Associates in Internal Medicine

Clinic Orientation

2009

I. The AIM Clinic How-To Work Guide

1.       Some History and Background

Ø       The Vanderbilt Clinics (in it’s original downtown location) was one of the first teaching clinics established in the North America, it was described in the Flexner Report.

Ø       The AIM Clinic was established within VC complex as a general internal medicine clinic in 1976. It serves the needs of the local community, as well as the referral population to the academic center.  Total visits to the clinic in 2008 is ~ 80,000.

Ø       AIM is a mixed faculty/resident practice- Attendings practice alongside residents, sharing the same space and patient panel. Residents will learn to care for their own patient panel under the supervision of these attendings. Average supervision ratio is less than 1 faculty: to 4 residents per clinic session.  There are 25 faculty clinic preceptors coming from diverse academic generalist backgrounds.

Ø       Currently AIM exists in 2 spaces–AIM Clinic in Vanderbilt bldg. and AIM-East across the street.  All resident practices are in AIM “West”, while AIM East houses IM subspecialty clinic. The Generalist Track program is based in AIM Module 240.

Ø       www.medicineclinic.org is our clinic website, be sure to explore it to see where you can lookup information in the future.

2.       The Administrative Staff/Area – VC Room 205 (staff pictures on website)

Ø       AIM Medical Director -Dr. Rafael Lantigua, Division of Gen Med -Dr. Steve Shea, Ambulatory Education Director -Nancy Chang, MD, Intern Training Director -Steve Mackey, MD, Generalist Track Director Alex Montero, MD. The Clinic Administrator -Mr.Lester Govia , Floor Supervisor -Ms. Divina Guilfu/Florence Daniels, Clinic Scheduler -Karilyn Martinez.

Ø       “Room 205” Administrative Office-contains our main teaching Conference room, Fax machine (x5-6279-staff will help fax), copy machine (pass word 02205), and Resident Mail Boxes. There is an outgoing “mailbox” where you leave unstamped envelopes to be stamped and mailed by the hospital mailroom. There are 4 on-site Spanish interpreters.

Ø       AIM Telephone room –(x5-6354/ MD only 5-5549) 3 full time staffers field over ~300 calls a day. Telephone RN Message Center- RNs takes and triage incoming patient phone message for residents. Expect to see these messages coming thru your emails. RN will only page you or access clinic preceptors when you are not available to address urgent pt messages.

3.       AIM is divided into 5 different areas- a.k.a Module or Firm

Ø       Each module has a waiting area, 4-5 physician exam rooms +/- 1RN office.

§         Room 214 houses our Walk-in clinic set up to provide coverage for doctors who are not available. Sick pts or those seeking refills will come here and see someone the same day

Ø       Staffing- In each module, 3 Front-desk PFAs are responsible for patient check-in, registration, discharging/follow up appt/consults/test scheduling, and chart maintenance.  One medical assistant (checks wt, ht, calc. BMI, pain scale, smoking hx; chaperone GYN exams, performs stat lab/EKG, and restocks rooms). The RNs administer medications, vaccinations, FSG test, and special counseling.  Be sure to introduce yourself and get to know your staff team members and their roles (pictures/name are posted on website under “Staff”). 

Ø       Resident/Firms-Each resident is assigned to a “Firm” or home module, as well as a supervising Firm attending. Residents will usually been assigned to a room in their home module, if space is tight with a lot of same Firm residents in clinic the same day, you may be floated to another module.

§         NYS law requires unlicensed residents to write prescriptions with the license number of their supervising attending. To simplify the process for the clinic, we have assigned you to a designated FIRM attending whose license #/NPI can be used by you for this purpose. Please restrict this use to only your clinic patients, not your inpts.

§         Along with clinic preceptors who are always on-site, a designated Firm attendings (or Firm Chiefs when Firm attending are not available) are helpful for discussing complex pts, questions that may arise between visits, help with administrative issues, and even continuity of care (more info on website).

Ø       Supervision- Preceptors are located in Rm 231, 214, and 240. This means each main AIM hallway has at a minimum 2 preceptors. The PIC room is also where the central printer is located, this is where your notes and prescriptions will print out to.

 

4.       Typical Patient Flow 

§         Prior to arrival, patients will generally receive both mail and telephone reminders alerting them to their appt. Average patient show rate is about 75%, with lower show rates for new patients. When you have a lightly scheduled clinic or a lot of no shows you may be asked to help out to see unscheduled new or follow up patients.

§         Once a patient arrives and is registered, his/her chart usually ends up in 2 possible places.  Before being processed by the MA, the chart will be located in your box at main desk.  After the patient is weighed, the chart will appear in the rack next to your exam room door. (The MAs generally tries to get all the weight and vitals done on pts, but during peak pt arrival hrs in clinic 9am and 1pm, you may not want to sit and wait for them to process all the arrivals, feel free to grab the chart and get started if there is a wait fo vitals)

§         The Soarian program is our current clinic scheduling program, it is new and still underdevelopment. We will show you this program during orientation, it allows you to do a few basic functions like viewing schedule and tracking arrival time. For now the MD booking function is off limits while the program is still being phased in.

§         Once you get the patient’s chart, call out the name of your patient. With so many common names, we have a policy of asking pts for a DOB to confirm that the right person answered. Over half of our patients are Spanish speaking only. Be sure to use the translators if you are not fluent. (call x5-6262). If there is a long wait time for the on-site interpreter, use the Phone translator on your desktop speaker phone, access code is attached to the cord on the phone.

§         Always remember to undress and appropriately gown patients for exams. Exam done through clothing should be minimized.  Unless truly pressed for time (or pt is unable to get on the exam table due to mobility problems), all pts should be undressed and examined head to toe for their initial comprehensive visit. (gowns in exam table)

§         Time Management- you do not need to be overly comprehensive in every clinic encounter. Understand that ambulatory pt care occurs over time. Unlike inpatient care, not everything needs to be decided nor completed in one visit. Realized that patients can always return on a shorter interval for more focused follow up visits.  The key to outpt care is to figure what needs to be prioritize and done each time.

§         Note writing: charting should be maintained in electronic format. Despite using the computer, be sure to always maintain eye contact and avoid typing notes when you interview patients.  See below for more on note writing in clinic.

  1. Computer Programs There are several computer programs to be familiar with in clinic.

§         Soarian- this is the clinic scheduling program which is accessed with your WEBCIS ID and password. The program will allow you to view schedule and track your arrivals. The program is a bit clunky and will hopefully improve in the next few months.

§         WEBCIS- is the main EMR program used in clinic and the hospital It allows you to access data, maintain an outpatient list, fax prescriptions. and enter free text clinic notes. When writing notes, first used the “save draft” function, and submit the note as final only after you discussed the case with your preceptor.

§         We are preparing a transition to Ambulatory Eclipsys (a.k.a Ambulatory Care Manager) in the end of 2009. More details will be provided on this in the future. This EMR has the potential to bring us closer to a paperless operation. For now, the most helpful feature on the Eclipsys (Ambulatory Manager) is an “inbox” where outpatient results of labs/Xrays you ordered will be retrieved.

 

  1. Clinic Note Writing –. The Main intention of writing encounter notes is to concisely RECORD AND COMMUNICATE the findings and your thoughts from the encounter. Always aim for quality- clarity, organization, thoughtfulness, NOT quantity nor data hording.  Use this task as a way to help you put the case together after seeing the pt. It is good to adapt a standard template in writing notes (see AIM template). Avoid carrying over large chunks of unrefreshed/unreviewed or redundant copy and pastings on your notes. Try to limit each clinic note to 1-2 page printed (at smallest webcis font). “Run-on” notes that goes way long, impairs the ability of others (or even yourself) to grasp the true clinical picture.  We recommend that you keep your health maintenance check list on the bottom of your note so it is not distracting, and is a good reminder at the end of your visit.

 

Standard AIM template – categories listed must be on every note (pointers in parenthesis)

o        Name, MRN number, Emergency/proxy contact 

o        Problem List (problem list need to be reviewed and “weeded” at each visit,  avoid redundancy, avoid “run-on” problem lists)

                                              -Active                                    

                                              -Pmhx/Psurghx- inactive problems that are not currently relevant

o        Chief complaint/HPI/Interim History

o        ROS (questions unrelated to HPI)

o        Med Allergy (document reaction to meds)

o        Updated Med list (reconcile patient bottles at every visit, do not cut and paste list blindly, watch for polypharmacy)

o        FmHx Sochx (can be copied and carried onto f/u visit notes as it may help you with ongoing care)

o        Physical Exam

o        Data (do not cut and paste webcis results, interpret results concisely.  Old results may be be better included under proper heading of problem list. No need to carry miscellaneous results to perpetuity )

o        Assessment –(one line summarize the big picture, stability of patient’s course, new findings of interest)

o        Problem/Plan-  (define issues by problems not organ system. A problem is a diagnosis, abnormal finding, or symptom under eval.  Also be sure to document patient education)

o        Health Maintenance (record vaccine hx, dates of last mammo, pap, colon etc..)

Example of a clinic note is attached on the end of this packet, and on the clinic website under “charting”

7.       Presenting to the PIC and the discharge process

§         After you see the patient, jot down some preliminary notes (or write a note in draft form), and come discuss the case with the PIC. He/she will help you identify the major issues, and come up with a plan.  Clinic case presentations need to be much more concise than inpatient presentations. Aim for 3-5 minutes to cover the H&P and get to your assessment and plan.

§         If you are not sure how to proceed on a case, or are overwhelmed by the patient volume, be sure to step out early and speak to your PICs early. They will be able to help with prioritizing a case, time management tips, or help you to redistribute patients to other less busy colleagues.

§         Once the case presentation is finished, submit and finalize the note in Webcis. If it helps you think more clearly, you may ask the patient to step out of the room while you are composing the note. Your PIC will need to cosign a hard copy of your notes before the pt is d/c’d. (electronic signature will start once we start using Eclipsys)

§         Make sure your patients have enough refills until the next visit, this can be done by looking at the date and # of refills left on your pts’ bottles.  Print Rxs from WEBCIS outpt med function. Unlicensed interns will need to make sure his/her attending’s License number is written on all Rxs. Medical supply Prescriptions like wheelchairs, fingerstick test strips will require a ICD diagnosis code (i.e. diabetes 250.01) and frequency of testing, and an attending’s NPI number.

§         Due to NYS serialized Rx papers, printing Webcis Rx in clinic requires you to specify the proper printer tray for each pt. To start hit the printer icon in the L upper corner within Adobe, then hit properties → paper to choose tray 2 so the Rx will print on serialized paper rather than the plain paper in the “automatic detect” mode.   (see pictures below) Do not select tray 1, that tray is a manual hand feed mode.

§         Lastly, complete the discharge instruction sheet/test ordering requisitions and billing sheet. Make sure to include your first and last name and ICD 9 code for radiology/lab tests (this is important so patients do not get billed for inappropriate testing). Learning these administrative tasks may take a few weeks, be sure to ask your PIC for help! Our paper based requisitions should disappear by the end of this year when we start using Eclipsys.

§         When changing your patients’ meds, be sure to provide an updated medication list, this can be printed from Webcis Rx writer (in English and Spanish)   

§         Finally, put chart, billing sheet, prescriptions, order forms in the “send home box” at the front desk.  Your patients will have a seat in the waiting area, while the front desk begins to process discharge paperwork and follow up testings/appts.

§         To minimize additional clinic time stress, consider saving time consuming tasks (family phone calls/forms for patients/prior authorizations) for the end of clinic, or another day. Patients can return to pick up forms on another day. You can also mail it back home to them.

§         When finished with clinic, be sure to look at your cubby or door rack to make sure no patients or no messages are left behind. Be sure to say goodbye to your staff to let them know that you are done.

 

  1. Miscellaneous AIM facts-

§         Social Workers- there are four AIM social workers.  Patient can be scheduled to see a social worker, or use the same day “walk-in” service.  Reasons and scope for SW visits are detailed on the medicineclinic.org website under “social worker”.

§         Telephone Room (3 receptionist fields over 300 calls a day, highest call volumes from 10-3pm). They sit next to a phone-triage RN who takes and relays messages for MD.  Use your business cards and encourage your patient to call this number, x 5-6354 and DO NOT give out your beeper or cell phone number.  The clinic phone number is covered 24x7.  You will occasionally receive email messages from our triage nurses. Please respond to them to confirm that you have received their messages. Non-urgent messages will be placed in your clinic mailboxes. Urgent messages for unavailable residents will be answered by the PIC or the walkin clinic.  Discourage your patients and agency nurses from paging you directly through the hospital operators (5-667x), as it is both not safe (especially when your beeper is not turned on), and may be disruptive to your day. Our Clinic RN message center is the safest method to ensure all messages are triaged and prioritized before it is dispatched.

§         The Anticoagulations Clinic is staffed by 5 Nurse Practioners in AIM. This service assist AIM MDs with monitoring and managing patients’ warfarin dosing.

§         “Pap clinic” is a place to send all of your screening pap exams, it is staffed by NPs.

§         Resident Clinic Mailboxes- lab radiology results/equipment orders/visiting home nursing forms will come here.   Be sure to sign to acknowledge your approval of the orders, and return signature requests in a timely fashion.  When not on vacation, please always check and clear out your mailbox every time you come to clinic, or at a minimum every 2-3 weeks. These mail ARE important to your patients, if you do not return these order in a timely fashion, your patients may lose their services.

§         The WEBCIS Outpatient List –Add all of your newly seen patients to this list. This function will help you to keep on top of your patient panel. This list can help with cross coverage, weekly lab checks, and with various QA/QI activities that you will participate in.

§         AIM Diabetes Teaching and Management Clinic helps our residents care for uncontrolled diabetics and those who need intense education.   The clinic is especially helpful for close monitoring of uncontrolled pts.

Frequently asked questions

  1. How do I keep track of labs ordered on my out-patients?

·         Lab Results- Our clinic nurses get daily lab reports for all 150 doctors in AIM, she review these results for markedly abnormal values and will alert you (or PIC if you are away) of these immediately. Mildly abnormal numbers will be placed in your mailbox  With so many doctors in the clinic, for ultimate safety, we also recommend that you track your own outpts labs by adding your clinic patients to the Webcis “outpatient list” and running a weekly check on the 7 day lab summary (this should take you < 5 minutes each week).  Another option is to use the Eclipsys Ambulatory Manager’s inbox to track results on your outpatients.

·         Radiology reports are printed and mailed to us weekly from the Radiology dept.  To be certain that the rare but very important test result do not get lost by mail, we recommend each of you to keep a short list of important studies ordered on your PDA to follow up on personally. 

·         NEW 2009 Eclipsys inbox –start logging on the “Ambulatory Care Manager” weekly, you will see a inbox where your patients’ lab or radiology results are sent as soon as they are finalized. Be sure to write your name clearly on each requisition so the results will be directed back to you.

  1. How do I get my discharged patients to follow up quickly in clinic?

·         It is always best of the intern who took care of the pt to provide the patients’ future primary care in clinic. When that person is not available in the short term, feel free to book the pt with your resident, our NPs for follow up, or any other available MD in clinic. Just be sure that a clear discharge summary is in the system to briefly detail hospital course and things to follow up upon. The rapid follow up MD/NP will take care of the urgent issues and refer your pt back to you for future ongoing care.

  1. What if all of my clinic slots are fully booked, and I want to get a patient on the schedule?

·         As you start your new practices, you should realize that the show-rate for new clinic patients is somewhere around 50-60%. For example, when 5 patients are booked, only 3-4 will show up.   You can consider allowing overbooking to yourself or you can have the patients scheduled with our NP Follow Up clinic or any other available AIM MD providers with an upcoming open appt.  Write a note in the computer to let the interim provider know what needs to be done, or followed up on.

  1. How should my patients call me, and how are the phone messages handled?

·         Patient telephone calls comes to the clinic’s main number 305-6354.  Phone calls for MDs are currently handled by our “phone triage nurse” team.  This nurse may text page or email you based on the urgency of the message.  If you are not available (vacation/nite rotations), the PIC will assist in responding to these urgent messages. Be sure to sign out your beeper “out of hospital” when you are not working, it is also helpful to turn on the email vacation notification on your work email if you are not in town. This would help the nurses to know whether the message was delivered.

·         A few home visiting nurses/patients/pharmacies have an old habit of paging doctors thru the hospital operators to an outside line (these outside pages will show up on your pager looking like -5667x). As stated above, you should instruct them to avoid this practice, as our clinic telephone line is a much safer option, with coverage by MD/RN 24x7.

  1. What about phone calls from patients overnight or on weekends?

·         During the after-clinic hrs, 2 outpatient block residents, along with one attending physician are assigned to cover the AIM phone call service. Notes of your patients’ phone call will kept on WEBCIS or emailed to you depending on urgency.  

  1. What is the billing/encounter sheet and how do I fill it out?

·         An encounter form is a billing document to go along with every patient visit.  In general one picks one primary diagnosis/ICD 9 code, along with up to two other secondary diagnosis codes.  The level of visit is purely based on the complexity of visit. Without going into too much details, one should keep in mind that “Level 1” visit is an extremely straight forward focused visit, and “Level 5” visit is generally one with well documented extensive history, exam, and complex decision making. Ask your PIC to help gauge the appropriate levels.

·         Only patients who are completely new to AIM clinic should be marked as a “initial visit”.  A patient who was followed by a recently departed resident provider, should be billed as a “follow up” patient, as they are not “new” to the clinic.

·         Finally, be sure to sign the encounter form at the end of the visit.

  1. Why do patients bring us so many different forms to fill?!?

·         It is a fact of life that physicians are called on to attest to their patients’ medical history for a growing number of reasons and agencies. These forms include those for school/work/outside clinic physical forms, home care (M11Q), disability, welfare, housing, transportation etc...  Remember our patients are mostly indigent and disadvantaged, and these forms may allow them to access important services.  Be sure to ask your preceptors for help whenever you encounter an unfamiliar form or request.  Unless you are having a slow day in clinic, do not attempt to complete the forms during your session. It may get you stressed out or frustrated during a busy clinic session. Tell your patients that you do not have time to work on forms while seeing pts, but will have it ready for them in several days. You can either have them return to pick it up or mail it out for them.

·          

  1. What is the AIM intake/discharge instruction sheet?

This sheet list the intake vital signs and weight for the patient. It also helps us communicate clearly to the staff what they need to schedule before the patient leaves, i.e. return to clinic date, consultations, and testing.   After you finish your note, write down on the d/c instructions what you need the staff to do for you (i.e. “Labs before return, mammography, renal clinic”).  For JCAHO compliance be sure to complete the tobacco and pt education assessment sections, and check medication reconciliation if performed.

  1. What is the intake screening sheet?

·         This is a sheet devised to assist physicians with obtaining comprehensive histories from pts. The sheets are filled out by new patients to our practice, and others who have new clinic chart volumes made.  Please review the content of the sheet with the patient, and sign the bottom to acknowledge your review. (In general pts are suppose to have completed the sheet before seeing you, however if the sheet is not completed, please go through the questions with them as it is also helpful for your history taking.)

  1. How do I obtain prior authorizations on prescriptions?

·   Obtaining prior authorizations for medications or pre-certification for testing and or other services is an unfortunate part of our physician’s daily tasks. This type of external physician management did grow from the excessive practice pattern of modern day medicine. Luckily, most insurance companies do provide a comparable and efficacious list of alternative medications; so before launching on this tedious endeavor, review the companies’ formulary or preferred medication list first. Before you launch on the process of getting the PA, run the case by a PIC.  They may be helpful with talking you thru the PA procedure, or even suggesting alternate meds or testing that may not need prior authorization.

  1. What are those resident binders in the PIC room?

·         Most of our residents now keep their pts’ data on the EMR, a few still prefer to have a clinic binder to help hang on to miscellaneous clinic related paper work. Please email Dr. Nancy Chang if you would like a binder for this purpose. We will make one up for you and put it in your home firm.

  1. This is way too much information, how do you expect me to remember all this?

·   Don’t worry, we don’t expect you to remember a thing after you read this. Information is only helpful when you need it, so checkout our clinic website www.medicineclinic.org and learn where you can find all of these information when you need it later in the year. I would also recommend that you reread this orientation packet again 3 months after working in AIM, you will absorb more relevant information once you start seeing patients in clinic.

 

AIM Clinic Cancellations Policy:

 

To ensure our patients’ continuity and quality of care, your best efforts should be made to avoid unnecessary or last minute clinic cancellations. Cancellations of any outpatient clinics or conferences must be approved in advance by the Chief Residents and/or Dr. Nancy Chang 

 

If you do need to cancel a session, please alert us as soon as possible;

 

For:

  1. Predictable cancellations- (example: away electives, ACLS/BCLS training, Boards part III, routine physician appointments, jury duty, conferences, “special” family events) Please communicate this request to us at least 2 months in advance.   Email instruction below.
  2. Unpredictable cancellations- (example: last minute fellowship interviews, last minute jury duty notices, personal/family illnesses) these must be communicated as soon as you are aware of the dates.  
  3. Cancellations during the OPD blocks need to be approved in advance by Dr. Nancy Chang. Coverage will be required for cancelled walk-in clinics (coverage may be required for last minute (<1wk) cancellations of preop/AIM diabetes).
  4. Clinic will not be cancelled or altered to accommodate personally arranged shift swaps and pay back.
  5. Fellowship/job Interviews (Jan-April)-Please Email us as soon as you know the dates. Depending on the number of sessions/pts cancelled, we may ask you to provide alternate clinic dates to ensure patient care do not get compromised.  During OPD blocks, coverage will be required for cancelled any walk-in clinics. To help you plan your interview dates, feel free to email Dr. Chang for an advance copy of the OPD block schedules.

 

 

All AIM Clinic cancellation emails should be addressed to all 3 of the following: Karilyn Martinez (kam9005@nyp.org), chief residents (intmedchiefs@columbia.edu), and Nancy Chang (nmc5@columbia.edu).   ACNC residents must contact chiefs and Dr. Finkelstein.

 

Thanks for wading through this complex document, put it away for now and refer to it again in 2 -4 more months, I think you may find it even more helpful with some real world clinic experience.

Please always access the clinic website for more extensive listings of clinic info. Also always feel free to email me with any other clinic related questions.  My email and other information about the clinic can be easily found on the home page of the www.medicineclinic.org website.                                 

 

AIM Sample Note

http://www.medicineclinic.org/charting.html

 

AIM recommended preventive testing

http://www.medicineclinic.org/Screening%20Chart%202009.htm

 

AIM Firm Listing

http://www.medicineclinic.org/Fim2005.htm

 

Webcis Rx Printing