Clinic Appointments/Encounters

Below are some encounters that a provider may have on a daily basis.

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

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.

Wheezing

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.

Abscess/ Incision and Drainage

Make sure to obtain a culture if not done so in the ED.
Change packing as indicated. Subsequent packing changes can be done by health aide in the village if stable to go home.

Otitis Media

Review pediatric guidelines for management and treatment.
If patient has had >4 AOM in a 6 month period or chronic effusion for 3 months despite treatment they should have a direct referral to ENT. Follow procedure for direct ENT referrals.

Strep Pharyngitis

Please obtain a POC RST swab and culture at the same time. If RST in negative please send culture to the Bethel lab for culture conformation. 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.
Review chart for recurrent RST. If patient has had at least 4 please refer to ENT for tonsillectomy if parent desires. Follow procedure for ENT direct referrals.

Broken limbs/casting

Review previous radiological images.
Review previous telerad documentation from orthopedic consults. If no previous telerad was sent please send one at this encounter. Please follow procedures for sending Orthopedic Telerad consult.
Continue with plan of care as documented with casting/cast removal.

Septic Joints

Any patient who presents with red, swollen joint with or without fever and unable to bare weight requires further evaluation.
Joint effusions may be tapped in Bethel. Please contact ED physician if you are unable to perform this task in clinic. More complex effusions are evaluated in Anchorage and will require direct orthopedic consultation. Follow procedure for orthopedic consult.
Please send a culture of the fluid and initiate antibiotics promptly.

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.

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.

Admitting a Patient from Clinic to Inpatient

Contact provider on Northwing for admission. Providers are divided into 2 sections: Yukon and Kusko depending on which village the patient is from will determine which provider you page. The clinic clerk can help assist you.
Determine if admitting provider will be seeing the patient in clinic or if patient may be transferred to inpatient unit.
Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN #.
Have nurse or office assistant page the admitting provider with FIN # so orders can be written.
Clinic charge nurse will contact charge nurse on NW for a “ heads up”
Complete your clinic documentation and interventions as needed. Please keep patient and family updates on status of transfer.
Once bed has been assigned, provider on NW completes admission orders; clinic nurse will provide sign out to admitting nurse on Northwing.
Patient will be transferred to the inpatient unit.

Some points to Remember Pediatric patients can be admitted to family medicine or the pediatric service depending on acuity of patient. If you have a child that is not a Chronic Peds Patient (CPP), which you can tell by looking at the Alerts on the banner bar, he or she can be admitted to the Family Medicine Ward doctor. If it is a complicated child and /or is a CPP, the child should be admitted to the Pediatrician on Call doctor. You can always call Peds or the FM Ward Docs if you have a question about whether you should admit the patient.

Talk with the ward doctor about which antibiotics to start fluids etc. so those can be started in the outpatient side and get the admission process initiated more quickly. The types of admissions for our hospital are mainly enlarging abscess and/or cellulitis that have failed outpatient treatment, large lower extremity cellulitis/abscesses that have not yet had outpatient treatment, pneumonia, bronchiolitis, suicidal ideation, COPD exacerbation, fever in a neonate and labor.

Chronic Pediatric Patients (designated with CPP in the alert section) are admitted to the pediatric service. If you are admitting to Pediatric Service contact pediatric provider on call and follow the same flow above.

Transferring a patient from Clinic to Emergency Dept

• Call ED physician to obtain an accepting physician. Inform clinic charge nurse and ED charge nurse of transfer to ER. • Complete clinic documentation with important transfer information. • Nurse will give report to ER and transfer patient to ER when room available. • Always keep parent/patient informed of status of situation • IF you have an emergent patient take them directly to ER trauma bay and call for help. • IF you have an unstable, unresponsive patient in clinic have the clerk call a code.

Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac.

• Contact accepting facility. ANMC/Providence contact appropriate on call service. Once you have obtained an accepting physician initiate transport. Remember if you are transferring a patient to a non native facility you will need to obtain approval from contract health. • If stable contact our travel office and complete a patient transport order form. Have parent sign a consent to transfer patient and discuss risk/benefit. • If unstable initiate transfer via Medevac. See Medevac Section. Patient will need to be transferred to ER until transport arrives. See transfer to ER section. • Complete Raven note / transfer summary with pertinent details. • Obtain all radiological images on disk from radiology department. • Complete Transfer form (PTOS) with all appropriate signatures. • Remind clerk to print out all Raven documents and labs and place in transfer packet. • Always keep patient/caregiver informed of status of situation.

Adult Preoperative Exams

We do a large amount of colonoscopies and EGDs. Our current colon cancer screening starts at age 40. When you see a patient and you want to refer them for a screening colonoscopy or EGD please look at their medical condition, 02 requirements and BMI.

Anyone requiring home 02 or having complicated respiratory issues or a BMI greater than 45 should be referred to ANMC for their procedures. That order would be REFER TO ADULT SURGERY EXTERNAL.

For SRC screenings anyone that is complicated or has a BMI over 40 should be referred to Bethel or ANMC. For Bethel procedures done by a Family Medicine or Surgeon order REFER TO ADULT SURGERY YK INTERNAL.

For patients who specifically request an Anchorage provider here in Bethel, order REFER TO ADULT SURGERY ANMC INTERNAL.

For the pre-op itself, look at the entire patient and do a full physical. We have a detailed Powerplan that lays out what labs and EKGs to order for what patients. If you are in doubt, order a CBC, CMP, HCG POC, EKG on every patient to make sure all the preop screening is done. See below for the name of the power plan – AMB Pre-Op Orders

For documenting the note – please select the OP Primary Care Well or Sick Visit Note type. Then select the Precompleted Note – Pre OP H & P Colonoscopy, as displayed below. Follow the guides and document accordingly. At the end of the note please select the "approved for surgery or not" and sign your note, making sure you have done your medicine reconciliation.

If you have any questions regarding the patient’s condition to have the surgery, call the Certified Registered Nursing Anesthetists – CRNAs. Their phone number is 907-545-4014. It is much better for you to confer with them and decide together the day before a procedure whether or not you think the patient is table to do it. There is no reason to make someone go through the prep and then cancel the procedure the next day. That is just mean.

Pediatric Pre-operative Exams

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

Medication Refills

Medication refills are part of your daily clinic responsibilities. They will arrive in your Message Center in RAVEN. Our pharmacists have a med refill protocol that will allow them to refill meds for 6 months if they meet certain criteria, as well as allow them to order labs in your name for your review. Please review the labs and if able, give 6–11 months of refills. If a controlled med is written for, including Tramadol, Midrin, or any narcotics, you will need to print the prescription and sign it and deliver it to pharmacy. Pharmacy has to have your original signature to dispense any controlled substance.

If someone is on vacation you may be asked to refill meds for patients from their panel. Review the patient's labs and refill them as needed. If they are on a chronic pain agreement please refill them as well. Part of our obligation in doing a pain agreement with a patient is that when that provider is out someone will fulfill their agreement and refill their pain meds. When doing RMTs with the villages, at times they will need a med refill. Order it in RAVEN using the right click over the Medication for refills once you have verified that it is appropriate for them to get the refill.

Sexually Transmitted Disease

We have a very large amount of STDs in the Delta region as well. When someone asks for a STD check, do Urine or Cervical GC/CT, RPR and HIV tests. When doing the urine STD test, it needs to be done with a dirty urine without having to wipe beforehand. Also ask if they are interested in Hepatitis B and C tests as well.

We use Expedited Partner Therapy on anyone who is positive for GC or CT screening. They either come to the hospital or to the village clinic and receive their treatment. Also, they get the number of bags of meds for the number of partners they have. A Partner Notification Sheet needs to be filled out so Public Health knows who was treated. See the attached explanation on how the process works in RAVEN.

===Chronic Pain Visits== link to this new section ===Radio Medical Traffic (RMT)=== link to section ===Chronic Pediatric Patient Appointments=== (link to peds section)