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Head TS Post Clinic Duties

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1) Update the TS Referrals Spreadsheet with all new referrals by Sunday night

  • During sign out, make a list of all new referrals.
  • Check the EHHapp to make sure a referral is not curbsided. If it is curbsided, email the Chief TS for further instructions.
  • You must confirm with the clinical team that the order was placed and signed (check the “Amb Referrals,” "Consults," "Procedure," or "Imaging" tab in Chart Review in Epic)
  • If the order was not placed/signed, the Head TS must do this and pend to an attending for signature
  • For all previous referrals that you want to ask ACT to follow-up on, please make sure that it is not more than 3 months old. If it is, it will have to be replaced with a new order.
  • List all new referrals to specialists outside of EHHOP in the Referrals Spreadsheet under the TS Referral Request tab(completing each field name, MRN, type of referral, indication/one-liner, urgency, and restrictions/misc notes).
  • For MHC referrals, please use the Google Form under the "TS" section of the EHHOP MHC Referrals Page.
  • For all other ancillary clinic referrals (WHC, EHHOPhtho, EHHOP Podiatry, EHHOP Cardiology), please list the referrals in the Ancillary Clinic Referrals Spreadsheet under the appropriate tab.
  • Nutrition does not require a referral. Just ask the CMs to schedule the patient for any nutrition appointment.

2) Email Pharmacy Chair with all PDAP Rx by Sunday night

  • Confirm with the Pharmacy Chair (Ben Shuham) what the patient needs to bring to the next visit (proof of income documentation, check if the application requires a fee) and please note in your sign-out. If the pt is returning to drop this information off, please ask CMs to make a note in Cerner as to what they need to be reminded to bring.
  • See below (3: Pharmacy Protocol) about information clinic team needs to collect from patient prior to PDAP
  • Add PDAP-ed medication to Current Medications List, with a note “PDAP.”

3) Begin Pharmacy Protocol for Non-Formulary or Blacklisted Rx

  • Teaching seniors must make sure every medication prescribed or refilled by the clinical team is on the formulary list. (check the “Medications” tab in Chart Review in Epic)
  • If an off-formulary medication is needed, you must ask clinical team to sign out the following information:
  • At the end of the clinic day, email the Pharmacy Chair with this information and he/she will handle from there (i.e. check with Sinai pharmacy about price, if too expensive initiate PDAP).

4) Notify the Chief TS about long-term patient care issues

Tell them about potential chronic care patients, City Health Works patients, or any problems during the day.

5) Follow up on labs

  • Should be checked at the latest by Sunday at noon, with additional follow up for labs that take time to result (e.g., A1c, Pap smear, GC/CT).
  • Note: If lab results are not appearing in your Epic In Basket, follow the instructions just below this list.
  • For abnormal results that are critical (i.e. high K, glucose > 300 w/ gap, Hgb < 8 and pt symptomatic) — email Dr. Thomas and Meah with the subject line URGENT, or call one of them! CC the Chief TS.
  • For abnormal results that are not critical: log the result and your plan (in Epic!). A quick way to do this is the Result Note (in the Results folder). You can type a quick note about the labs and route it to Dr. Meah, the Attending of the day, the Chief TS and the clinical team
  • Contact the CMs if pt needs to be brought back to clinic for an add'l Labs Only or Clinic visit AND include an Addendum to TS the Note in Epic (see instructions below)
  • Pend any additional follow-up Labs in Epic
  • Call patients to discuss any abnormal results, or any results that they may have requested
  • Usually we only call patients with abnormal results and/or if there is a change in plan because of the lab results
  • It is good to let patients know that if they don’t hear from us that everything was okay
  • We do not call for normal Pap results, but you can ask patients if they want to know — and call them if they say yes.

Finding Disappearing Lab Results

If you are unable to see lab results in your Epic In Basket under the Results tab it is likely that the "Done" button was clicked for that result by someone else in the pool. You still need to review and write result notes on these results. To find the missing results:

  • Open your Epic In Basket and go to the Results tab
  • Click Search on the bar directly above the display window
  • When the search window opens all options should be checked. Under Message Types, uncheck all options except Results. Leave all other boxes checked under the other headings.
  • Under Date Message Received change the date range to (the Saturday of clinic - the current date).
  • Click Search
  • You should now see the results of all labs that were completed on clinic day
  • You may document result notes on these by clicking Result Note on the bar above the display window

6) Complete the TS sign out (Plan of Care notes)

This is due by Sunday night at the latest. You can add addendums as needed for add'l labs. If the Senior Clinician has NOT yet written his/her note, please e-mail them a reminder Sunday afternoon! There are two ways to do this, depending on whether or not the Attending has closed the chart (this is also explained in the sign-out protocol)

If the Attending has closed the chart

  • You must create an Addendum: Click on the Epic drop down tab on the top left corner of the screen
  • Select Patient Care → Addendum → then enter the MRN of the patient
  • Select today’s Office Visit and select “Accept”
  • You are now back in Visit Navigator, so click on EHHOP TS Sign-out to find your preliminary sign-out
  • Update the sign-out with results and other notes
  • Click on Follow-up and under “Send Chart Upon Closing Section,” add the clinician team and Chief TS so that you can route the chart to them

If the Attending has NOT closed the chart

  • Go back to Schedule and open the patient’s still open chart
  • This takes you back to Visit Navigator, click on EHHOP TS Sign-out to find your preliminary sign-out
  • Update the sign-out with results and other notes
  • Click on Follow-up and under “Send Chart Upon Closing Section,” add the clinician team and Chief TS so that you can route the chart to them
  • The attending will not be able to close the chart if you do not close your “Plan of Care” note! To close it, when you access your note from the visit navigator, use the drop-down box to change from “sign on close encounter” –> “sign on accept” or “sign on close.”

How to route your TS Note

In addition to co-signing to the Attending of the day, you should route your notes to the Chief TS and the clinician team, e.g. Senior Clinician. If it is a complicated case, where you will need Dr. Meah’s input, route it to Dr. Meah as well!

The easiest way to route your TS note is to use the "Follow-Up" section of the Visit Navigator, wherein you can list people under "Send Chart Upon Closing Section."

For complicated patients or questions with management that are not settled by Sunday night

  • Email Dr. Meah and Dr. Thomas with the Chief TS CC'ed.
  • For each pt (initials and MRN), summarize the key points, your plan, and your question. If needed, pend prescriptions to a Telephone Encounter or the last office visit.
  • If the plans require 1) new Rxs, 2) significant communication with the patient, you must log a telephone encounter after communicating with the patient. Otherwise, just addend your TS note to say that the patient was notified of the plan.

7) Email Teams

  • Include relevant labs
  • Questions appropriate for Senior Clinicians and Junior Clinicians

8) Fixing Things

A special note on your responsibilities as Head TS. You are responsible for the medical care of the patients who are at Clinic for the week that you are scheduled. It is your responsibility to follow up with things that were done incorrectly that pertain to the clinical care. This includes fixing referrals, ordering labs, and coordinating with CMs to make followup appointments based on results. You may also have to contact patients to discuss their labs with them. You have the option of using the student clinicians for this, but at the end of the day it is your responsibility!

9) Help reschedule canceled/no-show patients

Go back to the Call Sheet for the week and write in your recommendations for the CMs as to when to reschedule no-shows from your clinic day. This is found under the "Rescheduled/No Shows" tab at the bottom. You can be general with this (i.e. needs to be seen next week, or can wait 2-3 months, etc.) or else put in specific dates for the CMs. Review the sign-in for the patient(s) and triage them based on their acuity. Because the CMs will be calling on Monday to reschedule these patients, this should be done by Sunday night

10) Sign out follow-ups to next TS by Wednesday

  • Email the next week’s TSs with the Chief TS CC'ed on Wednesday
  • Include any outstanding issues with patients
  • Include any issues to look out for at the next clinic