FINAL Global Module 10-11.pdf - AaronsWorld.com

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CLINICIAN RESPONSIBILITIES - PRIMARY/INTERN STUDENT Primary student clinicians are responsible for presenting their cases in case preview and review, directing patient interviews, taking the case notes and assessing the patient both subjectively and objectively. After collecting this information, students meet with the supervising faculty to discuss the diagnostic strategy, and once a diagnosis is reached, establish the plan. Primary student clinicians are encouraged to think through and develop their own strategy and management of the case, although the supervising clinical faculty makes the final decisions and is responsible for all aspects of case management. Specifically, primary student clinicians: o Preview the case with the attending clinical faculty member and secondary student clinician during case preview before initiating contact with the patient. o Monitor the electronic patient schedule and physically check the reception area for the first 15 minutes of a scheduled appointment in the event of a late patient. If a patient arrives more than 20 minutes late for their appointment, the receptionist will page the supervisor. The supervisor will determine the viability of starting the appointment or the need to reschedule the appointment. o Meet the patient in the reception area and escort the patient to the exam room. Clinicians should explain to a new patient how the clinic operates, how patient visits are conducted, and how many supervisors and/or observers will be attending the visit. (From this point onward, the patient is not left unattended, except for the purpose of providing privacy during disrobing and dressing when indicated by a procedure, when the student clinicians and supervisor discuss the case in private consultation, or during the resting phase of an acupuncture treatment.) Make sure to tell all patients to wait until the clinician returns before climbing onto the exam/massage table. Additionally, do not leave patients with limited physical or mental capacities unattended for more than brief periods of time. Young or profoundly mentally handicapped patients must not be left alone in the treatment room at any time. o Take case notes in black pen only, neatly, and in an organized manner, following the standard SOAP formats. An S, O, A, or P should be written for the appropriate section on the progress form. Draw a single line through any corrections and initial the correction. Do not scratch out any part of the chart notes. o Charts must be completed within 24 hours. Any unfinished charts including unfinished chart notes must be returned to Medical Records one hour after shift, or checked out with your name and your clinic location noted. o Carry out your supervisor’s instructions with respect to interviewing the patient, performing a physical exam, diagnostic studies, and making referrals and treatment plans. o Familiarize the secondary student clinician with their style of case management, and direct/support the secondary student clinician’s role as an observer and facilitator. o Sign the chart when it is completed, fill in the summary of patient contact “health data and medication list” forms on the inside cover of the chart, make certain that the superbill is completed correctly, including CPT and ICD9 codes, and obtain the supervisor’s signature on all forms and case notes. o Recommend that the patient is rescheduled after consultation with the supervisor. For the Naturopathic Team Care clinic, recommend that the patient is rescheduled at 18
a time that the supervisor and, if possible, the primary and/or secondary student clinicians are present. The supervisor, with the knowledge and consent of the patient, must approve exceptions. In the Acupuncture or CHM Team Care clinics, attempt to schedule on a shift with the primary intern unless specifically instructed otherwise by the supervisor. o Follow-up by telephone with the patient, with supervisor approval, when there is a cancellation or no-show for a scheduled visit (both FOC and ROC), to discover why the patient was unable to come in, determine the state of their health, and to reschedule an appointment. Limit the length of all phone calls to/from patients to no more than 3 minutes. Major changes or alterations to treatment plans should only be made during a patient care visit. All phone contacts need to be pre-approved by the supervising clinical faculty. Be certain to record any phone contact information in the patient chart and have it signed by the supervising clinical faculty. (Patients appreciate personal care and interest shown in their health care.) Check with the reception staff before proceeding to contact a patient as their reason for absence may already be known. Chart all phone contacts on a progress note that is signed by the supervisor. o Have the time sheet and summary of patient contacts signed off by the supervisor/clinical faculty at the end of each shift. o Properly drape patients and pull blinds when patients are to change into a gown. o Become familiar with clinic resources, such as patient protocols, therapeutic notebooks, forms, etc. o Only practice modalities in which coursework has been completed and that supervisors have approved (i.e., utilizing cranial sacral therapy and specialized techniques such as the use of tuning forks on acupuncture shifts should only occur on shifts when the supervisor is also proficient). IMPORTANT: No treatment modality is applied, supplement recommended, nor instruction given to the patient without the prior approval of the supervisor. This is practicing medicine without a license and sanctions would be placed on the student. 19
Page 1: TABLE OF CONTENTS TABLE OF CONTENTS
Page 4 and 5: II. CLINIC SHIFT POLICIES AND PROCE
Page 6 and 7: DRESS, HYGIENE, AND APPEARANCE REQU
Page 8 and 9: Integrated care shift - This shift
Page 10 and 11: Students will receive a grade of AC
Page 12 and 13: GRADING AND STUDENT PERFORMANCE Cli
Page 14 and 15: If students wish to file a grievanc
Page 16 and 17: o Violation of the Bastyr Center fo
Page 20 and 21: CLINICIAN RESPONSIBILITIES - SECOND
Page 22 and 23: DOCUMENTATION GUIDELINES (DG) Basty
Page 24 and 25: REFERRALS Patient Referral To BCNH
Page 26 and 27: NEEDLES NEEDLE STICK OR EXPOSURE IN
Page 28 and 29: IN CASE OF A SENTINEL EVENT A senti
Page 30 and 31: SUICIDAL/HOMICIDAL PATIENT PROCEDUR
Page 32 and 33: EMERGENCY PROCEDURE PROTOCOL FLOW S
Page 34 and 35: o The nature of the incident. o The
Page 36 and 37: o The student services office. o Th
Page 38 and 39: *Names of Bastyr clinicians and fac
Page 40 and 41: Patient Access Clinicians may not g
Page 42 and 43: MEDICAL RECORDS The medical records
Page 44 and 45: Faculty providers frequently receiv
Page 46 and 47: Check the form for completeness. Ha
Page 48 and 49: Exceptions Below is a list of the e
Page 50 and 51: GRIEVANCE/COMPLAINT POLICIY V. MISC
Page 52 and 53: CLINIC CLOSING TIME In general, the
Page 54 and 55: VI. APPENDICES I. CLINIC CONTRACT I
Page 56 and 57: Appendix 2 Bastyr University Health
Page 58 and 59: Appendix 4 MEDICAL ABBREVIATIONS Th
Page 60 and 61: GB gallbladder GC gonorrhea GH grow
Page 62 and 63: q (spell out) qam qd qh q2h qid qpm
Page 64 and 65: Appendix 5 PATIENT CO-MANAGEMENT: T
Page 66 and 67: Today’s Date Dr. Primary Care Doc
Page 68 and 69:
Today’s Date Doctor Name Doctor A
Page 70 and 71:
Impression: I am concerned about th
Page 72 and 73:
CLINIC PHONE DIRECTORY Bastyr Cente
Page 74 and 75:
AOM Clinical Faculty: Terry Courtne
Page 76:
ND Residents: Jessica Bean, ND 1st
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