TSWF Flight Event AIM Form User Guide

September 2019

This User Guide was not updated during the Jan-Apr 2020 Release and is still relevant.

Form Version: Sep-Dec 2019 Rev. 1

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Flight Event AIM form

Introduction………………………………………………………………………… 2

General Information.………………….………………………………………...... 3

Best Practice Procedures and Workflows……………………………………. 4

Form Tabs dm

Aviation………………………………………………………......... 5

ROS…………………………………………………………………. 7

PE/AP………………………………............................................. 8

Follow-up…………………………………………………………... 10

Adding Form to Favorites Instructions……………………………………….. 13

Copy Forward……………………………………………………………………… 16

AHLTA Options……………………………………………………………………. 19

Table of Contents

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Introduction to Flight Event AIM Form

Background/History: The Tri-Service Workflow (TSWF) Team has created AIM forms to bring team care to MTF workflow, save provider and staff time through standardization of AHLTA templates, and enhance documentation of the patient encounter. The focus of TSWF activities is to facilitate improvements by evaluating clinical workflows and creating standardized structured documentation tools that mirror clinical processes. This is done through the use of AIM (Alternate Input Method) forms with the goal of improving care and documentation in AHLTA and not just the use of a form for its own sake. The Flight Event AIM form allows for comprehensive data collection to better care for the aircrew and standardize the information gathered across platforms and locations. It was developed with input from Flight Surgeons and Senior Providers within the aviation community to provide a single template that can be utilized from initial visit through 72-hour follow up. The information gathered will be helpful to identify trends that impact the health of our aircrews and as such, the quality of the information provided will impact the quality of care provided now and in the future. Several features that are unique to this form will streamline care to the patient. These include multiple vital signs fields that allow for documentation of re-evaluation during a single encounter and embedded MoCA and MACE forms that can be printed for testing. Who is this form made for? This form was created to be used by Flight Surgeons and aviation corpsmen during the initial evaluation and subsequent follow up after an aviation event. For a complete list of all TSWF developed AIM forms, go to www.tswf-mhs.com. Why would I want to use this form for my notes? This form and associated workflow was designed to standardize health documentation practices in the MHS. Standardization of documentation can result in the following:

• Integrating clinical support staff into the care of patients

• Obtaining more thorough and better documentation

• Guiding providers toward using evidence-based care

• Standardizing suicide and safety evaluations

• Improving the speed and efficiency of documentation

• Improving coding accuracy

• Building in items required for inspection Features of the Tri-Service Workflow AIM forms and associated workflows:

• The copy-forward process: o Maintains continuity of clinical information o Carries forward treatment planning and ongoing course of care o Improves note writing efficiency

• The forms include clinical clues and reminders

• VA/DoD CPG decision support is available right at the point of care This user guide is a comprehensive AIM form reference that walks through all of the tabs on the TSWF Flight Incident AIM form. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: www.tswf-mhs.com. If you have questions or feedback about this User Guide, please contact us via the following link on MilSuite: https://www.milsuite.mil/book/groups/tswf.

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---------------------------- (Sequence of Clinical Workflow) --------------------------

Form Structure: - Mirrors clinical workflow (from left to right: intake, screening, ROS, PE, and care plan documentation) - Facilitates use of flight surgeons, aviation technicians and flight corpsmen for casualty documentation - Provides decision support from VA/DoD CPGs, Naval Safety Center, NICoE and other national level recommendations - Improves documentation efficiency

Form Basics:

General Information on Form Use

Forms are updated 3x/year.

Clinical clues are found throughout and give relevant information.

A red “X” indicates this section will be included in the note. AHLTA automatically marks this “X” after text has been entered. Clicking on the “X” after typing in the box will reset the box to its default text by erasing what has been entered. The Undo button (see the top of the screenshot above) can be clicked if this was done accidentally.

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Recommended Documentation Workflow

a. Aviation corpsman and/or provider opens the note and enters an initial set of vital signs. b. Corpsman and/or provider enters pertinent and appropriate details into the Aviation tab of the AIM

form. c. For a follow-up visit, staff copies forward essential elements of the note and reviews/updates all

copy-forward information in the note with the patient. d. The provider then takes “ownership” of the note (i.e. ‘edits’ S/O portion of the note) and reviews

all copied forward information, and everything entered by the corpsman. e. The provider then completes the rest of the documentation and signs the encounter.

PLEASE NOTE:

• A comprehensive visual change log has been created to assist users in identifying the changes made with each version’s update. Click here to access this presentation.

• Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data.

Best Practice Procedures and Workflows

The TSWF repository for training/educational materials and updates:

www.tswf-mhs.com

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Aviation Tab

This tab is for documentation of the patient’s demographics in order to complete the Part C Safety form (i.e. flyer and timeline information, medical and personal history, etc). For initial encounters it is recommended that all history and evaluation sections are thoroughly addressed. In this way, other providers can access this vital information for follow-up purposes in order to provide the best possible care.

Clicking here opens a ribbon with further information. All ribbons are shown open in this guide to reflect content.

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Aviation Tab, cont.

It is recommended to complete all fields on the Aviation tab to identify all factors which may affect the flyer’s condition.

Fields for documenting workout history and prior injuries are provided.

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Access any TSWF form from the Navigator via this link.

ROS tab

Use this tab to document the initial triage and/or follow-up ROS. Depending on your clinic, either the aviation corpsman or the provider might be responsible for completing this tab.

Small boxes are areas where you can add free-text to expound upon an entry if needed. And once there is text in that box, you’ll see the box change to look like this: By clicking on this button you can see what was written, and either add/edit or delete the text as appropriate. These free-text boxes are found throughout the form.

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Upon receiving the patient from the Paramedics, get as much of this information as possible depending on the acuity of their presentation. The elements found on this tab are used for data mining purposes to better care for the Aviation community in the future. Specific focus on the neurologic exam is warranted as this comprises the bulk of many patients’ physical complaints and sequelae.

PE/AP Tab

An Autoneg button is provided to allow quick documentation of normal exams. Select Autoneg and either deselect or change N to Y or N to A as appropriate.

Several features that are unique to this form will streamline care to the patient. These include multiple vital signs fields that allow for documentation of re-evaluation during a single encounter (keep in mind these vital signs will not go into the vital signs module). An embedded MACE 2 form that can be printed for testing is available as well.

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PE/AP Tab, cont.

An ICD-10 code is required as part of your documentation. Keep in mind that documenting here does NOT mean this code appears in the A/P module- it must be entered there as well.

Click the icon next to each system to see additional MEDCIN tree terms available for that system. (Click Close Trees to exit out.)

If you document that something is abnormal, further explanation is frequently needed. Free text can be added to any of the exam findings by clicking on the free text box next to the item.

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This tab is utilized for the 24, 48, or 72-hour follow-up visits. This assists with tracking the patient’s progress longitudinally.

Follow-up Tab

Specifics about hyperbaric treatment can be documented here.

A link to MACE 2 is provided.

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Follow-up Tab, cont.

With Motor Strength and reflexes, you can see the separation of right and left sides. If you accidentally select the Autoneg button, you can use the Undo button (along the top) to reset back to what it was.

Again, an ICD-10 code is required as part of your documentation.

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TSWF Flight Event AIM Form: Adding Form to Favorites Instructions

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The preferred method of accessing TSWF AIM forms is to have the Navigator in your Favorites. Loading from the Navigator will take you to the most current version of the form. Alternate Method: Add the specific TSWF AIM form to your Favorites…

1. Open “Tools” 2. Select “Template Management”

4. In “Template Name” line type “TSWF”

5. From “Owner Type” dropdown list select “Enterprise”

3. Click “Expanded Search” to locate TSWF– AIM forms

6. Click “Search” button

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7. In the “Search Results” list: Right click on the “TSWF- Flight Event – (Department of Defense)” AIM form

Do not use ‘Save As’ when adding this template to your favorites list. Do not set this form as your default encounter template unless you have specific instructions on how to do it from your local clinical systems trainer. ‘Save As’ will break the link to the Enterprise and keep the form from updating properly; setting as a default will also break the link if not done properly. We suggest cleaning out old and un-used templates from your favorites to help you quickly find the ones you most often use.

8. Select “Add Favorite” (Do not use “Save As”, as the form will not get updated properly…see below)

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TSWF Flight Event AIM Form: Copy-Forward Instructions

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Copy-Forward Instructions

The copy-forward process is integral to the Tri-Service Workflow. Following these steps will ensure that the appropriate data you enter today gets reused as efficiently as possible.

1. In Appointments view; Double-Click on the Patient. (This takes you to this “Current Encounter” view.) DO NOT OPEN S/O

2. Select the “Previous Encounters” module from the Folder List.

Consider including “cancelled/LWOBS” visits when reviewing this module.

4. Click the “Copy-Forward“ icon on the tool bar.

3. Click on the most recent and compatible TSWF encounter listed.

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AHLTA returns to the “Current Encounter”

5. Select “S/O”

DO NOT MAKE ANY EDITS WITHIN THE COPY-FORWARD TEMPLATE! - If the Copy-Forward Template is not automatically loaded; select it from the Template drop down menu.

7. Click “AutoEnter” after the selection of each tab.

6. Select appropriate tab(s) to copy-forward. DO NOT INCLUDE PE or ROS as it will include items from a previous encounter.

TSWF Copy-Forward process Specific elements of the Flight Incident note can be copy-forwarded. To do this, select the appropriate tab(s) and hit “AutoEnter.” Critical Assumptions You MUST complete copy-forward and open the TSWF AIM form before editing the content.

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8. Select “TSWF- Flight Event” AIM form

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AHLTA Options

Access by opening up any clinical encounter or tel-con to this screen. Click on the OPTIONS tab.

Line 1- will default to your name

Line 2- as directed by your MTF-in the LIVE system, AHLTA’s default is PHYSICIAN/WORKSTATION

Line 3- as directed by your MTF

Co-signer- as directed by your MTF

AUTO CITES- recommend checking Allergies and Questionnaires (if used). Uncheck anything else.

VITALS/LABS/RADS- this will automatically place ANY vitals/results in your note for the time period you selected- i.e. for the last 7 days. We recommend leaving all these unchecked. WARNING-THIS FUNCTION WILL AUTOMATICALLY PLACE INFORMATION IN YOUR NOTE REGARDLESS OF WHO ORDERS THE LABS. Individual labs/rads can be added to the encounter when viewing those results.

A/P Active Order Default: recommend checking all the boxes

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S/O Default- We recommend unchecking both of these boxes. Having them checked can cause unexpected behavior in the forms.

Disposition Follow Up Discussed with Default: Defaults to Patient. Option to override for exceptions is located in the DISPOSITION tab

E&M Calculator Defaults: Setting: Outpatient; Service Type: Outpatient Visit; Exam type: General Multi-System

Do NOT check AUTO PRINT or SENSITIVE

Include ICDCM/DoD Unique/CPT4/HCPCS codes in encounter note- check this box. This will place the codes on the signed encounter. No action required by user. Warn me if no procedure documented- for primary care, do not check this box. Auto Save- recommend unchecking this box. This used to be helpful but auto-saving freezes up AHLTA for a moment and it’s really just not needed.