= Step Required to Meet Safety or Regulatory Requirement
= Step Includes EHR = New Step / Changed!Staff who must adopt: Licensed & Unlicensed Providers (Attending Physicians, Fellow/Resident Physicians, Nurse Practitioners)
Sponsor/Originating Unit/Team: Primary Care Clinic
Task
# Task
description Details Task
time
1.
Teamlet Huddle
- Receive verbal notification from nursing staff about patient ready for provider during Pre-Clinic Teamlet Huddle with assigned nursing staff.- If notification not received, refresh the Home >Ambulatory Organizer> Day View list in EHR to check patient status changes to “Seen By Nurse” indicating patient is ready for provider.
0.5 mins
2.
Flag Change
Change flag from Blue “Awaits Consult” to Red “PT/MD in room”0.5 mins
3.
Enter Room
Knock and enter room, wash hands/hand sanitizer, introduce yourself & shake hands.0.5 mins
4.
Interpreter Phone
- Call interpreter if needed x5405 (interpreter phone located on wall).
- Document Interpreter ID # in the Subjective/History of Present Illness of your note.
0.5 mins
5.
Open Patient’s Chart
Open EHR> Ambulatory Organizer> click on patient’s name to open chart> MPage (1st tab in Menu)>
Admit|Clinic Tab
0.5 mins
6.
Patient ID
Ask patient: “May I confirm your name and day of birth for documentation purposes?” Check withpatient information in EHR banner bar.
0.5 mins
Standardized Work
Title: Provider Primary Care New/Return Visit Workflow Date: 11/13/2018 Version: 2.2
Task
# Task
description Details Task
time
8.
Review Intake Information
- Review nursing Intake Information. Address abnormal values in in step 14.
- Review Vital Signs (Note: intake nurses are to notify the provider of critical values (i.e.
SBP>180, HR>110, etc.)
0.5 mins
9.
Subjective/
History of Present Illness (HPI)
Bullet point in Subjective/History of Present Illness, in the format of
a. Patient Summary (Patient’s one liner age, current and past medical history):
(e.g. “65 year-old man with type 2 diabetes…”)
b. Last Visit’s events (date of last visit, what interventions implemented last visit, interval clinic visits with specialists, ER/UC visits, etc.).
a. If Initial Health Assessment (IHA), address any past visits (i.e. ER visits, subspecialty clinics).
c. Today’s complaints/events (New complaints, outside ER/UC visits, hospitalizations, abnormal intake information, etc.)
d. Interpreter # from step 4 if applicable.
3-10 mins
10.
Review of Systems (ROS)
Enter/Update ROS (may be completed outside of exam room). Cover 2 to 9 reviews of systems.
1-5 mins
11.
Health
Maintenance &
Registries
- Review Recommendations (Links to Health Maintenance in Menu):
a. Update “Pending” Recommendations.
a. Order pending Recommendations* by clicking pending recommendation and then clicking Actions, and the appropriate drop down
orderable. The order will appear in inbox
b. If Recommendation not indicated, select “Cancel
Permanently” and select appropriate reason (e.g. “Patient already had disease,”
“Shortened life expectancy”).
c. If Recommendation satisfied elsewhere (e.g. Pap performed at outside clinic within 3 years), select “Done Elsewhere” and list date satisfied.
1-5 mins
# description time
b. Update Consolidated Problems with each Recommendation addressed (e.g. “Encounter for screening for malignant neoplasm of cervix,” “Encounter for immunization.”)
-
Review Registries and order as appropriate if not addressed in Recommendations.-
*Of note—orders that fall under nursing standardized procedures and protocols (SPPs) (e.g.influenza vaccine, FIT ordering, mammogram/eye photo ordering and scheduling) are to be ordered and executed by nursing staff. Please review the updated SPPs at the Intranet> >
Clinical Resources> Clinical Protocols> Outpatient Care > Approved Protocols and Guidelines.
12.
Staying Healthy Assessment (SHA)
a. Review SHA with patient (if provided to patient)
b. Check the appropriate category under Clinic Use Only, and the appropriate intervention
(Counselled, Referred, Anticipatory Guidance, or Follow-up Ordered). At least one of each.
c. Check “Patient Declined the SHA” if appropriate
d. Sign, print name, and date once complete. Hand to nursing staff after visit, Teamlet Debrief (see step 24), OR leave in exam room (if complete).
1-3 mins
13.
Data Review
- Review and “tag” Labs. Multiple labs can be tagged by holding Ctrl and selecting desired resultsthen clicking “Tag.”
1-2 mins
Standardized Work
Title: Provider Primary Care New/Return Visit Workflow Date: 11/13/2018 Version: 2.2
Task
# Task
description Details Task
time
- Review Pathology, Microbiology, and Diagnostics. Highlight desired text and click Tag for it to populate in note.
- Review Histories (Procedure, Family, Social, Pregnancy if applicable)
14.
Consolidated Problems
a. Add ALL problems to Consolidated Problems (including from steps 7-13)
b. Review Chronic Medical Problems with patient using Consolidated Problems list
1-3 mins
15.
Home Medication Review
Of note: Home Medications History and compliance is updated by nursing during Nursing Intake.
a. Select Home Medications, Select Meds History to view/update current medication list
2 mins
# description time
b. Click on House icon to return to MPage
16.
Physical Exam
a. Perform Physical Exam as appropriateb. Document under Objective/Physical Exam in the room or after the visit
c. Attendings, residents with modified presenting privileges (MPP) & NPs: Skip to step 19 “Plan Discussion”
d. Unlicensed & licensed residents without MPP: Continue to next step
1-3 mins
17.
Precepting 1
a. Inform patient that you will discuss medical problems with the attending and return.b. Clean hands upon leaving room.
0.5 mins
18.
Precepting 2
Leave patient in room to staff with attending in resident work room.a. Open MPage
b. Discuss with precepting attending
If applicable, gather more information with patient +/- attending. If more medical history/physical needed, return to patient room to collect information and return to precepting attending.
5-20 mins
19.
Plan Discussion
Discuss plan with patientOPTIONAL: Add your own patient instructions in the Visit Summary a. Go to Visit Summary in the Table of Contents
Scroll down to Instructions and add free text to the comment box
3-5 mins
Standardized Work
Title: Provider Primary Care New/Return Visit Workflow Date: 11/13/2018 Version: 2.2
Task
# Task
description Details Task
time
clinic.
b. Renew Rx: in Admit|Clinic > click Medications > Right-Click appropriate medications> click
“Renew.” Forward order to your precepting attending in clinic and click “Co-sign required.”
c. Request precepting attending to promptly sign medication orders prior to patient’s discharge.
d. Once medication orders signed, under Medications click “Outpatient” and perform discharge medication reconciliation.
e. For Vaccines or Medications given in-clinic, click on the circle under the Green Arrow B. Licensed providers: Perform discharge medication recommendation by clicking Medications >
“Outpatient.”
f. Order new Rx in Sure Script
g. If wish to discontinue Rx, click on circle under the Red Box
h. If wish to continue Rx but NOT refill, click on circle under the Green Arrow
i. For Vaccines or Medications given in-clinic, click on the circle under the Green Arrow
# description time
Prior to patient discharge, the Medications Section should have green check marks beside
“Meds History” and “Outpatient.”
21.
Clinic Orders
In New Order Entry (in Mpage):a. Order Visit Charge
a. If return visit (based on complexity): Visit Charges>Established>choose 99213-5.
b. If IHA (based on age): Visit Charges>Preventative>choose 99385(18-39 years)/99386 (40-64)/99387 (>64)
b. Order Labs/Diagnostics, other in-office vaccinations (if applicable and not ordered via nursing Standardized Procedures and Protocols), specialty consult requests, counselling codes, etc.
c. Begin e-Consults (if applicable, and add eConsult # to your note)
d. Order “Clinic Follow up” and “Discharge Patient”
e. In Green Scratchpad, assign orders to appropriate Consolidated Problems then click Sign.
2 mins
Standardized Work
Title: Provider Primary Care New/Return Visit Workflow Date: 11/13/2018 Version: 2.2
Task
# Task
description Details Task
time
22.
Create Note
Click Select Other Notea. Select note template “Ambulatory Office Visit Note”
a. If IHA, select note type “Ambulatory IHA Provider Note”
b. If return, select note type “Adult Primary Care Outpt Provider Note”
0.5 mins
23.
Discharge Patient
a. Wash hands/hand sanitizer prior upon leaving room.
b. Change flag from Red “PT/MD in room” to Orange “Awaits Nurse/Tx”
0.5 mins
24.
Teamlet Debrief
a. Verbal discussion of discharge plan with nursing.b. Hand completed SHA (if completed during visit) to nursing for scanning OR leave in exam room.
0.5 mins
25.
No-Show Check Return to the Home Screen Day View list in EHR and click refresh to check if another patient’s status changes to “Seen By Nurse,” indicating patient is ready for provider.
a. If a patient is “No Show”ed, open patient’s chart and click Communicate.
0.5 mins
# description time
b. Address message “To” the nursing staff with whom you worked, and select “No Show/Broken Appointment” under “Subject.”
c. Select appropriate method of contact as provided in the Communicate text box, and send to nursing staff.
If the No-Showed patient was an NEW, select address the above message to your Scheduling Center teammember (see Internal Medicine Primary Care Teams list).
Cycle time: (enter observed cycle time or sum task times) 22-62
mins
Standardized Work
Title: Provider Primary Care New/Return Visit Workflow Date: 11/13/2018 Version: 2.2
Standardized Work Signature Sheet
I have read and agree to follow the above referenced Standardized Work. I understand that this is the “current best thinking” of how to do the tasks. If I have ideas on how this work can be improved, I am encouraged and expected to make suggestions directly to my supervisor or I can make a recommendation at a team meeting (if applicable).
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