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.
- 1 Well Visits
- 2 Sick Visits
- 3 Adolescent Facility Clearance
- 4 Chronic Pain Visits
- 5 Hospital Discharge Follow up
- 6 Orthopedics
- 7 Preoperative Exams Adult
- 8 Pre-operative Exams (Pediatrics)
- 9 Pediatrics
- 10 Women's Health
- 11 Admitting a Patient from Clinic to Inpatient
- 12 Transferring a patient from Clinic to Emergency Dept
- 13 Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac
- 14 Procedures
- 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.
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.
- 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.
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.
- 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 for PE tubes if family agrees. Follow procedure for direct ENT referrals.
- 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.
- 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.
- 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
- 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.
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.
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.
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.
There are Telerad referral papers in each SRC. In Bethel the forms are at the front desk in each clinic. Forms need to be walked to radiology and they will fax form to ANMC along with telerading the films. We are in the process of transitioning to electronic forms for this process so that all will eventually be done via PowerChart/FirstNet and Tiger Connect.
If you need an answer from the orthopedist quickly, you can call ANMC and speak to the orthopedist on call about 30-45 minutes after you send the Telerad. 907-729-1791, fax 907-729-1789.
At the outpatient clinic in Bethel we do casting and splinting. Most reductions are sent to the ER for sedation. We do uncomplicated casting and splinting in the SRCs and some reductions using conscious sedation if able. Otherwise the patient will have to be sent in to Bethel for reduction.
You may send a patient to Bethel for walk-in Physical Therapy, which is a 20 min appt. from 1- 3 pm each afternoon, if you think they would benefit from a short PT appt. Call PT before sending patient to see about availability. If it is a chronic pain patient, or a patient from a village, you should encourage them to make a forty-minute appointment with the physical therapist. Most PT should be done by appointment so the therapist has the full 40 min to evaluate the patient.
Orthopedics and a hand surgeon from ANMC will come to Bethel Specialty Orthopedic Clinic several times a year. Depending on the urgency of the problem, you can refer your patients to our Specialty Clinic or to ANMC.
All internal (i.e., Bethel) orthopedic referrals should go through PT first so that they can evaluate the urgency of the referral and make sure the specialist will have whatever evaluations they need (e.g., orthopedists like to have x-rays within 3 months before seeing the patient). To refer to the Specialty Orthopedic Clinic in Bethel, place order for "Refer to Physical Therapy Internal". Please check first to be sure that a referral has not already been made for the patient. If you have any questions, call PT and discuss the patient with them.
Preoperative Exams Adult
We do a large amount of colonoscopies and EGDs. Our current colon cancer screening starts at age 40.
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.
- 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
- once you have cleared the patient, you can order the colonoscopy prep by searching "Suprep"
- If you have any questions regarding the patient’s condition to have the surgery, please call the Certified Registered Nursing Anesthetists (CRNAs) at 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 able 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.
- 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
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 e.g., bronchiolitis and pneumonia. Kids with wheezing/rhinorrhea, stable respiratory assessment and O2 sats (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 Q4 hours in the village, the child must come to Bethel for evaluation.
Kids with a 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 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.
Each clinic does Women’s Health Care as able, including PAP smears, breast exams, IUD and Nexplanon placements/removal, and endometrial biopsies. There are several case managers who help with women’s health.
We follow the ASCCP guidelines for dealing with abnormal PAPs. There is a great app for it you can put on your smart phone. The current YKHC PAP guideline recommends no PAPs under 21 and then q3 years after that until 30. At 30 years to 65 years of age they need PAPs q5 years as long as there is no history of abnormalities. We now use liquid PAPs. If abnormal PAPs, they are followed in a database by the CDC Breast and Cervical Care Manager.
Any abnormal looking cervixes, endometrial biopsies and skin lesion removals 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 q2 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 will make sure that copies of the mammogram and sonogram go to ANMC for review prior to the patient’s visit.
Admitting a Patient from Clinic to Inpatient
The inpatient unit at YKHC in Bethel is North Wing. If you are seeing a patient you feel needs to be admitted, Tiger Connect the North Wing ward doctor for that village. The clinic clerk can help you determine which provider you should page.
Chronic Pediatric Patients (designated with CPP in the alert section) and complicated non-chronic pediatric patients are admitted to the pediatric service. If you are admitting to Pediatric Service contact the pediatric provider on call and follow the same flow as below.
The ward doctor will need to write the admitting orders once your Clinic Clerk has called registration and gotten an admission FIN (account number). There are different FINs for each encounter, so the Admission encounter FIN will be different from the ED or Ambulatory encounter FIN. The admitting provider may come to clinic or ED immediately to see the patient, but more likely they will ask you about the patient and then the doctor will see the patient on the floor.
Consult 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. Our hospital admissions are mainly large abscesses and/or cellulitises 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.
Patient Admission Flow from Clinic:
- Outpatient Provider to contact Northwing provider 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 or Chronic Peds. 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 # (outpatient nurse to call ER registration x6905, usually 3-5 minutes for them to call back)
- Outpatient nurse or office assistant to Tiger text 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 (include recent vitals, Hx, diagnosis, etc).
- Patient transferred to assigned room on inpatient unit after report given.
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 blue.
Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac
Bethel to Anchorage Medevacs detailed information
- 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 native patient to a non-native facility you will need to obtain approval from contract health at ANMC.
- If patient is 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 patient is 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.
We do many procedures in the Bethel outpatient clinics. All providers must be trained and credentialed to do specific procedures. Providers are granted privileges to do procedures during the credentialing process based on their experience and training.
Common Outpatient Procedures Include:
- Incision and Drainage of Abscess
- Toe Nail Removal
- Joint Injections/ Aspirations
- Skin Biopsy
- Mole / Skin Tag Removal
In order to add privileges for a procedure after initial credentialing, providers should be proctored by a credentialed provider, observed performing the procedure, and the training documented on a proctoring review sheet. These are then scanned to our credentialing specialist who will let the provider know when they can request an increase in privileges for that procedure.
Time Out should be done and documented for most procedures.
Informed consent should be obtained for most procedures, (e.g. IUDs, Nexplanon, LEEP, colposcopy, endometrial, excisional, and punch biopsies). There is a pdf binder file of all consent forms in the YKHC Intranet Document Library, which is accessed only from within YKHC's local network: YKHCintranet.ykhc.org
There are autotexts in RAVEN for many procedures.
- Some are listed as ..ed and include ..edabscdrsg, ..edabsci&d, ..edadultpe.
- Others autotexts are listed as ..proc and include ..prociudkyleena, ..prociudliletta, ..prockneeinjectsynvisc.