Associates in Internal Medicine
Clinic Orientation June 2010
1.
Some
History and Background
Ø The Columbia P&S’s Vanderbilt Clinics (it’s original downtown location) was one of the first teaching clinics established in the North America, it was described in the 1910 Flexner Report.
Ø
Our clinic was established within VC as a
general internal medicine teaching clinic in 1976. It is set up to serve the
ambulatory medical needs of the local
Ø AIM is a mixed faculty/resident teaching practice- Attendings practice alongside residents in clinic sharing the same patient panel. Residents learn to care for their own patient panel under the supervision of these same attendings. Our 25 faculty clinic preceptors coming from diverse academic generalist backgrounds, many of them winners of teaching awards, and all are familiar with our practice system, and enthusiastic to work with the residents.
Ø Currently AIM exists in 2 spaces–AIM Clinic in Vanderbilt bldg. and AIM-East across the street. All resident practices are in AIM while AIM East (1st fl of the Naomi Berrie Clinic) houses IM subspecialty clinic. (Cards, rheum, endocrine, GI, Renal).
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 Chair-Dr. Steve Shea.
Ø Ambulatory Education Director -Nancy Chang, MD, oversees all resident ambulatory training. nmc5@columbia.edu. Intern Outpatient Block Director -Steve Mackey, MD slm39@columbia.edu
Ø Clinic Scheduler Ms. Chris Collado, chc9091@nyp.org x 5-0677 manages day to day schedules for all 160 AIM providers.
Ø VC 2 “Room 205” is our administrative Office-Door code 143- this room contains our main teaching Conf room, Fax (x5-6279) and drop off folder (staff will fax and put receipt in your mailbox), copier (code02205), and mail boxes. There is an outgoing mail box where you leave items to be mailed. Our interpreters also sit here.
Ø AIM Telephone room –(x5-6354/ MD only access 5-5549 ) 3 full time staffers field over ~300 calls a day. Telephone RN Message Center- RNs triage incoming patient phone message for residents. Expect to see these messages coming thru your Eclipsys SHM (this links to your email as an alert). RN may page you or refer pts to the walkin clinic or 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.
§ 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 on the outpatient block who will help provide coverage for those not in clinic.
Ø Staffing- In each module, 2-3 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”). During your PGY 1 OPD block you will be given a “scavenger hunt” exercise to improve your familiarity with the clinic system.
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 session that day, you may be floated to another module.
§ 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 and help with administrative issues (VNS home orders often require the cosignature of your FIRM attending).
Ø Supervision- Teaching Conferences where your PICs sit are located in Room 231, 214, and 240. This means each main AIM hallway has at a minimum 2 preceptors.
4.
Typical
Patient Flow
§ Prior to arrival, patients will generally receive both mail and Televox telephone reminders alerting them to their appt. Average patient show rate is about 80%, with lower show rates for new patients. When you have a lightly scheduled clinic or no shows you may be asked by the staff to help out to see unscheduled 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 cubby 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 gets 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 for vitals). You can track pt arrival in your room by using Eclipsys and looking at the pts registered to your module. There is a column on this list for arrival time.
§ The Soarian program is our current clinic scheduling program. There is a link to instructions on the website. We will show you briefly this program during orientation, it allows you to do functions like viewing schedule, tracking arrival time, and making your own appts.
§ 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.
§ Despite the distraction with EMR, clinic time management stress, always work on maintaining your social skills and good bedside manners. Take the HPI first, maintain good eye contact, type when you have the pt change in or out of the gown. Do your bottle check for medication reconciliation.
§ 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 and sheet under you 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 admissions, not everything needs to be decided nor completed in one visit. Learn to direct your unfocused pts. 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 EMR and note writing in
clinic.
5.
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. It is available to you at home (with VPN connection). The program will allow you to view schedule, book pts for f/u, and track your arrivals.
§ Eclipsys XA-Ambulatory Care Manager- is our official EMR as off Jan 2010. It does documentation, paperless ordering, and has a lot of functions including returning your outpt results and messages to your “inbox”. More info will be provided in a separate Eclipsys training guide. With it’s many functions, Eclipsys is a slow and clunky program, it’s data display function leaves much to be desired for.
§ WEBCIS- was previously the main clinic EMR program used in clinic. It does a phenomenal job at quickly delivering data and notes to you in an instantaneous click. It also has a functional Rx fax function. It is a great complement to Eclipsys especially when trying to find clinically relevant data on pts.
6.
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 (we have several AIM templates). Avoid
carrying over large chunks of unrefreshed/unreviewed or redundant copy and
pastings on your notes. Try to limit each clinic note to 2 page printed.
“Run-on” notes that goes way long, impairs the ability of others (or even
yourself) to grasp the big clinical picture.
We recommend that you keep your health maintenance check list on the
bottom of your note (not in your problem list) so it is not distracting, and is
a good reminder at the end of your visit. More info on writing notes in our EMR
Eclipsys is attached.
Standard AIM template
– categories listed must be on every note (pointers in parenthesis)
|
o Coded Problem List- Please always enter your pt’s major medical conditions (CAD, CHF, DM etc). This check list of problem does not need to be imported to your note, but having a coded dx will help us generate your own pt chronic disease tracking registry. o This is your own free text problem List that summarizes the big picture on the pt (problem list has more informative narrative but need to be reviewed, updated, and “weeded” at each visit, to help present the best picture of your pt) -Active -Pmhx/Psurghx- inactive problems that are not currently relevant o Chief complaint/HPI/Interim History/ ROS § Social hx § Family hx o
Med Allergy/ADR (document reaction to meds) o
Updated Med list (reconcile patient bottles with
your Eclipsys Rx list at every visit) o
Physical Exam -You can import your vital signs
in one horizontal line by using F7 button o
Data text box (do not need to click large
chunks of data into your note, it’s already in the EMR) Use the free text box
at the bottom of the lab section to import relevant data. Keep this section mainly for new data. No
need to carry miscellaneous results to perpetuity. If there is an old EF on
an echo you want to record, put it into your problem list. It does not need
to live in the data section where it makes it impossible for others to read
your notes. o
Assessment –Always should be on every note. A
simple 1-3 lines summarizing the big picture, stability of patient’s course,
new sx or findings of interest. o
Problem/Plan-
(define issues by problems not organ system. A problem is a diagnosis,
abnormal finding, or symptom under eval.) 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 sheer number of the pt’s complaint, be sure to step out early and speak to your PICs early. They will be able to help with prioritizing a case, provide 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 Eclipsys. 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 cosign your completed notes electronically.
§
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 or the recent RENEW date on Eclipsys. Print new Rxs for pts.
§ Order what you need for the pts, return to clinic date, tests, labs, mammogram, etc. Again refer to the Eclipsys guide on the best way to do this.
§ When changing your patients’ meds, be sure to provide an updated medication list, this can be printed by clicking the Printer button in Eclipsys and clicking Ambulatory med list.
§ The billing sheet is a yellow form which you need to complete. Try to choose the major diagnosis reviewed by you and the pt during the visit. Also select codes for the intensity of the visit. Your PIC will help on this, then sign your name on the back page.
§ Finally, put chart (billing sheet, triage sheet, med list, Rx) 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/completing forms for patients ) for the end of clinic, or another day. Patients can always 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 and leaving. Please don’t leave through the back door without letting your staff know.
8.
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). Clinical calls are forwarded to our nurses who will send you SHM for non-urgent questions. Please use your business cards and encourage your patient to call this number, x 5-6354. DO NOT give out your beeper or cell phone number as it is not safe. The clinic phone number is covered 24x7. Please respond to SHM from our nurses. Emergent or Urgent messages for unavailable residents will be answered by the PIC or the pt may be referred to come to walkin clinic. Discourage your patients and home 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 inpatient work. 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- equipment orders/visiting home nursing forms/consult letters/ somre results will come here 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. For home care orders, be sure to sign to acknowledge your approval of the orders, and return signature requests in a timely fashion. NY VNS company requires that their home orders are cosigned by an attending, so you can leave these in your FIRM attending mailbox after you sign them. The clinic mail ARE important to your outpatients’ care, if you do not check your mailboxes regularly we will remind you.
§ 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.
9. Frequently
asked questions
· Lab and Xray Results- use the Eclipsys inbox –get into a habit of logging onto the “Ambulatory Care Manager” inbox weekly (even when you are not here in clinic). This “inbox” looks like an email, and is where your patients’ lab or radiology results are sent as soon as they are finalized. You will also seen SHM from nurses or docs here. Be sure to set the inbox filter to 1 month to pull in all available results. There are several results that are not returned to the inbox, these are pathology, cardiac testing, bone density, PFT. Please be sure to track these on webcis.
· 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.
· 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 other available AIM MD providers with an open appt. Write a note in the computer to let the interim provider know what needs to be done, or followed up on.
· 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 SHM 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. This would help the nurses to know if you are around.
· 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.
· 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 logged on Eclipsys or SHM to you depending on urgency.
· 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 or three 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 an extensive H&P AND a well documented note showing 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 back of the encounter form at the end of the visit.
· Many of our pts receive home nursing, home health aide, or home attendant services. This care is usually provided to those who have poorly self managed chronic diseases, recently discharged from the hospital or need self care assistance. We are serviced by 4 home nursing agency with VNS of NY as the largest company. The home care nurses communicate with us thru phone calls and with home care orders. Please always sign and return these orders promptly so your pts will receive proper care. (Of note, one of the 4 home care company -VNS of NY orders require attending cosignatures on unlicensed residents’ orders. When you receive those orders please sign and leave in your FIRM attending’s mailbox for cosignature)
·
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.
· 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.)
·
Obtaining
prior authorizations in AIM for medications or pre-certification for testing is
an unfortunate yet infrequent part of patient care in AIM. Before
doing a prior authorization for a Rx, realize that most insurance companies
provide comparable and efficacious list of alternative medications; so check
with your PIC who may be helpful with
talking you thru the PA procedure, or even suggesting alternate meds or testing
that may not need prior authorization.
· 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.
10. AIM Clinic
Cancellations Policy:
http://www.medicineclinic.org/Clinic%20Cancellations%20Policy.htm
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 recommended preventive testing
http://www.medicineclinic.org/Screening%20Chart%202009.htm
AIM Firm Listing