Preparing For and Navigating Clinic
Before starting your day and periodically throughout your clinic day:
- Review clinic schedule with assigned nurse. It is a good idea to review the chart, health summary, Vaccine Registry, radiological/ laboratory studies recently ordered PRIOR to seeing a patient. Another provider or several different providers or health aides may have seen many of our patients before being seen in the clinics in Bethel. This makes reviewing the chart essential to providing quality care. If you do not check the computer you will not know that labs exist. Avoid missing abnormal labs by checking the lab section on all follow up patients.
- Check to make sure that you have appropriately scheduled patients. For example, if you are unable to do a skin biopsy then the patient should be rescheduled with another provider. In general we try to work in any CPP patient that needs to be seen that day. There should be at least two pediatric providers in clinic every day; our access is fairly good. Some patients may be added as overbooks each day; if more time is needed to manage a particularly complicated problem, you may need to reschedule a longer visit for that purpose.
Hospital Discharge Follow ups
Have case manager or nurse obtain records from parent or from discharge facility. For example NICU discharges often come from Providence Medical Center. We do not have direct access to their system like ANMC. Check to make sure patient has appropriate follow up appointments with specialty providers if needed. If patient was started on meds, make sure they have them ordered in our system and refills ordered if needed.
ER Follow ups
Review previous documentation in the chart. Check labs, cultures and radiological images. Check to make sure patient is on appropriate dose of medications if dispensed from ER.
–Patients are often followed in clinic for several days while rooming in at the Hostel. For example, an infant <3 months old requiring IV antibiotics for rule out sepsis workup will often receive several days of outpatient IV Ceftriaxone until cultures have been confirmed negative. Unless a patient requires oxygen, IV fluids, or looks septic they will not be admitted. Patients that would often be an automatic admit in the Lower 48 may be treated as an outpatient in Bethel. Check with more experienced providers, before admitting a patient, until you are familiar with our system. Remember that some simple follow-ups are appropriately handled by the health aide in the village. For example, a patient need not return to Bethel for a pneumonia follow up exam. The health aide in the village can do this. The health aides are a great resource; so remember to use them if appropriate.
Consider having your nurse call in your Bethel patients to be seen earlier that day for village patients arriving later due to weather. If you have no patients to be seen consider pulling level 4/5 patients from the ER. Discuss with your charge nurse prior to pulling patients. ===Hallway Peds Consults===With pediatric providers integration into the family medicine hallways, we have changed the consult system to some extent. Curbside consults on patients being seen that day in the hallway or managed via RMT will usually be directed to the pediatric provider in that hallway. If it is a very complicated situation or will require ongoing management that might get in the way of your clinic schedule, the question can be referred to the hospitalist pediatric provider.
We frequently get dental pre-op patients who need to be examined prior to their procedure that day or the following day. There is a dental pre-op note in RAVEN. The powernote is self directing and needs to be completely filled out. If the child has any high risk medical conditions found on chart review or if the child has had any respiratory illness in the prior 4 weeks, the procedure needs to be canceled and rescheduled. If you decide not to clear the patient for surgery call the OR to let them know to reschedule the patient.
Our dental cases are elective. We are very conservative about only doing procedures on healthy low risk kids. We have CRNA’s that do anesthesia for pediatric cases here. Complicated patients who require an anesthesiologist’s presence are more appropriately managed in Anchorage. One of our jobs in doing preoperative exams is to determine if a patient has any risk factors that make him/her a poor candidate for surgery in Bethel. This includes any respiratory illness in the past four weeks! If the patient has a history of prior respiratory or other disease that has now resolved, please document that assessment. If you are uncertain if a patient is appropriate for surgery in Bethel, please discuss the case directly with the CRNA prior to approving or denying the surgery.
Adolescent McCann Treatment Center (MTC) and Bethel Youth Facility Patients
You will have adolescent patients who come from various facilities such as the McCann Treatment Center (MTC) and Bethel Youth Facility. In general, you should ask the escort why they are being brought in. Often times it is for a monthly physical that is required while they are in the facility. This is a good time to 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 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 you require further information, please contact the respective facility.
Child Advocacy Center Well Child (CAC) follow-up
These "CAC follow up appts" are 60 minute appointments for evaluation of cases of child sexual abuse which are non-acute greater than 96 hours. These patients have been interviewed at the CAC and are presenting for physical exam. Acute exams, less than 96 hours, are completed by a pediatric SANE provider who collects and processes forensic data including photographs with colposcope. See Suspected Prepubescent Child Sexual Abuse Procedure for details on the process.
Otitis media in patients less than 3 months of age
All infants less than 3 months of age that are diagnosed by a CHA to have otitis media should be seen and evaluated in Bethel before being started on any antibiotic.
Follow up appointments should be made with the provider who initially evaluated the patient. If provider is not available, please schedule with another pediatrician with appropriate sign out. Please update the problem lists.