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APPENDIX Q – VAPAHCS ENT RESIDENT HANDBOOK 2021-2022
Appendix Q – VAPAHCS ENT Resident Handbook 2021-2022
VA PALO ALTO HEALTHCARE SYSTEM ENT Clinic Resident Handbook - 2021-2022
Contents
MUST HAVE INFORMATION ...................................................... 3 Rotation Contacts and Scheduling Details ................................. 3 Checklist PRIOR to your VA rotation: ....................................... 4 PIV Badges (personal identification verification), IE= VA Badge .......... 4 Computer Login Codes and Password ........................................ 4 ENT Office Keys........................................................... 5 Important Contacts: ...................................................... 5 Administrative Support (aka: ADPAC/PSA/Admin.) ........................... 5 CPRS helpline 650-493-5000 (dial 1, 1, then extension) ................. 5 Ordering controlled substances ........................................... 5 ENT Nursing Staff and Administrative Staff ................................. 6 SCHEDULING DETAILS ......................................................... 7 Clinic and OR Schedule ................................................... 7 H&N Tumor Board/Radiology Rounds ........................................... 9 ED/Consult Calls ........................................................... 9 SURGICAL PROTOCOLS & SCHEDULING ........................................... 10 OR Attire Guidelines .................................................... 10 OR Scheduling Procedure ................................................. 10 Admitting Floors ....................................................... 11 ENT Outlook Calendar .................................................... 12 Adding patient to Outlook OR Calendar ................................. 12 Outlook OR Calendar Color Legend....................................... 12 Surgical Equipment Requests and Locations ............................... 13 Surgical Algorithms ..................................................... 13 VA DOCUMENTATION DETAILS .................................................. 14 Notes .................................................................... 14 Encounters ............................................................... 15 The six most important things you need to know about encounters: ...... 15
Computer Programs ....................................................... 16 CPRS (Computerized Patient Record System) ............................. 16 o Set-up Clinic List ................................................. 16 o Set-Up ENT Note Templates .......................................... 16 VISTA Imaging Display .................................................. 17 Report or Result look-up: .............................................. 17 iMed Consent .............................................................. 17 Missing consents for procedure reminder ................................... 17 Adjuvant consults ......................................................... 18 Non-VA Consult Contacts ................................................. 19 Return to Clinic Order .................................................. 21 Dictation ................................................................. 21 DICTATION KEYPAD FUNCTIONS .............................................. 22 Coding .................................................................... 23 MRSA Procedures ........................................................... 24 CODE X - System for bleeding emergencies .................................. 24 OTHER HELPFUL COMPUTER INFO ............................................... 25 Remote Access Set-Up .................................................... 25 Printer Set-up........................................................... 26 VETERAN SUPPORT ........................................................... 27 Case Manager/Social Worker .............................................. 27 Housing & Transportation ................................................ 27 Defender’s Lodge ....................................................... 27 Fischer House .......................................................... 27 Shuttle Bus ............................................................ 27 First Day Checklist ....................................................... 28 End of Residency Checkout list ............................................ 28 VA PALO ALTO ENT CONTACT LIST ............................................. 29
MUST HAVE INFORMATION
Rotation Contacts and Scheduling Details
Rotation Director: Davud Sirjani, MD, dsirjani@stanford.edu, 314-537-0242 (cell) (back up cell if it’s an emergency and he’s not picking up his cell: 314-680-5155)
Attendings who need Resident clinic coverage:
o Fred Baik: fbaik@stanford.edu o Jayakar Nayak: jnayak@stanford.edu o Hamed Sajjadi: hsajjadi@stanford.edu
o
Davud Sirjani: dsirjani@stanford.edu, o Chih-Kwang Sung: kwangs@stanford.edu
Private Attendings- residents do not cover:
• Bohdan Makarewycz: bohdan.makarewycz@va.gov Fellows- do not need Resident clinic coverage: Facial-Plastics –• Sarah Akkina:
Important ENT Contacts: Main # 650-493-5000 (dial 1 1 ext#) Location: PAD, Bldg 100, 2nd Floor ENT Clinic. Mailstop code 112ENT
ENT fax number: (650) 496-2502. If you need to send a fax, you can • Use the Xerox machine (will need to use your PIV card) • OR send from your computer if you already have an ecopy. If you do not have an ecopy, you can scan a copy using the Xerox machine. The link to efax is https://vhapalfaxrfax01/webutil/ Administrators: ENT Admin. email: v21palentadminpaloalto@va.gov Erik Nielsen: ext. 63202, erik.nielsen1@va.gov Maria Tham: ext. 66912, Maria.Tham@va.gov Surgical Onboarding Team: vhapalsuronboarding@va.gov
Charge Nurse: Ella Benadam-Lenrow: ext. 64047 Ella.Benadam-Lenrow@va.gov LVN: Crystal Vo: ext. 64046 Crystal.Vo@va.gov
Additional Required Conferences
Wednesday (non-op weeks) H&N Care coordination/Rad Rounds 8:30-9:30am. Clinic starts promptly at 9am and 1pm Please complete inpatient rounds and workload prior to start of clinic You must leave clinic by 3:30pm on Thursdays to attend Res Ed. All documentation must be done accurately and in a timely fashion (within 24 hours) Please see PAVAPGY3andPGY5.pdf for details on specific rotation goals and objectives.
RNP: Annie Yuan: ext. 65203 Annie.Yuan@va.gov PA-C: Leslie Chan: ext. 65535 Leslie.Chan@va.gov RN: TBD: ext. 66945
Clinic rules and expectations
VA Checklist before you start
Checklist PRIOR to your VA rotation: Otherwise you will not be able to start
Check expiration date 1 month prior to start date o If expired, email the VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. You will need to re-do the entire registration process (i.e., fingerprinting, background check, be sponsored, make appointment with HR to get new badge, etc.)
o o Fingerprints are valid for 120 days. If you have lost your badge, please contact your ENT Admin. for assistance. You will need to complete a VA Police Report before you can be sponsored for a replacement badge.
o To be sponsored, you need to contact an ADPAC and your ENT Admin. can help you with this.
o
To make an HR appointment, go to www.va-piv.com PIV Badge PIN number o If you do not have a 6-digit PIN number associated with your PIV badge, or if you have forgotten it, contact any ENT Admin. ASAP. They can reset the pin for you.
o
PIN # is REQUIRED in order to prescribe narcotics (see below). Surgical Service has numerous pin re-setters who can reset your pin. Listed below are some names: Erik Nielsen: (650-493-5000, Ext. 63202, Email: Erik.Nielsen1@va.gov Maria Tham: (650 495-5000, Ext. 66912, Email: Maria.Tham@va.gov Carol Stine: (650) 858-3917, Ext. 63917, Email: Carol.Stine2@va.gov Or write to VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. and someone will get back to you.
Computer Login Codes and Password
You can use your PIV card to log into the VA computer. You, as providers, also have a Windows login name- you need this to login to any computer. This starts with vhapal + part of your name. You must set up a 14-character password. o FYI. ENCRYPTION for VA EMAILS is through the use of your VA PIV card. If you have any issues with encryption, please contact any of the ENT Admins.
o
ENCRYPTION with Stanford email. Feel free to send encrypted emails using your Stanford email. CPRS- VA version of electronic medical records o These (known as Verify and Access codes) were given to you when you received your badge Password MUST be updated EVERY 90 days. DO NOT LET YOUR PASSWORD EXPIRE.
If you link your CPRS to your PIV badge, you can access CPRS with your PIV badge.
Please note that your VA accounts will automatically be discontinued if you do NOT use them for 180 days. If this does happen, contact ANY ENT Admin. ASAP. EXPECT a 48-hour – 10 business days delay in workflow as a request must be submitted through the Office of Information & Technology
TIP! You can update password via remote access! https://citrixaccess.va.gov o Contact ENT Admin. for more information on how to get remote access.
DICTATION CODE- to dictate Op-Reports o If you do not have one or forgot your code, contact: Ken Streibel or Ann Struck: ext. 64648 or ann.struck@va.gov TMS: When you were first boarded, you completed a couple of TMS classes that were assigned to you. Please note that the Privacy TMS course MUST be completed ANNUALLY. This course is VERY IMPORTANT to complete. If you do not, your NETWORK ACCESS WILL BE PROMPTLY AND AUTOMATICALLY discontinued on the due date! Once you lose your access it may take up to 24 hours to restore your access after you complete the Privacy TMS. DO NOT LET THIS HAPPEN.
ENT Office Keys
If you don’t have one, please contact any of the ENT Admin. ahead of time (it can take up to 2 months to get new keys). Please return all keys at the end of your residency. If you give your key to another
Resident (should not do so as each key is tracked to the person the key was originally assigned to),
please inform an admin. If you lose a key, there is a fine by the VA to get a replacement key.
Important Contacts: Administrative Support (aka: ADPAC/PSA/Admin.)
- BEST METHOD is to send an email to the ENT group Admin. email alias: v21palentadminpaloalto@va.gov Everyone listed below are in above mentioned group alias. So you do not need to send individual emails.
- Erik Nielsen o (650) 493-5000 ext. 63202, ENT Direct line: 650-849-0264
o
Email: erik.nielsen1@va.gov Maria Tham o (650) 493-5000 ext. 66912, ENT Direct line: 650-849-0264
o
Email:Maria.Tham@va.gov Backup contact personnel o Write to VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. and someone will get back to you.
CPRS helpline 650-493-5000 (dial 1, 1, then extension)
Business hours (8:00AM – 4:30PM Monday - Friday): ext. 62777 After hours: o o You can contact the AOD (ext. 60462 or ER Clerks (ext. 65470) OR for IT related issues, call Help Desk (ext. 64767) or 1-855-673-4357
Ordering controlled substances
You must use your PIV card and PIN to enter prescriptions for controlled substances (schedule 2-5). If you are unable to order controlled substance, please contact any of the ENT Admin. They can check to make sure that your access in CPRS is enabled. If there is a problem with the ePCS program affecting the ordering of outpatient prescriptions, choose from one of the contingency plan options:
Urgently needed controlled substances (C2-5) may be handwritten on form 10-2577f and turned into the Outpatient Pharmacy for immediate filling. Outpatient Pharmacy is located in Bldg 100, 1st Floor, Room E1-100. The hours are M – F: 9AM -7PM; Weekends and Holidays: 9AM -1PM & 1:30 – 5:30PM. If you do not have your own prescription pad, you can sign one out from the Outpatient Pharmacy. You can wait to enter all other controlled substance orders (for subsequent day pick up or mail) until the system is functioning.
ENT Nursing Staff and Administrative Staff
Ella Benadam-Lenrow (Charge Nurse) and Crystal Vo (LVN) o Contacts: Ella (ext. 64047), Ella.Benadam-Lenrow@va.gov Crystal (ext. 64046), Crystal.Vo@va.gov ENT RN - TBD
o Information to ask: Urgent/Specific ENT or OSS appointment scheduling Post-op follow-ups or ED consult follow up scheduling Post-op/Clinic visits/Consult planning Defender’s Lodge consult needs to be made Location of ENT supplies How to setup CPRS Patient who need imaging appointments or numbers
Leslie Chan, PA o Contact: (ext. 65535), leslie.chan@va.gov o o o o Will manage all NON- Cancer cases for Dr. Nayak, Dr. Sajjadi, Dr. Sung Staffs Dr. Nayak’s, Dr. Sung’s, and Dr. Sajjadi’s clinics Prepare Navigation CD for sinus cases Non-Cancer patients: pathology/imaging follow-ups, medical clearances Annie Yuan (RNP) o Contact: (ext. 65203), Pager 11671, Annie.Yuan@va.gov o Manages all Cancer cases for Dr. Baik, Dr. Sirjani, Dr. Sung
o o Staffs Dr. Baik and Dr. Sirjani’s clinic and NP Clinics (Op-Wed, Fridays) Cancer patients: pathology/imaging follow-ups, medical clearances
o
Coordinate TB patients Administrative Staff: Erik Nielsen (or ENT Admin. Maria etc) o Contacts: write to v21palentadminpaloalto@va.gov
o Enters all OR Cases in VISTA
o o o o o Should be alerted when ANY changes are made to OR schedule Call-schedule Schedules ENT Preop/OSS appointments Submits Pink Slips to OR Information to ask How to setup CPRS templates Patient who need imaging numbers
SCHEDULING DETAILS
Clinic and OR Schedule
Time AM 0800-1200
Monday- 8:30am
Minor Proc: PGY 3>5 Baik Clinic: PGY 5>3, NP FP clinic Sirjani Clinic: PGY 3, 5, NP
Tumor Board (8:30-9:30am) Nayak Clinic (9:00): PGY 3, 5, PA
**OR- Sajjadi: PGY 3 or 5 Sung Minor Procedures: PGY 3 or 5, PA **OR- Baik/Sirjani PGY3,5
PM 1200-1700
Baik Clinic: PGY 3,5, NP FP Clinic Sirjani Clinic: PGY 3, 5, NP,
R
Nayak Clinic: PGY 3, 5, R, PA
OR- Sung PGY 3 or 5 Sajjadi Clinic: PGY 3 or 5, R, PA **OR- Baik/Sirjani PGY 3, 5
NON-OPERATIVE WEEK (starting 7/1/21) Tuesday- 8:30am Wednesday- 8:30am Thursday- 7am
R: Research Resident **1 resident to scrub out for pre-ops OPERATIVE WEEK (starting 7/8/21)
Time Monday -8am Tuesday- 8:30am Wednesday- 7am
AM 0800-1200
OR- FP: PGY 3 or 5
Baik Clinic: PGY 3 or 5, NP Sirjani Clinic: PGY 3, 5, NP Tumor Board (8:30— 9:30am) OR- Nayak: PGY 3, 5 0900 Sung Clinic: R, PA **OR- Sajjadi: PGY 3 or 5
Sung Clinic/Minor Procedures: PGY 3 or 5, PA
PM 1200-1700
OR- FP: PGY 3 or 5
Baik Clinic: PGY 3 or 5, NP Sirjani Clinic: PGY 3, 5, R, NP OR- Nayak PGY 3, 5 Sung Clinic: R, PA
OR- Sung PGY 3 of 5 Sajjadi Clinic- JS, PGY3 or 5, R, PA
Thursday- 7am
R: Research Resident **1 resident to scrub out for pre-ops Friday- 7am
RNP clinic (AY)
Friday- 7am **2 ORs- Baik/Sirjani APP clinic (LC)
**2 ORs- Baik/Sirjani
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Additional Notes: • Monday OPERATIVE WEEK: check-in patient at 8AM, case starts at 9AM • All other OPERATIVE WEEK: check-in patient in at 7AM, case starts at 8AM • ALL PATIENTS: Surgical site MUST be marked, even bilateral or midline cases need a wrist band stating the procedure to be done.
RESEARCH RESIDENT (R: RESEARCH RESIDENT)
• If clinic needs extra-help from Research resident, please give those dates in advance. o Per Messner, Research Resident must have at least 2.5 days of research time per week on average. • During PGY3 or PGY5’s vacation/conference/interview period, Research resident usually works as full time • Check to see if help is needed for Monday procedures in Baik clinic the week before.
Page 8 of 30
H&N Tumor Board/Radiology Rounds
• When: Wednesday Every week: Virtual on Teams 8:30-9:00am • Annie will manage the list
ED/Consult Calls
•
ENT covers facial trauma (including TMJ) on EVEN months o ENT for Even months o Plastics on Odd months • Staffing: o Day consults staffed with attending who is in-house that day o Night consults staffed with on-call attending
•
Ask the person to place “consult to ENT” for us to write a consult note • Rehab/TBI/Spinal cord unit consults: do not delay or ignore the consults. YOU MUST SEE THOSE
CONSULTS NO MATTER WHAT! Please be courteous. • Dental: Vet is only eligible if: 1- it is an emergency, 2- if treatment is related to H&N Cancer, or 3- 100% service connected o o H&N Cancer related- place consult under “Dental Adjunct Medical Need Outpatient”. Dental DOES NOT provide dentures or prosthetics. This is all out of pocket for the patient. EVEN if the defect is related to H&N cancer or our surgery. Dental will only do the BARE minimum to get them ready for XRT or surgery. They extract teeth but do not replace. Please make sure the
patients know this ahead of time.
• Usually patient can come to clinic if they are safe to transfer to clinic • For Night Consult ENT Resident: Please do not tell ED that Patient should come to ENT clinic at 8 or
9AM next day. Sometimes there is no clinic especially if it is an Operation week (Two ORs going at the
same time on Friday). If patient needs to be seen urgently in the clinic at night, get the phone number of the patient and tell the ED that our clinic will contact the patient next morning and will see the patient next day (AM or PM). And please send the email to the VA ENT team (v21palentadminpaloalto@va.gov) and our Clinic nurses; Ella and Crystal. Ella.Benadam-
Lenrow@va.gov or Crystal.Vo@va.gov
OR Attire Guidelines
Please note the following regarding Operating Room attire: • Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.
• Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them.
• OR scrubs should not be worn at any time outside of the hospital perimeter.
• OR scrubs should be changed at least daily.
•
Like OR scrubs, cloth skull caps should be cleaned and changed daily. The American College of Surgeons statement on OR attire guidelines https://www.facs.org/aboutacs/statements/87-surgical-attire also supports the items above.
OR Scheduling Procedure
Below are steps to take for OR scheduling once patient is deemed a surgical candidate 1. Fill out OR Booking Sheet completely (and legibly!). This sheet is in every exam room and Resident rooms
a. Any changes to OR schedule, you must email the entire ENT Team
v21palentadminpaloalto@va.gov
b. CANCER CASES: OR Booking sheet given to Annie
2. c.
NON-CANCER CASES: OR Booking sheet given to Leslie Resident, Attending, and patient should agree on surgery date together. Look in OUTLOOK ENT OR calendar (if you need access to this calendar, contact Erik and/or Maria). Check with RNP/PA/RN if you are unsure about availability. a. SINUS CASES: Do not schedule OR date unless you have followed the algorithm and cleared the date with PA first.
3. Scheduling OR date on same clinic visit day: a. Surgery within 30 days of clinic visit, these elements must be completed: i. ENT Pre-op and H&P appointment (valid for 30 days) ii. Consent (obtained during ENT Pre-op appointment, valid for 60 days) iii. Anesthesia (OSS) appointment (preoperative medical clearance) iv. Any other medical clearances, lab work, and x-rays
b. Surgery less than 72 hours: i. URGENT CASES need a “Request to Add-On” slip (aka PINK SLIP; see OR Pink SlipRequest to Add-On Form-Orginal.docx found in the Resident Handbook Folder within the ENT S drive) ii. Look into OUTLOOK OR Calendar and coordinate with RNP/PA to schedule (talk to Ella if RNP/PA not available) iii. Turn copy of PINK SLIP in person to OR (Building 100, 3rd fl., E3-100)
iv. For any OR communication during work hours, please let either Leslie or Annie know of any add-ons or changes (i.e pink slips). v. After hour pink-slips or OR add-ons, you can communicate directly with the OR.
4. Scheduling OR date on another date:
a. If more than 72 hours: i. ENT RN/RNP/PA will notify patient once surgery is scheduled ii. Confirmed ENT Pre-op and OSS appointments iii. Surgery package sent 1. Contains surgery letter, surgeons credentialing information, any relevant information 2. FYI that credential information is also available online 5. FOR COMPLEX OR CASES: email OR team and Attending the plan the day prior to surgery a. Searcy, Nancy <Nancy.Searcy@va.gov>; Yanokodani, Colleen E. <Colleen.Yanokodani@va.gov>; Chan, Leslie C. <Leslie.Chan@va.gov>; Annie Yuan Annie.Yuan@va.gov
Admitting Floors
• 23-hour Observation: EDOU (emergency department obs unit)- 1st floor, back of ED o only if they will be here <23 hours; no discharge summaries necessary o 4 beds available o For patients who take shuttle or don’t have driver • 47-hour observation: beds available on 3C/2A/4C1 o Only if they will be here <48 hours; no d/c summaries necessary o 3C- +tele and +continuous pulse oximetry, q4h monitoring o 2A- +tele and +continuous pulse oximetry, q8h monitoring o 4C1- medicine room, no TELE, no continuous pulse ox, q8h monitoring • 3C: Surgical Floor, 1:5-6 ratio, o +continuous pulse oximetry monitoring (up to 10 beds) o +telemetry (up to 8 beds) o Q4h monitoring • 3C-SDU: 1:4 ratio, 4 PRIVATE rooms close to nurses’ station o Would NOT recommend for someone who needs close monitoring o +Telemetry, +continuous O2 monitoring o + trach care or patients who just comes out of ICU o q2h suctioning • IICU: Can use as female SDU (as female usually cannot go SDU at 3C) o less acute than MSICU o q1h suctioning • MSICU: o Free flap or Acute airway issues
• 4C:
o Usually medicine primary/Acute Rehab. Usually send patient who requires long hospital stays ex IV ABX, palliative care etc.
•
Surgeries, minor procedures, and staff schedules are posted here. If you need access, contact any ENT Admin. (Calendar needs to be shared from the Sensitive Surgical Sharepoint and then connected to Outlook.)
Adding patient to Outlook OR Calendar
Below are the steps to take to input a patient into the ENT shared Outlook calendar for surgeries. Usually one of the RN/RNP/PA will do this once they receive a completed OR Booking Sheet. 1. 2.
3. Go to OUTLOOK Calendar Go to “HOME” Tab click on “NEW APPOINTMENT” a. Subject Line: Last Name, First name, Last 4 SSN#, Attending, Surgery Procedure(s), Post-Op Admission Status
b. c. Location line: Enter Diagnosis Start Time: Surgery date and surgery start time
d. e.
End Time: Surgery date and surgery end time Body: i. In OUTLOOK OR Calendar double click “NONOPERATIVE WEEK” or “OPERATIVE WEEK.” It will ask you if you want to open the recurrence or the series. Click “OK”, then copy and paste into new appointment. Fill out all respective fields. Click on “CATEGORIZE” button and click Purple Category
Outlook OR Calendar Color Legend
Below is the color-coding system for the OUTLOOK OR Calendar and the elements they include in order to be that color • Light Green o Surgery placeholder; date usually not confirmed with patient and/or RN/RNP/PA coordinator Blue o Purple o o
Yellow o In-Clinic Procedure that Ella and Crystal handle Surgery date determined OR booking sheet filled out completely, and case is ready to be entered Vista. Person inputting patient information changes to purple (usually Annie/Leslie). Admin. has submitted the OR booking sheet into VISTA Package. Admin. changes to yellow
Green o
Red ENT Preop/OSS appointments complete, consent complete, labs and imaging complete, and medical clearance obtained. Chief Resident changes to green before surgery.
o Cancelled surgery cases
All surgical equipment and tools should be requested via the Surgical Request Form (AKA OR Booking Sheet) that is completed for all cases. These sheets are located in many rooms in the ENT clinic. Please circle the equipment needed and write in anything that is not already listed. Admin., then enters the request into CPRS, and Colleen Yanokodani, RN, in OR (Bldg 100, 3rd Fl., Room F3-102) makes sure that the equipment is brought to the operating room from the various surgical storage areas upstairs (P&P room, Omnicells in old holding area, C locker, etc.). If you need something while in the OR, you can ask the circulating nurse to get it for you. If there is something that you want to use that we normally do not stock, be prepared to wait at least 2 months, if not more. The VA has a specific request process that needs to be followed, and you need to talk to Colleen. The attending will need to complete and submit an Operating Room Procurement Committee Request Form (AKA the “gold form”) and begin the process of procuring the new equipment. This can take anywhere between 2 months and 1 year. Click the link (OR Request form (gold form).pdf) to see for an example of the gold form. Maria Tham can also provide you with more information.
Surgical Algorithms
Due to backlogs with surgery date availability, we are creating algorithms based on standards of care to simplify when a patient is a candidate for surgery. Currently, we have one algorithm completed for sinus surgery scheduling. The algorithm can be found in the document entitled “Sinus Scheduling algorithm.” Please contact RNP/PA/RN for more information.
The VA has an online Physician Reference Guide that contains everything you need to know about CPRS, the computer system used to document patient care. To access it from the Intranet, go to the VA home page (https://vaww.paloalto.va.gov), then under the Patient Care tab, choose CPRS Physician Reference Guide.
The CPRS team also created videos that you can review. Please click on below link.
Residents: Videos 1 – 11; Approximate Time: 90 Minutes https://dvagov.sharepoint.com/sites/PALClinfo/CPRS%20Training/Forms/All%20Documents.aspx?RootFolder=/s ites/PALClinfo/CPRS%20Training/CPRS%20Training%20Videos%202020&FolderCTID=0x01200018288C6F6A023E 42BC5A0FF8BF6495CD&View=%7b37420F91-60C7-456D-BA14-4E8F3C287354%7d
Notes
Create documentation by using the notes tab in CPRS, then “new note”. You can then go to the template tab and select a template from the “ENT” section through “Shared templates”
• Admission H&P: within 24hr of admission • Preop H&P: 30 days prior to procedure – Must contain 1. Diagnosis 2. PE findings (including Lung and Heart) 3. Procedure to be performed 4. Alternate treatment plans discussed 5. DC/anticoagulation • Updated Pre-op: Within 24hours of surgery (By Attending) – Must contain 1. No changes in condition 2. Proceed with scheduled operation • Brief OP NOTE: Before patient changes level of care (Before leaves the OR) • OP report: You can either dictate or write (if you write then you cannot go and edit: have to write just once, that’s it) • Discharge summary: Entered or dictated within 24hrs to DC
• Life-Sustaining Treatment – used to document CODE status (if not a full code, orders are entered) • POLST • Informed Consent: 60days of surgery
Every note you write must be accompanied by an ENCOUNTER in order for ENT to get payment/credit for the visit, whether that visit is in-patient, in the ED, or in clinic. There are 2 ways to enter an encounter: 1. select ENCOUNTER in CPR or 2. right-click while writing your note and select “Edit Encounter information.”
The six most important things you need to know about encounters:
1) Attendings must be selected as “Primary Provider.” Residents are not primary providers. 2) In the “Visit related to” box, you must choose YES or NO if the issue is service connected. If you are not sure, click on the patient’s name in CPRS to pull up the “patient inquiry box.” It will tell you if a condition is service related. 3) You must complete the diagnosis and procedure tabs 4) If the note is a consult, please link the note to the consult 5) For inpatients who are being seen in the ENT clinic and have a scheduled appt, change the “clinic”
location to reflect that you are seeing them in the ENT clinic
6) For patients you are seeing as a consult in the ED or on the unit, in order for ENT to get credit for it, first make sure the consulting team places an ENT CONSULT, then:
Clinic location box new visit tab ENT-STAFF (PAD) start new consult note like in #5
For more details about entering encounters, please ENT encounters details.docx.
For more details about Evaluation and Management Coding Guidelines, please see Evaluation &
Management Coding Guidelines 1995.docx and Time Based Coding Guidelines.docx, both found in the
Resident Handbook folder within the ENT folder of the S drive.
There are 3 main computer programs you need to know about for patient care. CPRS (Computerized Patient Record System)
Main program for all patient notes, imaging reports, etc. See also the previous page on VA Documentation. o Finding a patient: Entering First initial of last name and last 4 of SSN# Find through floor or clinic (i.e., PAD-ENT-SIRJANI)
o
o Entering notes and encounters for each clinic visit Inputting type of visit, diagnosis, procedures, etc. Inpatient/Outpatient ordering on left side menu
o o Inpatients going to OR Helpful to select all current orders and enter them in as delayed orders before the case
o
Consult requests Consults to other services, palliative care, transfer to 4C, Defender’s Lodge, nonformulary medications, speech, physical therapy, radiation therapy, oncology, etc. See next page for how to enter specific consults Set-up Clinic List Reason: list of patients for the current day and clinic automatically populates Steps: • 1. Select “zztest,Andrew” patient • 2. Select TOOLS tab, scroll down and select OPTIONS o Select LIST/TEAMS tab, select PATIENT SELECTION DEFAULTS Under LIST SOURCE, select COMBINATION Under SORT ORDER, select either ALPHABETICAL or APPOINTMENT DATE (depending on your preference)
o Select SOURCE COMBINATIONS Select source by • CLINIC and select and ADD all ENT specific clinics that you staff o I.e. (PAD-ENT-BAIK, PAD-ENT-NAYAK, PAD-ENTNEW-SUNG, PAD-ENT-SAJJADI, PAD-ENT-SIRJANI, PAD-ENT-SUNG, PAD-ENT-SUNG-PROCEDURE, PADENT-STAFF)
o o •
SPECIALTY and select and ADD all ENT specific Wards o I.e. (ENT-IICU, ENT-OBS, ENT-SMICU, ENT-WARD) Select NOTES tab, select DOCUMENT TITLES Search Document Titles starting with ENT and select and ADD all titled notes that are appropriate for your work
•
3. Click OK to save everything Set-Up ENT Note Templates Steps: • 1. Select “zztest,Andrew” patient • 2. Select NOTES tab, select TEMPLATES • 3. Right click SHARED FOLDER, scroll down and select EDIT TEMPLATES 4. Expand SHARED FOLDER in Shared Templates area, scroll down and click on ENT Folder and click on RIGHT ARROW to copy to my templates 5. Select OK to save everything
VISTA Imaging Display o Reason: Useful for audiograms or photos of patients. Access through CPRS, click on TOOLS tab, scroll down and select VISTA Imaging Display
o If you are unable to view images through Vista Imaging Display, please contact any ENT Admin. They will check your access.
o
To look at images: Go to CPRS, click TOOLS, scroll down and click on RADIOLOGY(INTELLISPACE/PAL-STENTOR) and select either PAD for PAD images or Other Sites for other sites You can also access Intellispace through the desktop. Currently, access is through the VA PIV card. If you cannot access Intellispace, please contact any ENT Admin. Report or Result look-up: Joint Legacy Viewer (JLV), Labs, Predefined Lab Worksheet, Clinical Reports • Must click on blue “Remote Data” in upper right corner of CPRS to pull in Data from Other VAs • PICIS – flowsheet for ICUs Need to access via Tools>Specialty Applications> PICIS Remote Application Change to Option to “RDP”: Use Window’s username (vhapal…) & PIV card password
• Vista Imaging (used mostly for ECGs, procedure documentation, advance directives, IMED Consents, etc.)
• Joint Legacy Viewer (JLV) -- used for most current outpatient meds for patients from other sites: SharePoint Resource: https://dvagov.sharepoint.com/sites/VACOVE2/JLV/Resources/Forms/AllItems.aspx?viewpath=%2F sites%2FVACOVE2%2FJLV%2FResources%2FForms%2FAllItems.aspx
iMed Consent
o Defined: Digital consent platform. o All procedures require an electronic informed consent documented in the medical record
o Access through CPRS, click on TOOLS tab, scroll down and select iMed Consent and follow instructions. Include any Attending that may be participating in the case.
o There have been many issues with access with IMED CONSENT due to software upgrades. If you have any issues accessing your IMED Consent, please contact any ENT Admin. to resolve for you.
o If the electronic consent is not working, you can fill out a hardcopy with signature and request an Admin. to upload it to Vista Imaging in CPRS.
Missing consents for procedure reminder
This is a reminder that almost anything you do that require an injection needs a consent (and a minor procedure note because it has certain required wording on that document i.e. timeout was done, consent obtained, etc. etc.). The only thing(s) so far that doesn’t require consent are: • Scope exams • Sinus debridements (though this is somewhat arguable… safe to just get consent) • Treatment of epistaxis • Drain/suture/staple removal
Adjuvant consults
1. Dental a. To place the dental consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “dental” (“dental adjunct to medical need outpatient” will populate), hit ENTER iv. Select “head and neck cancer care” v. Submit order (must be signed)
2. Radiation a. To place the radiation consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “Community care – Radiation therapy” and hit ENTER iv. Justification for Community Care-Radiation Therapy: VA does not provide v. Type: choose “Evaluation and Treatment” vi. Enter relevant information 1. Please paste into consult: initial eval + 1 office visit before treatment, diagnostic tests, tx, post tx follow-up visits x4 over 12 months from date of initial eval. vii. Most radiation consults go to Stanford viii. Submit order
3.
4. Cancer Survivorship Care plan (see below for details) a. To place a cancer survivorship consult in CPRS: i. Choose New consult choose last ENT clinic oncology visit (Sirjani, Sung, Baik)
Oncology a. To place the oncology consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “oncology” and then choose the correct service and location iv. Choose e-consult or Face-to-face
under
“consult to service” type “cancer” (“cancer survivorship/PAD Outpt” will populate), hit
ENTER ii. Fill in the associated fields (Cancer diagnosis, date of diagnosis, Date of last treatment) iii. Under “reason”, check “survivorship care plan.”
The American College of Surgeons Commission on Cancer requires accredited programs like VA Palo Alto to implement treatment summaries and survivorship care plans to help improve communication, quality, and coordination of care for cancer survivors. The timing of delivery of the survivorship care plans is within one year of the diagnosis of cancer and no later than six months after completion of adjuvant therapy (other than longterm hormonal therapy). The “one year from diagnosis” requirement to have a care plan delivered is extended to 18 months for patients receiving long-term hormonal therapy. Care plans are given to patients Stages I-III who are treated with curative intent. We are asking providers to place a survivorship consult on the date of the patient’s last chemotherapy or radiation treatment. For those patients who only get surgery as treatment, the survivorship consult can be placed on the day you see the patient back for his/her first follow up visit. The consult will alert Lakedia Bank (Oncology RNP) and they will either complete the care plan or provide assistance to the various departments on how to complete the care plan. The Accreditation Committee made the following changes to the established time frame and scope of implementation.
January 1, 2015 – implementation of pilot survivorship care plan process involving 10% of eligible patients. January 1, 2016 – Provide survivorship care plans to 25% of eligible patients. January 1, 2017 – Provide survivorship care plans to 50% of eligible patients. January 1, 2018 – Provide survivorship care plans to 75% of eligible patients. January 1, 2019 – Provide survivorship care plans to all eligible patients. For more information about the care plans, contact Lakedia Banks at x65848/64169.
Non-VA Consult Contacts
Allergy consults ENT clinic, Stanford 801 Welch Rd. Stanford, CA 94304 Ph 650-725-3009 (Lily) fx 650-725-6685
Please fax authorization to: Sarita (650) 736-2589
RAD ONC Stanford consults (preferred) Radiation Oncology Stanford Name of Provider: Quynh Le 875 Blake Wilbur Dr Clinic D Stanford, ca # (650) 723-6171 FAX: (650) 725-8231 Please paste into consult: initial eval + 1 office visit before treatment, diagnostic tests, tx, post tx follow-up visits x4 over 12 months from date of initial eval.
RAD ONC Turlock consults Stanford Emanuel Radiation Oncology Center 800 E. Tuolumne Rd Suite 101 Turlock, CA 95382 Phone: 209-664-5030
Community Hospital of the Monterey Peninsula Dr. Tamler and Dr. Holley
Radiation Oncology
23625 Holman Hwy. Monterey, CA 93940 Phone: 831-625-4630 Fax: 831-625-4635
Santa Cruz Radiation Oncology Medical Group
Dr. Meisel 1575 Soquel Dr. Santa Cruz, California 95065
Phone: (831) 462-3050 Fax: (831) 462-6068 Stanford Otology: Stanford Ear Institute 2452 Watson Ct Palo Alto, CA 94303 (650) 723-5281 Fax: (650) 725-8502
All follow-up appointments need to be entered into CPRS as a “return to clinic” order. Three (3) Month Follow-up Rule: • Within 3 months: o Enter order for appropriate Attending clinic and time frame E.g. +6w (for 6 weeks) or +2m(for 2 months)
• After 3 months: o Place into recall. Recall is a waitlist. o No appointment will be made, and patients will be mailed a postcard 2 weeks prior to intended appointment o If patient in recall and needs imaging prior to their 1-year follow-up, please note in special instructions E.g Patient to schedule MRI prior to ENT appointment o CANCER PATIENTS DO NOT GO INTO RECALL In special instructions, write “NO RECALL” and state reason • Reason example: Cancer surveillance, needs MRI/audio/PETCT arranged at the same time
Dictation
1.
2. 3. 3. Dial 800-394-3845. When the call is answered, you will be greeted with a voice prompt which gives you instructions. Enter your USER ID, followed by the # key. When prompted, key in the patient’s full 9-digit SS number, followed by the # key. When prompted, key in Work Type, followed by # key.
WORK TYPE REPORT WORK TYPES
WORK TYPE REPORT
30 31 ADMISSION H&P DISCHARGE SUMMARY 40 41 EEG/EMG NUCLEAR MED
32 33 34 35 36 37 38 39 OPERATIVE REPORT COMPENSATION & PENSION PROGRESS NOTE VASCULAR LAB EMERGENCY ROOM NOTE STAT DISCHARGE/TRANSFER CARDIAC CATH GI PROCEDURE 42 44 45 50 62 75 PULM SLEEP STUDY LETTER RADIOLOGY CONSULT STAT PROGRESS NOTE PATHOLOGY
4. At the sound of the tone, please begin your dictation. *** THE FOLLOWING MUST BE DICTATED DURING THE BEGINNING OF DICTATION*** • IDENTIFY PATIENT NAME (SPELL THE LAST NAME AND FIRST NAME). • ENTER FULL SOCIAL SECURITY NUMBER
5. 6.
7. CLINIC SPECIALTY TITLE (ORTHOPEDIC CONSULT, ORTHOPEDIC ATTENDING, ORTHOPEDIC PROGRESS NOTE) DATE/TIME OF SCHEDULED APPOINTMENT NAME OF CO-SIGNATURE (ATTENDING) IF APPROPRIATE.
If you wish to dictate multiple reports, press ‘8’ to end one and begin another. To obtain a job number for the report you just dictated, press ## before hanging up. KEEP THIS NUMBER UNTIL THE DICTATION IS AVAILABLE FOR ELECTRONIC SIGNATURE. To disconnect, simply hang up.
DICTATION KEYPAD FUNCTIONS PRESS 1 2 3
To pause dictation.
To resume dictating after pausing.
Rewind – rewinds approximately 3 seconds. Press ‘2’ to resume dictating. 8 To end current report & begin another ## To get job number of report just dictated before hanging up To disconnect, simply hang up.
Coding
If there are multiple surgeons scrubbed from the same service, the operative report must reflect the role of each person in the operative report to get the RVU credits. Please dictate accordingly: Please look at these definitions below and dictate accordingly.
Modifier 80
81
82 Definition Assistant Surgeon • Provides full assistance to the primary surgeon • Capable of taking over the surgery should the primary surgeon become incapacitated. If an assistant surgeon assists a primary surgeon and is present for the entire operation, or a substantial portion of the operation, then the assisting physician reports the same surgical procedure as the operating surgeon. The surgeon is required to specify in the body of the operative report what the assistant does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It may be helpful to mention in the indications paragraph why there is a need for an assistant.
•
Only one operative report is required. Minimum Assistant Surgeon • An assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon.
• The surgeon is required to specify in the body of the operative report what the assistant does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report.
• It is a good idea to mention in the indications paragraph why there is a need for an assistant.
•
Only one operative report is required. Assistant Surgeon (When Qualified Resident Surgeon is not Available) • Used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable.
62 Two Surgeons with Different Skill Sets • Each provider should document their own portion of the procedure. • Two separate operative reports.
Asymptomatic surgical patients with a positive swab are not required to be treated for MRSA unless they have an active MRSA infection, such as our cancer patient going for surgery on Friday. Then the recommended protocol is to collaborate with infectious disease (ID) to make sure that the Vancomycin (or other abx) blood levels remain between peak and trough and that any other required measures are taken. (This is something that needs to go into the resident handbook, so the residents are aware to coordinate with ID pre-op.) Patients with a positive MRSA swab are on contact precautions while in-patient, but they are not kept isolated, i.e., they can still go down to get a cup of coffee from Starbucks. (Yes, you’re right, not logical.)
Asymptomatic veterans who are out-patient are not monitored or followed. There is some controversy about the benefits of completing the nares swabs. Some hospitals no longer do them, since MRSA is now considered a “normal” part of most people’s microbiome.
CODE X - System for bleeding emergencies
In collaboration with nursing, VA has now developed a new system for bleeding emergencies that need to go to the OR off hours. When the nursing supervisor is called to get the OR team in, you/your resident-fellow needs to tell them it is a CODE X situation. This means that the nursing supervisor will call in 3 nurses to have adequate staff in the OR and arrange for extra resources such as blood runners. It is also a sign that the Massive transfusion Protocol should have been activated. If you think you require the cell saver or bypass machine please make sure to also have them call in a perfusionist. This status will be communicated to all of the nurses as they are called so they know they are coming into a critical situation and get set up ASAP.
Remote Access Set-Up
To obtain a Remote Access Account use this link: https://vaww.ramp.vansoc.va.gov/SelfService/
• (ONLY accessible within the VA network. YOU CAN ONLY PUT IN A REMOTE ACCESS request on a VA networked computer). You will be notified (by VA outlook email and/or the email you enter) when your account has been approved and activated. o Justification for Remote Access: Provide clinical care, need to be on-call, and require remote
access. Work in a sterile environment
o Supervisor: Mehgan Sobejana If you are unable to be onsite to put in this request, please contact your ENT Admin. (v21palentadmin paloalto@va.gov ) or someone from the Surgical onboarding team for assistance (vhapalsuronboarding@va.gov) Access remote access using the follow link: https://citrixaccess.va.gov If you have any further questions regarding Citrix Remote Access and associated resources, please contact the VA Service Desk/Help Desk (ext. 64767) or 1-855-673-4357
•
If you are using your PIV card, you will need a PIV card reader. Ask your Admin for one. • If you will be accessing with Mobile Pass, contact an ENT Admin. for details. • Please remember that you must use your remote access at least once every 90 days. If you do not,
your remote access will automatically be disconnected, and you will need to apply again.
• For a copy of the VA Remote Access “handbook,” contact any of the ENT Admins. It is also located on the ENT drive, which you have access to. S:\ENT\--Resident Handbook--
To set up:
1. Right click on the start button which is this symbol in Windows 10.
2. A window will open up. Click on RUN. (If you still have Windows 7, click on Start symbol)
3. When below screen shows up, type the below listed printer link in the blank field next to OPEN.
a. For the “Baby” Ricoh in the ENT/EYE HALLWAY (near Annie area), type in the Open box the following and hit OK. It will start connecting and you are done.
\\vhapalprtom01\pal-dp183971
b. For the Xerox in the clinic wait room (near Cece), type in the Open box the following and hit OK. It will start connecting and you are done. \\vhapalappom01\pal-dp194511
VETERAN SUPPORT
Case Manager/Social Worker
• Michelle Seli RN 62781, Case Manager o located in 3C- This person helps arrange all needed outpt care for post-op pts including placement, IV abx, trach supplies, etc. Sometime PGY3 gets pages every 5mins from CM. Try to build a good relationship with CM even though sometimes CM sends a lot of pages… Eventually CM is helping us for dispo. Giving them an early head-up is also important about what should be done and plans for each patient, just like talking to Crista at Stanford C2. Elizabeth Enriquez, MSW x67870, #11596 – Social worker for Inpatient ENT o Located in 3C- requires a consult o Helps with any social issues, complicated dispos, and advanced directives Martha Cutcomb, MSW x63967 and Rosalind Bowler MSW x65649 (Wednesdays only) x-Social Worker for Outpatient ENT
Housing & Transportation
Defender’s Lodge
o Criteria for requesting Defender’s Lodge Consult: Veteran is traveling 50> miles away Veteran has significant travel difficulties
o Veteran usually needs a driver with them
o Note that there has been numerous policy changes due to COVID-19. Double check with any ENT staff.
o Entering consult Click “CONSULT” tab, click “NEW CONSULT, select own name and clinic appointment Enter “DEFENDER’S LODGE” in Consult to Service/Specialty
Fischer House
o Housing for family and not Veteran/patient, has to be inpatient >3days, i.e., when patient is admitted for chemo/XRT, or prolonged hospitalization
Shuttle Bus
o o Click link for Shuttle bus schedule: https://www.paloalto.va.gov/shuttleschedule.asp SHUTTLE BUS DOES NOT TAKE ANY PATIENTS AFTER GENERAL ANESTHESIA. LOCAL is fine but not GETA. So those patients can go to Defender’s Lodge if they have a significant other or family member with them, if not we have to admit as Observation at C3 or EDOU.
First Day Checklist
On first day of rotation: • Window’s sign-in • PIV card encryption • CPRS sign-in IntelliSpace sign-in PIV PIN to order narcotics
• Put in your away dates in our calendar and confirm on-call schedules
Set-up: • Scrub card Clinic keys Dictation code ENT Admin. to add you to Outlook calendar Set-up printer Remote access
• CPRS: set note titles, clinics and templates
End of Residency Checkout list
At the end of your residency, please make an appointment with an ENT Admin to check out. These are the items you should bring 1. PIV Card 2. Clinic keys 3. VA sponsored electronics if any 4. ScrubX card 5. Any other item provided to you by the VA Please do not turn in items and sign out until you have completed all of your on-call duties. Please remember to complete and sign any outstanding notes/consults/encounters BEFORE YOU LEAVE.
PAD 3801 MIRANDA AVE, PALO ALTO CA 94304 T: 650-849-0264 or (650) 493-5000 Ext 60264 ENT Mailcode: 112ENT ENT/EYE FAX: (650) 496-2502 ENT mainline (thru operator): 63924, 65751 ENT mainline: 60264 PAD=56: SJC=57: MOD=54: MPD=52 To PAGE, go to or dial 65970 (live operator will connect
https://smartpage.stanford.edu/
you)
Last First Ext: Pager Room # email adress (preferred)
Akkina* Sarah 61122 E2-236
Baik* Fred 65240 13396 E2-256 fbaik@stanford.edu
Benadam-Lenrow Ella 64047 E2-241
Chan ENT Chief Resident ENT Exam Room 1 ENT Exam Room 2 ENT Exam Room 3 ENT Exam Room 4 ENT Jr. Resident ENT Main line ENT Minor Room EYE/ENT Conference Room Leslie 65535 E2-246 64049 E2-254 65193 E2-244 65348 E2-243 64622 E2-242 66214 E2-252 64048 E2-253 60264 63322 E2-250 65353 E2-140 ella.benadamlenrow@va.gov leslie.chan@va.gov
Makarewycz Bohdan 64622 none
Nayak* Nielsen Jayakar 61122 23098 E2-236 Erik 63202 bohdan.makarewycz@ va.gov jnayak@stanford.edu
erik.nielsen1@va.gov
Sajjadi*
Sirjani* Sobejana
Sung* Tham Maria 66912 E2-246/B3130
Hamed 63166 13199 E2-236 hsajjadi@stanford.ed u or otology@hotmail.co m
Davud 67145 23350 E2-248 Mehgan 60596 3rd fl. dsirjani@stanford.edu
mehgan.sobejana@va.go v
C. Kwang 61122 23479 E2-236 kwangs@stanford.edu maria.tham@va.gov
Vo
Crystal 64046 E2-241 Yanokodani Colleen 66022 3rd fl.
Yuan Annie 65203 11671 E2-246 crystal.vo@va.gov
colleen.yanokodani@va.g ov annie.yuan@va.gov
OTHER SERVICES
3A
Audiology/Speech Path. (PAD) Bed Control
CDs
CPRS Help hotline CT/MRI/Ultrasound/ Barium swallow
Decedent Affairs Defenders Lodge ECHO Fisher House
GT Removal Helpdesk (IT) - You
can also submit a ticket by using YOURIT icon on your desktop. Interventional Radiology Navarre Transport
Nuclear Medicine Oncology (Lakedia Banks, RNP)
OR (NAM) OSS RNP - Robin Boselli/Stephanie Kangas PFTs ROI SPD Telephone Care program
VA travel 6508523396 65597
66969 65495 65050 65956 62777 6508583949 65432 61333 64621 61630
, 68800 64767
68800
8336282773 65520 65848
, 64948 61656 64154 /6204 9 64207 67298 64212 8004550057 65686 or 64877
Bldg 100 Room D2108
Ext. 63824
Anna Noble
or 69914
(PET)
or 650-339-5117 62655
