to print just a med list; and it's very helpful. We've been discussing this with rooming assistants who may be printing a med list to help begin the medication reconciliation process when they room patients.

Go to the HUB, then choose MEDICAL SUMMARY. If you see not a med list but a long summary, click the green arrow next to PRINT at the bottom of the screen; click print options and UNCHECK everything but Medication list. Once you've done this once it should be your default setting.  If you update the list before the patient exits you can give them a corrected list to take home.

As always, if these instructions are unclear--please ask a staff for help.

JS Free Clinic New Standardized Method of Documenting Reproductive Status of Adult Female patients

At its clinical services meeting June 6, 2012, the group adopted the following protocol for the standardization of documentation of reproductive status of adult female patients.

If you have questions about how to follow these instructions, please contact staff physician Katherine Cole at kjcolemd@gmail.com or medical director Winston Liaw at winstonrliaw@gmail.com. 

Based on the information obtained , providers will complete the progress note at every clinical visit as follows:

--Provider will note LMP (last menstrual period) which rooming assistant will have filled out on the vital sign sheet.

--Click on GYN in adult female patient progress note (if you do not see GYN history in the progress note, please contact Margaret Skelly, margaret@jsfreeclinic.org).

--Complete 2 lines in the progress note, which are visible in one screen:

1) Periods:  (examples of possible notations --regular, menopausal )

2) Birth Control: (examples of possible notations--none-patient desires to conceive, none--not at risk for pregnancy, Partner had vasectomy, Bilateral tubal ligation 2006).

This information will need to be confirmed at every visit, but if there are no changes in status, no changes will need to be made once you have clicked on GYN to import it into the progress note. 

Based on the information gathered and documented, providers will be able to decide whether any further steps are needed in regard to medication management of acute and chronic medical problems,  contraception counselling , or preconception counselling . This document does not address management of these issues.

Background to this decision:

Medical  providers need  to be aware of reproductive status prior to prescribing acute and chronic medications to women, and to be able to provide counselling regarding use of medications during  pregnancy or when patient is at risk for pregnancy. Providers should also offer preconception counselling and contraceptive counselling and services when indicated.

At JSFC over the last 2 years we have identified this problem, and at  prior clinical services meetings adopted several changes including :

 1) Implemented a health history form that is completed at enrollment; the form specifically asks female patients about reproductive status and contraceptive use

2) Added “ Last Menstrual period “ to the vital sign  sheet prepared by rooming assistants prior to the visit with a medical provider. 

3) Changed our policy from referring women to county clinics for contraception counselling and services to providing these services to patients when possible, and referring when needed for procedures we are unable to  provide.

4) Added a women’s health clinic, two afternoons per month through GMU Path program .

After the implementation of eClinicalWorks it became apparent that we had no  standardized  method  for our providers to document reproductive information. The system has multiple places and ways this information could be entered. This makes locating the information difficult to find during visits and when quality reviews are done.

Continuing to improve our use of eClinical Works

I do not have any amazing new discoveries about using the EMR, but would just like to recommend some housekeeping things and some reminders:

1) Now that all but new patients have their chronic diagnoses codes in the system, it's time to do some housework--some of the diagnoses  are incorrect, and some problems in the chronic problem list need to be resolved--or put in the past medical history list.  

I find the best way to do this is to go to the problem list in the hub and pick "remove/ and add to Past Medical history".

2) When seeing a follow up patient--you must always check NKDA if no allergies have been added. This is a safety feature.

3) Check to see if surgical, hospitalizations and family history have been entered, and update them.

4) When seeing a patient there are 4 places that are very helpful to check-:

     --Referrals (have any been done that the patient is waiting for?)

     --Patient Docs (have any labs, radiology, consultants notes been added?)

    --Alerts--Are any recurring items due?

    --Immunizations--has the patient had pneumovax if indicated? do other immunizations recommended for this patient need to be recommended for the patient to obtain at the health department? 

5) At every visit check to see if the tobacco, alcohol, and drug history have been added.  

6) Document every contact outside of a visit, refill, care coordination work in a message (called New telephone encounter in eClinical) . Medications can be ordered, and updated from the message window. 

7) Continue to document contraception status if the patient is in the reproductive age. 

Alerts, Immunizations, Referrals

What do these 3 words have in common?
They are places you need to look when you see a patient.

Click on Alerts : an astute provider may have entered a date that a preventive measure, PHQ9 or follow up exam is due. And more importantly when you want to alert yourself or a future provider of a date --enter it. Useful items to enter: Prevention--mammograms, fecal occult blood tests, Paps, DEXA scans, Eye Exams; Follow up exams--short term repeat Mammograms, other radiology studies that need follow up such as CT or MRI of a finding.

Click on Immunizations: Has the patient received pneumovax ? Has it been entered as past immunization in this section of the EMR?

Click on Referrals:  Has a referral been made? has the appt been obtained? has the report from the consultant been received?

If you aren't sure about how to enter an alert or immunization or order a referral in the EMR---Ask a colleague when you are in the clinic or let me know.

Prescribing medications in the EMR

It has taken me several months to figure out the best way to prescribe medications in the treatment section of a progress note: ie. so they will correctly populate the ongoing medication list. 
For most of us it is easier to be shown  how to do this when you are in the clinic, but let me give you the main concepts and if you need one of us to show you when you are next in the clinic please ask!

1)Current medication Section:
When you are in a progress note and  you are seeing a patient for whom medications have already been entered these will show up in the "Current med" section. You can update  this section if the patient is taking different medications.(for example a consultant prescribed a medication that the patient is now taking--or if the patient never started the medication you prescribed 3 months ago and has decided not to take it).  However (and this is important )--adding a medication here does not Link it to a diagnosis, but that's okay because you will be do it later in the Treatment section which I'm going to decribe to you

2) Assessment Section
You need to assess any problem that you assessed at the visit for which you plan to prescribe or change a medication. And for clarity, for now ,it is useful to assess all the problems for which the patient is taking a medication so you can get it linked to the diagnosis and show that you want the patient to continue it.

3) Treatment Section:
click on treatment and you will see a screen that lists the diagnoses that you have assessed. If the medications that are in the current med list have ever been linked to a diagnosis you will see them listed as you tab across the diagnoses. If you see the medication you can prescribe and/or change from this screen--click under the word  "Comments"-and a list will come up --that says start, decrease, increase etc.. click the appropriate action and the prescribing screen will appear; make your changes in this screen.

However, and for now because the meds are mostly NOT linked,  this is the usual way it goes:

 If the medication that is listed in current meds has never been linked to the diagnosis you won't see it--and you need to take one more step before you change it. You need to go to the Current med screen--and go through all the medications--linking them to a diagnosis--and clicking the C (for continue) button. You can link a med that has no diagnosis to "other" (this should be rare, but might be useful for a multivitamin).

After you have closed this screen you are back to the main treatment screen and you can make changes as reviewed  above. This is preferable to Stopping a medication --and Represcribing it at a new dose or sig-from the current med screen -because if you stop and represcribe it from the from this screen, the ongoing med list will not populate correctly and it won't be clear that you just changed a dose or sig.

Messsaging within the EMR: 

AKA "don't use the message jellybean" for messaging for clinical care.
All messages directly concerning patient care are most efficiently done within the patient’s chart through “Telephone Encounter”.The title “Telephone Encounter” is very confusing;  Think --”Messaging “ not just telephone encounters. (It took me several months to figure this out).

From the patient “HUB”, select  “new telephone encounter”. From this window you can do many things such as:

1) Document an actual telephone encounter with a consultant, or the patient or patient’s family member.

2) Send a message to staff to call the patient to make an appt, or ask staff to add a lab order, or to contact the patient to ask them to pick an order etc.

3) Send a message to another provider to coordinate care of a problem.

4) Document  orders for a new prescriptions either to Nova Scripts  , or print a new prescription for a patient to pick up. This is useful whenever a medication change is made outside of a patient visit. These  messages should be addressed to Lilian unless she specifically tells you to mark it addressed because she’s already taken care of her part of the issue.

Mark the encounter as “Addressed” if no other action is needed; otherwise leave it “Open” and send it to the member of the staff whom you want to see it by clicking “okay”.

Other interoffice messages can be sent with the “M” jellybean at the top of the screen.
This will become more useful as we all get used to checking for these messages when we log into the EMR. Message sent this way will not be connected to a patient chart so it makes it awkward for patient care messages. Staff will not be seeing these except on days that they are at JSFC--so your  regular email might work better for most kinds of messages now.

As always--if you want someone to show you this feature--ask Margaret, Lilian or a provider colleague who is using this function.

Let's try a Blog for learning to use the EMR

I'm hoping this Blog will help  providers at JS Free Clinic as we learn to use the EMR.  We'll be able to post questions for each other to answer and help each other learn!

Here are some initial notes:

Margaret  and Lilian  can answer questions about  how to use eClinical works. Providers can help each other during patient care sessions--so ask your colleague questions. We are finding that we each learn some new thing each week. 

Margaret has ask us to  to lock our notes at the end of the visit, but only after the patient checks out. You can tell if the patient checks out by looking at the schedule. 

Be sure that the medication list is up to date at the end of every visit, so that medication ordering and refills can be done correctly when you are not around.  It seems that the med list in eCW does not always reflect the list as previously ordered—so until we know this is functioning properly, be sure to read the plan in the last provider’s note carefully.

All referrals to outside providers, including eye exams, should be done through the eCW. Send them to Lilian .  By clicking on “referrals” you can view what referrals have been done.

Prescriptions for the patient to take to a pharmacy can be written and printed through the EMR saving you the extra step of handwriting the prescription.

Start entering an ALERT —with dates for future needed diagnostics ( Mammograms, needed follow up exams, Dexascans).  Ask if you aren’t sure how to do this. Grace Hipona is good at it!

Past immunizations can be entered into the immunization section.