GUIDE TO THRIVING AT THE DOC - Duke University
GUIDE TO THRIVING AT THE DOCINTRODUCTIONThe BasicsHours and ParkingImportant Phone Numbers (p pager, m mobile)Copy machinesLate Policy for PatientsMAESTRO CAREHow to Schedule an AppointmentTroubleshootingA Checklist to Complete During a Patient VisitMaking your encounter more efficientEpic inBasketSmartphrasesTemplates for clinic notesTemplates to use in your HPITemplates to use in your “Objective”To use in your assessment and planBehavioral Health-related smartphrasesTemplates for patient instructionsSocial work-related templatesDocumentation Outside a VisitOrdering an Outpatient Blood TransfusionVisit TypesDocumentation of Psychosocial NeedsMEDICAL RESOURCES IN THE CLINICProceduresMedications Available in ClinicMed/Psych ConsultationDepression Management AlgorithmTable 1: Initiating Antidepressant Treatment with Sertraline*Table 2: Switching to or augmenting with Venlafaxine XRTable 3: Switching to or augmenting with Bupropion XLTable 4: Augmenting with MirtazapineCDC Vaccination TimelinesPhysical TherapyDiabetes- and Hypertension-Related Services at the DOCCLINICAL PHARMACY SERVICESStaffReferring Your Patient to the PharmacistWhenHowManagement of Potassium:Additional Treatment Considerations:DOC Anticoagulation ClinicReferral 51516171818202020202020212121
During the Anticoagulation AppointmentINR Checks at HomeINR Checks During Physician AppointmentFollow-upContacting patients who are overdue for INR checkBridging WarfarinPrescription RefillsHow to Make Prescription Drugs AffordablePatient Assistance Programs (PAP)Senior PharmAssistPatient Has Medicaid OnlyNC MedAssist: long-term solution for patients without insuranceDuke Hospital Sponsorship: short-term solution for patients without insuranceDifficulties Getting Prescription Drug 262626CARE MANAGEMENT AND ACCESS TO CARE27HomeBASE careDuke Connected Care and DukeWELLHow to make basic care affordable and accessibleSubsidized health insurance via the affordable care actNorth Piedmont Community Care (NPCC) / Durham Community Health Network (DCHN)NC breast and cervical cancer control programDuke Charity CareThe DOC FundDurham Medical Respite ProgramResources for Essential Daily NeedsMedical TransportationMedicaidNo MedicaidTransportation for cancer treatmentNon-Medical TransportationHOME HEALTH AND PERSONAL CARE SERVICESHome Health ServicesPersonal Care ORAL HEALTH31Clinical social workStaffHow to Refer to Social WorkSocial Work DutiesBehavioral Health ConsultantsOther Mental Health ResourcesPatients with Private InsurancePatients with MedicarePatients with Medicaid or no insuranceMental Health CrisesDomestic Violence ServicesPage 23131313131323232323233Last revised: 29 June 2016
CONTROLLED SUBSTANCES34DOC Prevent and Intervene Now (PAIN) GroupInitiating narcoticsWhat patientsContraindicationsWhat to do before initiating narcoticsMedication choice & dosingFollow-up visitsPain ContractsWhen to startFirst narcotic prescriptionFollow-up visitsViolationsReinstatement of pain contractBenzodiazepinesUrine Drug ScreensIn-HouseSend-OutControlled Substances SchedulesMEDICAL RESOURCES OUTSIDE OF THE CLINICDirect Admissions & ED EvaluationsDuke Regional HospitalDuke University HospitalRadiologyOphthalmology for low income/MedicaidPodiatrySmoking Cessation OptionsAlzheimer Disease SupportCancer-Related SupportHome Visit ProgramDental Care, free or low-costFor patients with MedicaidFor those with Medicare or no insurance (Sliding Fee Scale)For those with Medicare or no insuranceFor those with Medicare who require medically necessary dental treatmentObstetricsMEDICAL 383838383839393939393939404041Diabetes SuppliesDurable Medical EquipmentSimple equipmentMotorized chairCPAP/BIPAPDiagnosing OSATreating OSATroubleshooting OSAHome O2Medicare Requirements for Home OxygenEnsure4141414141414141424243Page 3Last revised: 29 June 2016
DOCTORING FROM HOME (OR THE CCU)Away from ClinicDOC After-Hours Telephone Home Call CoverageHow to manage common callsImportant Contact Numbers:FILLING OUT FORMS444444444445Partnership FoldersTypes of FormsDisability FormsFL-2 FormsLetters4545454545CREDITS47Page 4Last revised: 29 June 2016
INTRODUCTIONTHE BASICSDuke Outpatient Clinic (“DOC”)nd4220 N Roxboro Rd (2 floor of the Durham Medical Center building)Durham, NC 27704Main clinic number: (919) 471-8344Fax number: (919) 477-3110Fax number (refills): 919-477-5435Door codes (all doors from waiting room to clinic area): 2-4-3-1HOURS AND PARKINGClinic hours are 8am to 5pm. Enter through the front door and exit through the back door. You must leave thebuilding by 6:30pm, or alarms will go off and the clinic will get charged a big fee! Please park at the side or backof the building so that patients can park in the front.IMPORTANT PHONE NUMBERS (P PAGER, M MOBILE)Medical Director & Clinic Group A Leader, Lynn Bowlby, MD ,.919-660-9048, m. 774-991-0041Clinic Group B Leader, Dani Zipkin, MD .p. 919-970-8947Clinic Group C Leader, Larry Greenblatt, MD .919-660-9047, p. 919-970-0496Medical Director of Behavior Health, Greg Brown, MD. . .p. 919-970-2532Ambulatory Chief Resident (Aparna Swaminathan) . . 919-970-9823Teal Side Preceptor Room . .919-660-9024Lavender Side Preceptor Room , . .919-660-9023Clinic Operations Director . . 919-660-9044Front Desk. .919-660-9007; 919-660-9006; 919-660-9010Financial Care Counselor . . . 919-477-0829; 919-471-9475Social Worker, Jan Dillard . 919-471-0084, p.919-970-4530Clinical Pharmacist, Holly Causey , .919-477-5904, p. 919-970-3532Clinical Pharmacy Assistant , . 919-660-9058Nurse Manager . . , .919-660-9057Nurse Triage . , .919-660-9016Nursing Pager .,.p. 919-970-3624 (970-DOCHelp)HomeBASE Care Manager, Marigny Manson . . .919-309-6562Medical Records, Carolyn Lawrence , 919-660-9045Laboratory, Angela Wilson . 919-471-0546Scheduling Hub, Rita Clark .919-479-2454Scheduling Hub, Rita Maynor .919-479-2464DHTS Help Desk . 919-684-2243COPY MACHINES-One located in the waiting room next to the cubicles, the code is taped to the machineAnother is located in medical records, no code neededNursing can help you make copiesLATE POLICY FOR PATIENTS-Patient are considered late if they arrive 20 minutes after their scheduled appointmentPatients arriving less than 20 minutes late will be seenPatients who are elderly, rely on others for transportation, are in the homeBase program, or have anissue that requires urgent medical attention will also be seen regardless of when they arriveIf a patient is 20 minutes late:Page 5Last revised: 29 June 2016
ooooNursing staff may ask you it you’re willing to see the patient, but the general goal is to seeeveryone who walks in to clinicIf you’re able, see the patientIf you’re behind or have other people waiting, feel free to see others first, then see the late patientIf you really don’t think you’ll have time, nursing staff may add the patient to someone else’sschedule or schedule them for a later appointment in the dayPage 6Last revised: 29 June 2016
MAESTRO CAREHOW TO SCHEDULE AN APPOINTMENT-Make a follow-up appointment by indicating a return appointment time range in the follow up section(using the “For:” field) in the visit navigator in Maestro (for example, “2-4 months with PCP)Patients can call the scheduling hub at (919) 471-8344 (extension 1) during business hours to request anappointment (should be encouraged to ask for you by name)To request an appointment for your patient, send an InBasket message to the “FRONT DESK POOL,”which will pop up when you type “P DUKE OUTPATIENT” in the “to” field. Be sure to include the patient’sname, MRN, time frame requested, reason for appointment, and person with whom they should bescheduledTROUBLESHOOTINGHelpdesk: (919) 684-2243, choose option #5Maestro “Super Users” at DOC: Dr. Bowlby & Dr. ZipkinA CHECKLIST TO COMPLETE DURING A PATIENT VISITThe majority of your patient care note can actually be completed prior to the end of the visit. The following“checklist” highlights the different steps you should take during the visit in the “visit navigator” section of eachpatient’s chart. Note that bolded items must be completed prior to discharging a patient from the visit.1. Document and/or review the “Chief Complaint”2. Review documented “Allergies” (be sure to “mark as reviewed”)3. Review and update the patient’s “Problem List” (be sure to “mark as reviewed”)4. Review and revise patient history (PMH, PSH, family, social)5. Review, reconcile, and refill patient medications under the “Medications” tab6. Review and update the “Healthcare Maintenance” tab7. Record a diagnosis (or multiple diagnoses) for the visit under “Visit Diagnoses” (note: you can“push” problems from the “Problem List” section into “Visit Diagnoses” by clicking on the small arrow nextto each problem). Do NOT put ‘health maintenance’ as the first visit diagnosis, as we can’t bill visits thatway.8. Document HPI9. Order any additional tests or referrals under “Meds and Orders” (everything you order must be“associated” with a visit diagnosis)a. PEND orders until you know who you’re signing out with, so orders and referrals can link withcorrect attending.10. Document assessment and plan (note: use .DIAGMED to pull in each visit diagnosis with attachedorders)11. Document a follow up in the “follow-up” section, specifically in the “For:” field (for example, “f/u in2-4 months with PCP for HTN management”)12. Route your note to the attending you signed out with (also in the “follow-up” section)13. Write patient instructions in the “Patient Instructions” section (see Smart Phrases below)14. Print the “After-Visit Summary (AVS)” and hand it directly to the patientMAKING YOUR ENCOUNTER MORE EFFICIENT Order items on the left hand column for better function during all encountersMove diagnoses between History, Problem List, and VisitReview Flowsheets (vitals, diabetes detail)Common Diagnosis buttons: populate these for easy use for routine healthcare maintenance ordersOrders favorites: Go to Epic menu à preference list composer à Patient Care ToolsMedication prescribing: delete END DATE, make sure quantity is correct, refills for 30 or 90 day supply.Be aware that we CANNOT discontinue meds in the system, must add that on as a note to the pharmacywhen you do a new Rx.Page 7Last revised: 29 June 2016
Uploading images: Take a photo using the Epic Haiku app (ask a resident or attending to show you how).It will automatically upload to the “Media” tab of the patient’s chart. Copy and paste the image into yournoteo To get Haiku on your phone, go obile/SitePages/Home.aspxSpeed buttons for check out in the ‘follow up’ sectionLetters to patients: Select recipient at the top à compose letter (right click to make selected texteditable to get rid of extraneous stuff in lab results à (1) ROUTE or (2) SEND the lettero Click “route” to send the letter to your medical records pool or designated person, who will mailthe letter to the patient (preferred).o Click “send” to print letters and then have someone send them. To print later, go to Letters tab inChart Review.See Dr. Zipkin for extra tips!EPIC INBASKETWhen you need help with something and want to route an encounter to your nurse, please refer to the partnershipmap to know who your team nurse is (Group A is Amber Walters, Group B is Diana (Glenda) Wamsley, Group Cis Johna Weilacher) and put that nurse in the routing field. Move folders up and down per your preferences (use the wrench) Involve the nursing team where appropriate. They can contact patients on your behalf if needed. Patient Calls: click “QuickNote” to bounce back to nurse, or “Enc” to document your portion of the call.Do not use “comment”, as this doesn’t go anywhere. Patient advice request: click “Reply to pt,” or “MyChtEnc”. Route if needed. Clicking on “tel call” createsa new encounter. Results: click “Rslt Release” to release the results in MyChart (if patient has MyChart). Click “Letter” topopulate a letter with the results, and then route the letter to the medical records pool so they can sendthe letter to the patient. Click “result note” to comment and route to nurse for helpo Please note that abnormal results for HIV, GC, Chlamydia, and Syphilis are to be sent to MollyJarvis. She collects them and reports to the health department for us. This is in addition to younotifying the patient and treating them. Rx request: click “EditRx,” or “Approve All.” If you want to enlist nursing help, click “Enc,” or “QuickNote.” Referral message: Right click, reply to all or reply to sender CC’d charts: Specialists route their notes to you, as the patient’s PCP. These are mostly FYI. Staff Messages: This is like email, except harder to figure out who is sending and who is copied. Thesemessages are not recorded in the patient’s chart. Patient station (icon on topmost banner of Epic): Click on this to start any new encounter or go into anexisting open encounter, whether routed to you or not. Orders only encounters: For times when a patient needs to return for blood work outside an encounter;make all orders “future”, even if being done that same day.SMARTPHRASESNote: To insert the smartphrases below into your note or patient instructions, each phrase must be preceded by aperiod (“.”). For example, to insert a template for a follow-up visit, start typing “.dazfu” and choose thesmartphrase you’re looking for from the drop-down menu that pops up.TEMPLATES FOR CLINIC NOTESName of OCGROUPDMDescriptionTemplate for an annual visitTemplate for a follow-up visitTemplate for a patient who is new to the DOCInsert this template into the “HPI” section of your new or follow-upnote if the visit is a hospital follow-up appointmentTemplate for DM group visitPage 8Last revised: 29 June 2016
ALEUNDER50Template for HTN group visitTemplate for SAR handing patient off to internTemplate for new female patient under age 50Template for new male patient under age 50TEMPLATES TO USE IN YOUR HPIName of CDNRDISCUSSIONWEIGHTLOSSSURGERYDescriptionHPI info for a routine diabetes visitHPI info for routine asthma visitHPI info for routine COPD visitTo document DNR discussion in HPIFor patients who present for f/u of weight loss attempt in preparationfor bariatric surgeryTEMPLATES TO USE IN YOUR “OBJECTIVE”Name of JDescriptionQuick trend of weightsQuick trend of temperaturesQuick trend of BPsQuick trend of pulsesQuick trend of diabetes dataTo document a diabetic foot exam (including monofilament)Template for knee injection procedureTemplate for shoulder injection procedureTO USE IN YOUR ASSESSMENT AND PLANName of FACEDOCUMENTATIONHOMEHEALTHSETUPDescriptionPulls in all orders as linked to diagnoses, with nicely formatted areafor writing your thoughtsInclude in the a/p for a patient who has DM and all parameters are inorderInclude in the a/p for a patient with uncontrolled DMText for the a/p about management of uncomplicated lower back painText for the a/p about using the new ACC lipid guidelinesText for the a/p about management of xerosisOrder and certification for home care services (include in yourprogress note)Info for YOU (not the patient) on how to order home healthBEHAVIORAL HEALTH-RELATED SMARTPHRASESName of templateFFGAD7DescriptionValidated, widely-used 7-item anxiety screening RISISLINE2-item validated PTSD screening tool (from the VA)Brief depression screenFull PHQ-9 in compact formatPulls PHQ-9 flowsheet into noteCAGE questionnaire for alcohol abuse3-item standard alcohol abuse screening10-item standard alcohol abuse screening (more accurate)10-item drug abuse (prescription or otherwise) screeningCalculator for adverse childhood eventsPhone number for Durham Center Access Crisis Line and SuicidePage 9Last revised: 29 June 2016
SUICIDERISKDOCCRISISSERVICESPrevention LineSuicide risk assessmentList of crisis resourcesTEMPLATES FOR PATIENT INSTRUCTIONSName of OCADVANCEDDIRECTIVESDescriptionDr. Zipkin’s brief recommendations for low carb dietIncludes “my plate” and table of glycemic index ofcommon foodsTable of glycemic index of common foodsOptions for daily exerciseSmoking cessation hotlineInstructions for patient on how to get informationfrom Medline PlusAsthma action planBehavioral interventions for depressionInstructions re: hypoglycemia for patients on insulinInstructions re: diabetes care if taking insulinInstructions re: diabetes care if taking oral medsInstructions re: insulin sliding scaleFor patients who have a psychiatrist and arerequesting medsLow literacy information about narcoticsInformation about narcotics12 patient education videos regarding opioidsExplains the group visits (DM,HTN and pain)Explains MyChart and how to installInformation for YOU (not patient) about PACE(program of all-inclusive care for the elderly) andreferral instructionsFor patients with Medicaid or without insurancewho need to connect with substance abuse, mentalhealth, or developmental disability servicesInformation about signing up for the exchangesHow to get free transportation if you have MedicaidInformation regarding what a clinical pharmacist willdo and what to bring to an appointment withpharmacyInstructions re: what AD are and where to find theappropriate formsSOCIAL WORK -RELATED TEMPLATESName of Standard screening tool looking for risk factors for unstablehousing and homelessness (from the VA)Use when referring a patient to DOC social worker (use in thetext of an InBasket message to Jan Dillard)Info for patient on how to apply for patient assistance programto get medications sponsoredInfo for patient about how to become his or her own payee ifhe/she currently has a representative payeeLetter documenting a patient’s need for electricity, heating, orPage 10Last revised: 29 June 2016
DOCHOMEVISITREFERRALair conditioningUse when referring patient for a home visit by the DOC teamDOCUMENTATION OUTSIDE A VISITMaestro Care has specific documentation pathways that vary based on whether you are documenting informationduring a patient visit versus outside of a patient visit. The following table highlights the workflow for a fewdifferent types of documentation outside of a patient visit in Maestro Care.Documentation Purpose (whencompleted outside of patient visit)Medication refillDocumenting a phoneconversationEncounter TypeOrdering a referralOrders Only Encounter ORIn Baske
Important Phone Numbers (p pager, m mobile) 5 Copy machines 5 Late Policy for Patients 5 . Physical Therapy 18 Diabetes- and Hypertension-Related Services at the DOC 18 CLINICAL PHARMACY SERVICES 20 Staff 20 Referring Your Patient to the Pharmacist 20 When 20
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