New Patient Visit

Follow-up Visits

Telephone Medicine

Referral To A Consulting Physician

Ordering And Following-up On Studies

Policy and procedure for New Patient Visit

1. Residents will be scheduled a full hour to obtain:
   • A complete medical history and physical examination
   • To make a comprehensive assessment of the patients problems and develop an initial plan for evaluation and treatment.
   • It is expected that the time will be used to actively interview the patient or family member, completely examine the patient, including breast, genitalia, and rectal exams, and discuss with the patient your findings and your recommendations.  
      
2. Chart documentation
   • Choose “Name/Add” and add your patients name, DOB, MR number, and choose yourself as the Provider.
   • Choose “Write/Allergies” and add the patient’s allergies
   • Choose “Write/Diagnoses” and add the patient’s current and past diagnoses
   • Choose “Write/Medications” and add the patient’s current medication list
   • Choose “Write/Expanders/Surgery/Record” and add the patient’s past surgical history
   • Choose “Write/New Note/ Note/ New patient (male or female) H and P. Press F9 to go from one part of H and P to another.
     • History of Present Illness: Free text
     • PMH:-Imported from the Diagnoses you entered
     • Past Surgical History: Imported from the Surgery Expander
     • Medications: Imported from the Medications
     • Health Maintenance: document immunizations, cancer screening, FLP, bone density
     • Social History: document smoking, drugs, etoh, sexual preferences, employment
     • Family History: document
     • Review of Systems: State full ROS completed, pertinent positives include: then list in order of priority.
     • Physical Exam: The template gives you a normal physical exam. By using F9 you move from system to system. If you do not like the choices, you may free text in the pop-up boxes under the choices and press enter.
     • Assessment and Plan: This is where you should spend your time. Be complete in your discussion of their medical problems and your short term and long term plan for:
       • Evaluation
       • Therapy
       • Follow-up
3. At the time of discharge, the patient should have a listing of his/her medications and an understanding of the plan of care, including scheduled tests, scheduled follow up, scheduled referrals.
   • While in the note, press “alt M”. This will take you to their medications.
     Mark any medication you need to write an Rx for by highlighting it and choosing F6 to mark it. Any medication that is highlighted will also be printed as an Rx.
   • Go to Utility/Rx Writer. Review Rx, give 1 months worth with 3 refills routinely, make sure your name is at the top, and scroll through the Rxs by choosing “Next”
   • Choose Print-Print all and there will be three Rx’x on each piece of paper.
   • Choose Print List- Patient- and print the patient a list.
   • Fill our request for all x-rays, cardiac, pulmonary studies. The requests are found on the wall in the doctors’ room. Include diagnosis and signature.
   • Be sure to give your patient a follow-up appointment and instructions to call you if needed.

   Heath Maintenance includes when appropriate: Immunizations (pneumococcal, influenza, tetanus,) Bone Density, Mammograms, Stool OB times 3, PSA, Pap Smears,Colonoscopies, FLP

Policy and Procedure for follow-up visits

1. Each resident is scheduled for 30 minutes during the follow up appointment. The resident must review the patient’s chart prior to the examination noting the following:
   • Current vital signs and BMI as compared to prior visit
   • Current medications as listed in Welford
   • Current medical problems as listed in Welford Diagnoses and also in the last progress note
   • Current status of health maintenance
   • Current status of lab monitoring of for medications and disease states

   The history must be focused on the current complaint and the chronic active medical problems. The ROS should be a focused ROS, always including pain, smoking cessation, nutrition and exercise. The physical exam should also be focused.

2. The note is recorded in Welford under ACC Clinic Note
   • HPI: Free text
   • Diagnoses: imported from diagnoses
   • Medications: imported from medications
   • Health maintenance – you may enter this either into the Lab Book or into the Health Maintenance Expander
     • Lab Book – Choose the test tube, add the test, result, and correct date
     • Expander-
       • To record from note to expnader: highlight the HM in the note, choose the balloon, choose HM and choose record
       • To import from expander, put the curser at HM, choose the balloon, shoose HM, choose playback.
   • Pain Assessment: address location, exacerbating factors, duration, method of relief
   • Tobacco Use: address need to quit and offer help with pathc, SSRI, Wellbutin
   • Blood Glucose/Blood Pressure range: record home monitoring done by patient
   • Physical Exam: pertinent to the visit, always include a BP
   • Assessment and Plan: Plan for evaluation, treatment and follow-up of problem
     • Fill out requests forms
     • Make appropriate referral ( see referral policy)
     • Appropriate follow-up intervals are;
       • Yearly if no active medical problems
       • Every 6 months for patients on any medications but otherwise stable
       • Every 4 months for patients with multiple medical problems which are well controlled
       • Every 3 months for patients with multiple medical problems which are difficult to control
       • Weekly or every two weeks for any unstable problem, including uncontrolled hypertension, uncontrolled diabetes, acute infectious process, CHF, abdominal pain of unknown etiology, etc.
   • Medications Reviewed: yes
   • Prescriptions given: “see Med Log” or list new Rx given
   • Return to Clinic: 1 week, month, etc

Policy and procedure for telephone medicine:

1. During working hours, nurses will consult residents regarding patient problems.  The nurse will give the resident a brief description of the problem.  The resident will return the patients phone call, collect a focused, accurate history and triage the care in the following way:
   • If the resident deems by the history that the patient is acutely ill- immediate referral to the ER:  Example; cardiac chest pain, shortness of breath, changed mental status, uncontrolled acute pain, more than 24 hours of nausea and vomiting, any acute abdominal pain, temperature greater than 101.5 in patients over 70 or with chronic medical problems. 
   • If the resident deems by the history that the patient is sub-acutely ill, the patient will bee seen in the Internal Medicine Clinic if at all possible the same day, if not possible, the next day.  Examples: uncontrolled chronic pain, poorly controlled blood pressure, URI symptoms, less than 24 hours of GI symptoms, new pain of mild to moderate severity.
   • If the resident deems by history that the patient is not ill and the problem can easily be handled over the phone, he/she may do so and document such in the progress notes (in Welford).  The patient must be instructed and the note must reflect that he/she should call back if not better.
   • No controlled substances may be given over the phone.
2. During evening hours and weekends, the resident should follow the same procedure as above.  However, if you feel that the patient needs to be seen before Monday, but not emergently, suggest that they come to the ER during a non-busy time- early in the morning. 
    

Policy for patient referral to a consulting physician:

1. Discuss referral with attending in the clinic
2. Contact the consulting physician by phone
   1. Call the office and ask to speak to the doctor when he/she is free – leave your beeper number with the office staff if the doctor can not talk to you at that time.
   2. Give the doctor a brief history as to why you are asking for a consultation for your patient, informing him/her that you are a resident in the clinic and that your patient does not have insurance.
   3. If the doctor agrees, contact the patient and have them call the office to make an appointment. Instruct the patient that if he/she has any difficulty, they are to call you. Despite the consulting doctor agreeing to see your patient, the message does not always make it to the front-desk. You can call the front-desk and inform them that the doctor did agree to see your patient.
   4. Do not tell the patient that he/she will be seen for free. Some doctors work out payment plans for the patients.
3. Write a letter to the doctor briefly discussing the problem for which the patient is being referred and the specific question that you would like to have answered. Send clinically significant data, including a summary of care.To refer a patient for GI evaluation – call 7398 and speak to the physician’s assistant who answers the phone. She will set your patient up for the needed procedure. However, you must send a referral letter to the doctor and appropriate tests.

To refer a patient for GI evaluation – Call x7398 and speak to the physician’s assistant who answers the phone.  She will set your patient up for the needed procedure.   However, you must send a referral letter to the doctor and appropriate tests.

To refer to Parkland Ophthomology Clinic for Diabetic Eye Exam : give the patient the number ( Clerk has it) and tell them it will take 2 to 3 months for them to get the appointment.

To refer to Parkland Dysplasia Clinic: Call 214- 590-5569 to make verbal referral to Parkland Dysplaisia Clinic. Fax a Demographic sheet and the two abnormal pap tests to 214-590-2771. Call the patient and notify them of the referral and that they should call to make an appointment.

Referral to Parkland Clinics: see Red Book in the clinic

Commonly used referrals:

Policy and Procedure for Prescription Refills:

1. Nurses will refill most of the patients’ medications according to the policy and procedure for refills.
   • Can not refill narcotics or psychoactive medication without doctors prior approval
   • Will document appropriate lab monitoring as determined by the “medication monitoring tools “ on Welford.  If appropriate tests are not documented in Welford, the patient will be called to tell them they will need a blood test before their next refill.  A one month refill can be given at that time.  The patient should be seen before the next refill or the test should be done.
   • Refills should be for 3 months.
2. The medical director will review and sign all refills and a Rx Log will be placed in the patients charts
3. When a nurse calls you for a refill collect the following data before giving the refill:
   • Last visit
   • Last laboratory monitoring done for the drug in question
   • Next scheduled visit for the patient
   • Order any monitoring you want done
   • Re-fill only one month worth of medication, informing the patient of the need to get the tests done. 
4. No narcotics may be given over the phone after hours. 
   

Policy and Procedure for Ordering and following up on studies.

1. Ordering:
   • Blood work: Check off on front sheet with appropriate diagnosis for test ordered
   • Radiology: Check off on front sheet, fill out request with clinical history and your signature.
   • Nuclear Medicine: Check off or write in on front sheet, fill out request with clinical history and signature.
   • Non-invasive Cardiology: Check off or write on front sheet, fill out request with clinical history and signature.
   • Pulmonary Functions: Check off or write on front sheet, fill out request with clinical history and signature.
   • Colonoscopies: Call 7398 ( Dr. Loeb, et al), ask for an appointment for your patient, send a short note with pertinent labs.
   • Pap: Check off on front sheet, and fill out Pap request form
2. Following-up
   • Go to Jackson Clinic Medical Records twice a week ( once on your clinic day and one other time): review and address the test results for your patients.
   • You may enter the tests you ordered for your patient into Welford’s Orders: this will give you a reminder that you have ordered the test and to check on it.
   • You may enter the tests you ordered for your patient into Welford’s Datebook: this will also give you a reminder of what tests you have ordered and to check on them
   • You may make a hand written list and use it to remind you to check on your patients’ tests.

Whether you use Welford to remind you or a hand written list, it is your medical-legal responsibility to be sure you have seen the results of every test you ordered. This is a skill you will need to use for the rest of your life, so develop a system.