Clinic Appointments/Encounters

INTRODUCTION

As a regional medical center, we have limited specialist access in house. Thus, as general outpatient providers, we evaluate and manage many different chronic and acute medical problems that would usually be seen by a specialist. With our extensive network of specialists, we are able to coordinate management for these more specialized issues. Some of these specialties include orthopedics, pediatrics, and women's health.

During appointments in outpatient clinics, providers are expected to complete both sick and well visit encounters. Descriptions and helpful hints for some of our more common visits are below.

Well Visits

• Review patient paper chart as well as RAVEN for past medical and surgical history, recent hospitalizations and recent illnesses documented on RMT. Review current medications.
• Document Physical Exam and relevant forms patient may require.
• Apply Fluoride varnish to teeth if indicated. Fluorides as well as instructions are located in physician consult room.
• Give pediatric patients a reach out and read book at appropriate ages. The books are located in the physician consult room
• Adult / Adolescent patients - Remember to complete SBIRT (ages 14-20) and Behavioral Health Assessment Form for ages 12-20. Make appropriate referrals as needed. Consult IMPACT if needed.
• Sports Physical - Make sure parent has completed history on hard copy form. Document physical exam on form. Make a photocopy and give parent the original form. Make sure a copy of the form is scanned into RAVEN. Please make sure to check for hernia on exam if not previously documented.

Many programs require a PPD to be placed and reported before patient can start school. Please make sure this is documented in RAVEN.

Sick Visits

Head Injury/Concussions

ASAA Healthcare Provider Release and Return to Play Protocol

• see the Head Injury/Concussions YKHC Wiki Page and Head Injury/Concussion (<18 years) YKHC Clinical Guideline for more details

ER Rechecks

Review the ER notes and assessment and plan. Check labs, cultures and radiological images. Check to make sure patient is on appropriate dose of medications if dispensed from ER. If patient requires IV medications make sure they are ordered promptly as they come from inpatient pharmacy. If patient needs to stay an additional night in Bethel please provide them with a note for travel.

Otitis Media, Acute

• Review the Otitis Media YKHC wiki page and Otitis Media, Acute (3 months to 12 years) YKHC Clinical Guideline for more details.

Strep Pharyngitis

• Please obtain a POC RST swab and culture at the same time. If RST is negative, please send culture to the Bethel lab for culture confirmation. The ordering provider must follow the culture since they will return to your box only. If you do a culture on a Friday, please make sure you have a proxy to follow up if you are a locums provider. You have 10 days to treat the patient before complications of rheumatic heart disease ensues.
• We do not screen children < 3 y/o routinely.
• see the Pharyngitis (Adults and Pediatrics) (Group A Strep) YKHC Clinical Guideline for more details
• Review chart for recurrent RST. If patient meets Diagnostic Criteria and parent desires, refer to ENT for tonsillectomy. (see the Strep Pharyngitis YKHC Wiki Page for more details)

Bronchiolitis/Wheezing

• see the Bronchiolitis/Wheezing YKHC Wiki Page and Bronchiolitis/Wheezing (3-24 months) YKHC Clinical Guideline for more details
• Review oxygen saturations with the nurse as well as respiratory status.
• Administer albuterol / ipratropium nebs as indicated. Monitor vitals more frequently.
• Obtain RSV and flu swabs during respiratory season for age appropriate patients.
• If patient requires a nebulizer for home they can be dispensed by respiratory therapy. Complete necessary forms and page respiratory therapy to bring a nebulizer to clinic.
• If pediatric patient refer to pediatrician for follow up evaluation.

Adolescent Facility Clearance

You will have adolescent patients who come from various facilities such as the McCann Treatment Center (MTC) and Bethel Youth Facility.

• Ask the escort why they are being brought in. Often times it is for a physical that is required while they are presenting to the facility. It can also be for acute injuries or illness
• Address any medical concerns, refill chronic meds, update immunizations etc.
• The initial exam for patients first entering the MTC needs to include an EKG, a CBC, and a comprehensive metabolic panel as these patients are at risk for anemia, hepatotoxicity, and prolonged QT. These studies need not be repeated after the initial exam unless an abnormality is detected.
• All YKHC residential facilities require a completed medication reconciliation form and a copy of the exam with any recommendations at the time of the visit – please complete your note and send a copy with the escort if the facility is unable to view in RAVEN.
• If you require further information, please contact the respective facility.

Chronic Pain Visits

We do have some chronic pain patients, but not as many as other facilities. An interdisciplinary team, including providers with extra training in chronic pain management and pharmacists, has been developed to help manage the care of these patients. For more details about the care of these patients in Bethel, please follow the link above.

• see the Chronic Pain YKHC Wiki Page and Chronic Pain YKHC Clinical Protocol for more details.

Hospital Discharge Follow up

• Review hospital discharge summary in RAVEN. If patient was discharged from an outside facility check RAVEN multimedia section. Contact case manager to obtain discharge summary documentation if not located in two previous locations.
• Review medications with patient and discontinue appropriate medications in RAVEN. Please provide patient with adequate refills until subsequent follow up appointments. Remember to discontinue medications, which are no longer prescribed.
• Draw appropriate follow up labs if needed.
• If patient requires ongoing pain medication or pain contract please document accordingly following Chronic Pain Patient guidelines.

Orthopedics

We see a large amount of orthopedic medicine. X-rays that you are concerned about or any fractures should be sent via Telerad to the orthopedic surgeon at the ANMC and they will get back to you usually in 1-2 hours.

See the Teleradiology section on the Imaging Services page for more details about how to send a Telerad.

When a patient is scheduled for orthopedic surgery, the ANMC orthopedic case management team should forward the ortho note to the provider who is scheduled to complete a pre-op exam. Pre-op physicals prior to orthopedic procedures are good for 6 months.

Preoperative Exams Adult

We do a large amount of colonoscopies and EGDs. There is high incidence of colon cancer in the Native Alaska population, so patients are screened starting at age 40 or 10 years before the age at diagnosis of a first degree relative (if a mother was diagnosed at age 44, the child will be screened at age 34). YKHC will only perform colonoscopies on non-complicated patients. Patients with oxygen dependence, complicated respiratory issues, or a BMI greater than 45 must be referred to ANMC.

For all pre-op appointments

• please look at the entire patient chart and do a full physical
• We have a detailed AMB Pre-op Orders PowerPlan that lays out what labs and EKGs to order for what patients
• For adult patients, if you are in doubt, order a CBC, CMP, HCG POC, EKG on every patient to make sure all the pre-op screening is done.
• The medicine reconciliation should be completed.

Documentation

• For documenting the note, please select the OP Preop H & P.
• Several public autotext are available and can be found by typing ..surg
• At the end of the note please indicate the Cleared for Surgery/Not Cleared for Surgery status
• Make sure to complete the medication reconciliation

Colonoscopy pre-ops

• At the end of the visit, decide the risk stratification for surgery. If the risk stratification is low, you can order the colonoscopy prep by searching Suprep.
• If you have any questions regarding the patient’s condition to have the surgery, contact the Certified Registered Nursing Anesthetists (CRNAs) on call. It is much better for you to decide if the patient is ok to undergo the procedure the day before. There is no reason to make someone go through the prep and then cancel the procedure the next day.

• Reasons to refer to ANMC
  • Anyone requiring home O2
  • patients having complicated respiratory issues
  • BMI greater than 45
  • (see instructions for referrals).

Pre-operative Exams (Pediatrics)

• Only pediatricians and pediatric providers do pediatric pre-ops/pre-dental procedure exams. See Pediatrician Clinics Section for details

Pediatrics

We have a pediatrician on call every day for the inpatient pediatric patients and for consults. You can also use the pediatricians in the clinics for simple questions.

Children 90 days and under who have a fever 100.4 or higher, or any source of infection, such as otitis media or pneumonia need to be seen by the ED for a septic work up. We do not give antibiotics to children under 90 days without having them evaluated in Bethel. Have the infant sent to Bethel emergency room for evaluation.

There is quite a bit of respiratory illness in the Delta like bronchiolitis and pneumonia. Kids with wheezing/rhinorrhea, stable respiratory assessment and oxygen saturations (probable bronchiolitis) can be given albuterol nebs in the village and followed closely. We do not routinely give steroids for a first visit of bronchiolitis. If you are giving nebulizers more than every four hours in the village, the child must come to Bethel for evaluation.

Kids with a catheter proven UTI need treatment for their UTI once the culture results are back. If the patient is stable they will not get antibiotics until the culture results are back. See the YKHC Pediatric Clinical Guidelines.

See the YKHC Clinical Guidelines for greater detail concerning common pediatric problems and recommendations for management at YKHC.

Chronic Pediatric Patients are pediatric patients that have complex medical problems or require significant care coordination. These patients are usually scheduled with a pediatrician; however, they occasionally are scheduled with family medicine providers. If you are seeing a chronic pediatric patient or a child that you think should be chronic peds, please discuss management with a pediatrician.

If you are seeing a child with concern for Developmental Delay, please see the Pediatric Developmental Delay Section for more details.

Women's Health

See the Women's Health Main Page for more details

All family medicine provider can do Women’s Health Care, but we also have dedicated Women’s Health Providers. A Nurse Practitioner or Physician Assistant must have special training and proctoring to insert and/or remove IUDs and Nexplanon. There are several Women’s Health case managers.

We follow the ASCCP guidelines for dealing with abnormal Pap smears, and there is an app you can put on your smart phone. The current YKHC Pap guideline recommends no PAPs under 21. Women ages 21 -30 should have a Pap every three years. At 30 years to 65 years of age, women need a Pap every 5 years as long as here is no history of abnormalities. If there is an abnormal Pap, the patient isfollowed in a database by the CDC Breast and Cervical Care Manager.

Any abnormal looking cervixes, the need for an endometrial biopsies, or a skin lesion in the perineum that you feel need further work up can be referred to Women’s Health in Bethel. Feel free to contact the Gynecology Case Manager for that @ 543-6557.

Mammograms can begin at age 40, but our current YKHC guideline is to start at age 45 and do them every two years. If you have a patient with an abnormal breast exam, send her to Bethel for a mammogram and a breast ultrasound. Both must be done prior to the surgeon seeing them. You need to clearly document where the mass is. If she is under 40, they will only do a sonogram. If she is over 40, they will do both a sonogram/mammogram.

For all referrals to ANMC surgery, whether to see the general surgeon in Bethel Specialty Clinic and/or a surgeon in ANMC, you will need to have a phone consult with an ANMC surgeon and this should be documented on the specialty referral form. The WH Grant Case Manager (see below) will make sure that copies of the mammogram and sonogram go to ANMC for review prior to the patient’s visit.

Outpatient Main Page