Rheumatology "Nuts & Bolts"
Clinic staff should give you a brief orientation to the clinic when you arrive. When seeing a new consult, first read the consult request in CPRS to see why the patient was referred, and then briefly review the other medical problems, medications, labs, and X-ray reports. To complete the Consult, go to Action/Complete Results tab, then choose Arthritis Consult Report, and follow the template (see also below). As you review the record and see the patient, try to type the relevant data onto the note template, especially the Assessment & Plan, then "Save Without Signature" so you can finish the note later, as there’s rarely enough time during clinic to complete notes between patients. Please do not paste results into your note—these are available elsewhere in CPRS, so just refer and summarize them. During the initial visit you may find it necessary to focus the patient on the problem for which he or she was referred, rather than try to address all of their complaints at one sitting.
Schedule follow-up visits on the Arthritis/Rheumatology Clinic Exit Instructions sheet, and give a specific time interval (e.g. 6 months) rather than a range (e.g. 4-6 months). To avoid overloading the clinic with unnecessary follow-ups we generally don’t bring back patients in a week or so just to discuss results of lab tests or assess treatment response, especially if they live far away. Other than evaluating specific symptoms and signs or performing procedures, most things can be done over the phone, so please make sure patients have an Arthritis Section business card and have them call if they want to talk to us. Document phone conversations with a "Rheumatology/Arthritis Telephone Contact" note, as an addendum to your original note, or if the patient isn't reachable by phone, a "Correspondence" note). Patients with chronic rheumatic disease who are stable usually do not need to be seen more often than 6-12 months. To help the patient remember complex instructions, write them down clearly on the Exit Instructions sheet. Do use the medication reconciliation sheet and note any additions or changes in medications, and document med reconciliation in your note.
Our pharmacist (Chalin Nguyen) is present on Monday afternoon clinics to review medications (particularly new ones) with patients, so whenever you prescribe a new drug, check the appropriate spot on the Exit Instructions sheet to set up a pharmacy session. Chalin Nguyen will also see patients back who have started on new medications, such as allopurinol. Pharmacists are very helpful in titrating allopurinol dosage to achieve a target uric acid under 6.0. If a pharmacist isn't available in clinic please send patients directly to Outpatient Pharmacy to review their meds. Also available in clinic are patient educational materials, arthrocentesis kits, and a microscope for synovial fluid analysis.
ORDERS
You should order all labs, medications, X-rays, and consults in CPRS (try to use the customized Arthritis quick order menu under "Meds by DRUG CLASS/SUPPLIES” or Orders by INDICATION (DISEASE MGMT) "). When ordering lab tests, write down the lab # on the Exit Instructions sheet and give it to the patient to take to the laboratory. To minimize ordering redundant tests, look under "Selected Tests" (specify “All Results” as the default only goes back 6 months) and also check “Remote Data” and/or “VistaWeb” to see if the test has already been done in the past. For X-rays, check "X ray" on the Exit Instructions sheet, and direct the patient to Radiology after you have ordered the exam. Remember, an expensive test such as an MRI may not always be indicated if the result will not change your management (incidentally, when ordering an MRI please also fill out the MRI Worksheet which is under "Orders" & "Seattle Consults"). DEXAs are ordered under "General Radiology".
MEDICATIONS
Review the computerized med list (as it appears on the note template) with the patient to see if it corresponds to what he or she is actually taking and make the appropriate revisions. This is part of a "Medication Reconciliation" protocol required for all patient visits; ask the RN or pharmacist to help you with it. We generally only refill “rheum-related” meds, but for patients who don't have a primary MD yet we may have to refill non-rheum meds until they do. When refilling long-term rheum meds like allopurinol or hydroxychloroquine, order a 90-days’ supply with 3 refills, which should last them the whole year as long as the dose remains stable. Clarify what meds are for (e.g. allopurinol “to prevent gout attacks”, ibuprofen PRN “for joint pain”). When prescribing a trial of a new medication; order at most a 30-days’ supply with a 1-2 refills, in case the new medication does not work or the patient cannot tolerate it. Medication changes should be accompanied by the appropriate revisions in CPRS, e.g. if you switch from one NSAID to another, discontinue the current NSAID, and write "replaces __" in the patient instructions for the second. Keep in mind that some meds should be used cautiously, if at all, in patients with renal insufficiency; these include NSAIDs, methotrexate, and colchicine. We generally try to avoid prescribing narcotics except for patients with severe, refractory pain and low abuse potential; orders for schedule II drugs such as oxycodone, morphine, and methadone must be printed out and signed. When ordering non-formulary drugs; please remember to fill out the NDR (non-formulary drug request) in addition to ordering the drug. Please document adverse drug reactions in CPRS under "Orders" then "Allergies/Adverse Reactions/NKA", and any non-VA meds under "Orders" then "Record Med - non VA".
PROCEDURES
Before performing a joint aspiration and/or injection, please complete an informed consent form using iMedConsent (look under Tools, select iMedConsent, select Rheumatology. Make sure you advise the patient of the low risk of bleeding (unlikely in the absence of coagulopathy), infection (minimized by aseptic technique), or a steroid-induced arthritis flare (which is self-limited). After performing the procedure please document it using the Procedure Note Template. Include in the Procedure Note the following items:
1) Consent
2) Patient and procedure identified via standardized approach
3) Pertinent medical images reviewed by two members of the procedure team, and
4) Time-out conducted immediately prior to the start of the procedure
Also, please order the steroid injection (methylprednisolone suspension, intra-articular) as an outpatient medicine. If you aspirate a joint and look for crystals yourself, document your findings in your note as "preliminary" and add "specimen sent to the lab for confirmation".
For details, refer to the following webpage: http://www.patientsafety.va.gov/professionals/onthejob/surgery.asp
WRITING NOTES
For new patient consults, it is important to complete the consult in CPRS, which then “closes” the consult and alerts the referring provider of the results. When you start a note on a new patient, you will be asked if you want to view pending consults. Click "Yes", and if the patient has a Rheumatology/Arthritis consult pending, select the title "Rheumatology/Arthritis Consult Report" and link it with the consult request by completing the consult, under the “Action” tab. If you have problems linking consult notes to consult requests (or with any other CPRS function) call the helpdesk at x64357. When you complete the consult, a copy of your note will automatically go to the referring provider.
For follow-up patients please use the "Rheumatology/ Arthritis Outpatient Follow-up Visit Note" template. Feel free to modify any template by adding or deleting items as appropriate. All notes need to be completed within 2 work days of the patient visit.
Try to minimize copy and paste: do not paste in information such as lab, x-ray results that are available elsewhere in CPRS, rather synthesize/summarize in your note. Be as clear and specific as possible in your Assessment & Plan (which I think is the most important part of the note), include a differential diagnosis where appropriate, and try to provide a rationale for any recommendations you make (e.g. why you're stopping a med). Remember to document when the patient should return for follow-up if any.
Remember to document in your note the name of the attending that saw the patient with you. If the attending is a visiting consultant (other than Dr. Jernberg), designate Dr. Bach, Kieffer or I as the expected cosigner depending who is in clinic on that day. The names of the visiting rheumatologists are Elizabeth Jernberg, Wayne Tsuji, and Dina Titova.
ENCOUNTER FORMS
The Encounter Form must be completed on the day the patient was seen and clinical notes are to be completed and signed within 24 hours of the visit. When you're about to sign the note, CPRS will ask you whether you're the "primary provider for this encounter". Answer NO, put the supervising attending’s name as the primary, then fill out the electronic Encounter Form to document (1) the type of encounter, i.e. Consultation (initial visit to Rheumatology for a new consult entered by the primary care physician) or Established (follow-up visit), (2) the level of visit; for Consults this is generally Detailed (99243) or Comprehensive Moderate (99244) and for Established patients, it's 99213 or 99214, (please see the specific training module on Evaluation and Management coding http://center.puget-sound.med.va.gov/sites/cprs/default.aspx). Also, be sure to note any procedures performed, and (4) the diagnosis codes (primary rheumatologic conditions and, if applicable, secondary medical conditions).
Do not forget to mark off whether or not the patient's visit is for a service-connected condition (FYI no rheumatologic condition is currently considered to be related to Agent Orange or "MST" i.e. Military Sexual Trauma). Finally, please note the attending physician who supervised the visit—in most cases this will be either Dr. Ng, Dr. Bach or Dr. Kieffer since the visiting rheumatologists will not be listed in CPRS. The RN or attending can help you fill out this form. There will no doubt be other questions that arise during clinic; please do not hesitate to ask.
