SCFM CLINIC

The nurses are helpful in setting up referrals, prior authorizations for meds, radiology studies, pulling up labs, and scheduling appts.

Dress is strictly professional. No scrubs. Ties seem to be optional. Lab coats are rare. Need to wear ID badge.

Present all patients to attending. Make sure attending signs all encounter forms and stamped progress note sheets.

Update the yellow history sheet, green maintenance sheet, med lists, and pain form every visit. Make sure all diabetics have a diabetic flow sheet. Give patients a blue check out slip to schedule follow up appts.

Dictations must be done before 8 am next morning. Dial 5163, enter your dictation code, work type 19, pt ID number is 000000. Start by stating your name, “dictating clinic note on patient so-and-so (spell name)”, patient DOB, date of clinic, and attending. SOAP format note. Conclude dictation by stating AGAIN something like “This patient was discussed with Dr. so-and-so who was present as clinic attending.”

Previously transcribed dictations will generally appear on your desk while you are in clinic. Review, sign, and put in basket in Darla’s office.

New patient visits, OB visits, and WCC visits do not require a dictation if appropriate forms are completed.

Provide patient education handouts when possible. They are coded in right side of chart and found on the desktop of all computers (many available in both English and Spanish). Record the date and initial.

Small white slip messages sometimes appear in your charts and these are messages to you from attendings based on chart reviews. Specific comments should be acted upon, signed, and then returned to the box on the attending’s desk.

Messages are now handled through EPIC. They should be returned within 24 hours. You may occasionally be asked during clinic day to answer messages from other residents if they are unavailable and it is an urgent matter. If chart is needed and not provided, you can request it from anyone in the Records Room. Normal labs and studies can be signed off on and filed. Call patient and notify them of normal results or fill out gray card to mail to them. Abnormal labs and studies need to be acted upon! You need to look at the patient chart for more info and call the patient if necessary to inform them of what needs to be done next, if indicated. Make sure to check your box regularly as well – some things simply can’t be put into EPIC!

Rx's for narcotics require an attending's signature unless you have your own DEA#. Check in chart to see when benzos, narcotics & other addictives were last filled before refilling. All patients on chronic narcotics must be seen every month and have a signed narcotics contract in the chart. Keep pink chronic pain sheet and gold pain assessment form up to date. You have the right to randomly check for positive urines on your patients and should consider doing so at least 4 times a year.

All sample medications should have label instructions with the patient’s name, instructions on use, lot # and # boxes given. Leave a copy in the free drug closet. This is important to keep the free drug closet alive.

Remember to refer patients without insurance to our CICP program (it helps pay for visits, imaging, labs, and hospital stays) and get those who need it into the drug subsidy program (all with Deb).

Also refer women to the CWCCI program prior to doing paps and mammos so that if an abnormal result requires further work up, it will subsequently be covered. Usually they only accept older women, ask Dolinda for details.