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PWF3w – AP Well Adult – Physician Workflow Part 3w
Dec 5, 2019
•
Mark Morgan
categories:
Assessment & Plan
A/P:
#WELL ADULT VISIT for
age
yo
M
F
gender
-
premenopausal
perimenopausal
postmenopausal
-tobacco status
never
current
former
-BMI status
normal (18.5-25)
overweight (25-30)
obese (>30)
-high-risk sexual behavior
no
yes
-Spent
minutes discussing the following preventative health topics and screenings:
USPSTF Guidelines (A/B Recommendations)
-AAA U/S screening
M 65-75yo who haved smoked
-
patient declined
patient accepted
ordered
-ASA for Primary CVD prevention
M/F 50-59yo with >10% CV risk
-
patient declined
patient accepted/agreed
ordered
-Cervical CA screening
F 21-65yo
-
patient uptodate for screening
patient due for screening
patient declined/deferred
patient requested
PAP performed, obtained sample and sent to lab
separate appointment arranged
not indicated for patient at this time
-Folic acid 0.4-0.8mg daily supplementation to prevent neural tube defects
F planning or capable of having children
-
patient already taking
patient declined
patient accepted/requested
medication prescribed
patient preferred OTC prep, gave recommendations
not indicated for patient at this time
-Contraception Management
-Current Method -
choose below
Pill
Patch
Ring
Progestin shot
Progestin implant
Hormone IUD
Copper IUD
abstinence/condoms/spermicide/withdrawal/fertility awareness/lactation/EC method
BTL
partner vasectomy
*
-After discussion and shared decision making,
patient desires to continue current method and understands risks & benefits & alternatives to current method
patient desires/agreeable to switching methods
-Actions:
IUD not currently due for replacing
IUD due for replacing & patient referred/scheduled for procedure
Progestin implant not currently due for replacing
Progestin implant due for replacing & patient referred/scheduled for procedure
Next progestin injection not yet due
Next progestin IM injection due and ordered/rx'd
Current contraceptive with adequate supply/refills
Current contraceptive supply low and needs refill, prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient resuming contraceptivez
Permanent contraceptive method without issues, will continue
-New Desired Method -
choose below
Pill
Patch
Ring
Progestin shot
Progestin implant
Hormone IUD
Copper IUD
abstinence/condoms/spermicide/withdrawal/fertility awareness/lactation/EC method
BTL
partner vasectomy
*
-Recommendations to minimize gaps in contraception coverage and unintended pregnancy -->
-Option (1) Take first pill as soon as pill pack received.
-Option (2) Take your first pill soon after next period begins.
-If first pill taken ≤ 5 days after the start of menses, no backup method needed.
-If first pill taken > 5 days after the start of your period, use back-up method for the first 7 days
-Take 1 pill each day. Take pill at the same time each day (especially if progestin-only pill).
-After finishing a pack of pills, start a new pack the next day. Should have NO day without a pill.
-If missed ONE pill: Take pill as soon as possible.
-If missed TWO pills or more: Take pill as soon as possible. Take next pill at the
usual time. Use condoms for 7 days. Use emergency contraception if having
unprotected sex.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Option (1) Put on first patch as soon as pack received.
-Option (2) Put on first patch soon after next period begins.
-If first patch put on ≤ 5 days after the start of menses, no backup method needed.
-If first patch put on > 5 days after the start of your period, use back-up method for the first 7 days
-Use new patch every week for 3 weeks and no patch for the 4th week.
-Expect menses during the patch-free week. May have a light menses or no menses at all.
-Start a new box of patches at the end of the 4th week.
-If the patch comes off, put it back on right away. If it does not stick, use a new patch.
-If the patch falls off for more than a day, put on new patch and use condoms for the next 7 days. Put on next patch a week from the date of this new patch.
-If forgot to change patch after 7 days:
-patch has enough hormones for 9 days; if patch on for 9 days or less put on a new patch.
-If patch on for more than 9 days, put on a new patch and use condoms for the next 7 days.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Option (1) Put in first ring as soon as pack received.
-Option (2) Put in first ring soon after next period begins.
-If first ring put in ≤ 5 days after the start of menses, no backup method needed.
-If first ring put in > 5 days after the start of your period, use back-up method for the first 7 days
-Leave the ring in vagina for 3 weeks, and remove it for the 4th week.
-Ring is removed by hooking a finger under the rim and pulling it out.
-Most women have menses during the ring-free week.
-Insert a new ring at the end of the 4th week.
-Can store the ring at room temperature up to four months. In the refrigerator, the ring lasts
much longer.
-If no/reduced menses desired and because the ring has enough hormones to last 35 days, can leave in for more than 3 weeks. Change the ring on the same day of each month (for instance, March 1st, April 1st, May 1st, etc.). If removing the old ring and inserting the new ring on the same day, may not have menses.
-If ring comes out: the ring can stay out of body for up to 3 hours and still prevent pregnancy. If the ring is out of body for more than 3 hours, put it back into vagina and use condoms for the next 7 days.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Use back-up method for the first 7 days following injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate1).dateAdd(77)
THRU
calc value
score1=(DepoDate1).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Use back-up method for the first 7 days following implant insertion.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Use back-up method for the first 7 days following IUD insertion.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Use back-up method for the first 7 days following IUD insertion.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Assuming no gap: take 1st pill of new pack the day after taking any pill in old pack (regardless of timing of cycle, patient may wait until completion of old pack before starting new pack/contraceptive if desired).
-Actions:
Patient desiring/agreeable to switching to different oral contraceptive pill due to reasons previously described
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Goal of 1 day overlap of old and new methods.
-Start patch 1 day before stopping pill or continue taking pill for 1 day after placing patch.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient placing patch
-Assuming no gap: no overlap required, insert ring the day after taking any pill in pack.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting vaginal ring
-Goal of 7 day overlap of old and new methods.
-Have first injection 7 days before stopping pill or continue taking pill for 7 days after getting injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate2).dateAdd(77)
THRU
calc value
score1=(DepoDate2).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Goal of 4 day overlap of old and new methods.
-Have implant inserted 4 days before stopping pill or continue taking pill for 4 days after getting implant inserted.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 7 day overlap of old and new methods.
-Have hormone IUD inserted 7 days before stopping pill or continue taking pill for 7 days after getting hormone IUD inserted.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have copper IUD inserted no more than 5 days after stopping pill. No overlap needed.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 1 day overlap of old and new methods.
-Start pill 1 day before stopping patch or keep wearing patch for 1 day after taking first pill.
-Actions:
Patient desiring/agreeable to switching to oral contraceptive pill due to reasons previously described
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Assuming no gap: insert ring and remove patch on the same day. No overlap required.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Goal of 7 days overlap of old and new methods.
-Have First injection 7 days before stopping patch or keep wearing patch for 7 days after injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate3).dateAdd(77)
THRU
calc value
score1=(DepoDate3).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Goal of 4 days overlap between old and new methods.
-Have progestin implant inserted 4 days before stopping patch or keep wearing patch for 4 days after implant insertion.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have hormone IUD inserted 7 days before stopping patch or keep wearing patch for 7 days after hormone IUD inserted.
-Goal of 7 days overlap between old and new methods.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have copper IUD inserted no more than 5 days after removing patch. No overlap needed.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 1 day of overlap between old and new methods.
-Start pill 1 day before removing ring or keep in ring for 1 day after starting pill pack.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Goal of 2 days of overlap between old and new methods.
-Start patch 2 days before stopping ring or keep in ring for 2 days after placing patch.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Goal of 7 days of overlap between old and new methods.
-Have first injection 7 days before stopping ring or keep in ring for 7 days after having first injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate4).dateAdd(77)
THRU
calc value
score1=(DepoDate4).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Goal of 4 days of overlap between old and new methods.
-Have implant inserted 4 days before stopping ring or keep in ring for 4 days after having implant inserted.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 7 days of overlap between old and new methods.
-Have hormone IUD inserted 7 days before stopping ring or keep in ring for 7 days after having hormone IUD inserted.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have copper IUD inserted no more than 5 days after removing ring. No overlap required.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Start pill pack up to 15 weeks after the last injection.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Place patch up to 15 weeks after the last injection.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Insert ring up to 15 weeks after the last injection.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Have implant inserted up to 15 weeks after the last injection.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have hormone IUD inserted up to 15 weeks after the last injection.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have copper IUD inserted up to 16 weeks after the last injection.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 7 days overlap between old and new methods.
-Start pill pack 7 days before implant is removed or continue pill pack for 7 days after implant is removed.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Goal of overlap of 7 days between old and new methods.
-Place patch 7 days before implant is removed or use backup contraception for first 7 days after after removal and placing patch.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Goal of overlap of 7 days between old and new methods.
-Insert ring 7 days before implant is removed or use backup contraception for first 7 days after implant removal and insertion of ring.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Goal of 7 days of overlap between old and new methods.
-Have first injection 7 days before implant is removed or use backup contraception for 7 days after removal of implant and first injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate5).dateAdd(77)
THRU
calc value
score1=(DepoDate5).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Have copper IUD inserted no more than 5 days after implant is removed or use backup contraception until copper IUD inserted. No overlap required.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 7 days of overlap between old and new methods.
-Start pill pack 7 days before hormone IUD is removed or use backup contraception for 7 days after removal of IUD and starting pill pack.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Goal of 7 days of overlap between old and new methods.
-Place patch 7 days before IUD is removed or use backup contraception for 7 days after removal of hormone IUD and placing patch.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Goal of 7 days of overlap between old and new methods.
-Insert ring 7 days before IUD is removed or use backup contraception for 7 days after removal of hormone IUD and insertion of ring.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Goal of 7 days of overlap between old and new methods.
-Have first injection 7 days before hormone IUD is removed or use backup contraception for 7 days after removal of hormone IUD and first injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate6).dateAdd(77)
THRU
calc value
score1=(DepoDate6).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Goal of 4 days of overlap between old and new methods.
-Have implant inserted 4 days before hormone IUD is removed or use backup contraception for 4 days after removal of hormone IUD and insertion of implant.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have copper IUD inserted right after hormone IUD is removed. No overlap required.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Goal of 7 days of overlap between old and new methods.
-Start pill pack 7 days before copper IUD is removed or use backup contraception for 7 days after removal of copper IUD and starting pill pack.
-Actions:
New OCP prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient taking new OCP
-Goal of 7 days of overlap between old and new methods.
-Place patch 7 days before copper IUD is removed or use backup contraception for 7 days after removal of copper IUD and placing patch.
-Actions:
Patch prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient using patch
-Goal of 7 days of overlap between old and new methods.
-Insert ring 7 days before copper IUD is removed or use backup contraception for 7 days after removal of copper IUD and inserting ring.
-Actions:
Vaginal ring prescribed and patient to pickup on pharmacy
No HCG test required
HCG negative
HCG ordered and f/u results prior to patient inserting ring
-Goal of 7 days of overlap between old and new methods.
-Have first injection 7 days before copper IUD is removed or use backup contraception for 7 days after removal of copper IUD and first injection.
-Actions:
Progestin IM injection ordered and to be administered in clinic
Progestin IM injection prescribed, instructed to pickup on pharmacy and bring to clinic for administration
No HCG test required
HCG negative
HCG ordered and f/u results prior to injection being administered
-Date estimated/anticipated given:
-Next window:
calc value
score1=(DepoDate7).dateAdd(77)
THRU
calc value
score1=(DepoDate7).dateAdd(105)
11-15wk range backed by high quality evidence of efficacy
.
-If miss window for next injection, will need pregnancy test prior to injection.
-Goal of 4 days of overlap between old and new methods.
-Have implant inserted 4 days before copper IUD is removed or use backup contraception for 4 days after removal of copper IUD and insertion of implant.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
-Have hormone IUD inserted right after copper IUD is removed and use back-up method for 7 days.
-Actions:
patient referred for procedure
procedure performed at same visit & see procedure note
patient appt scheduled for procedure
Not applicable - please select two different methods.
Not applicable - please select two different methods.
Not applicable - please select two different methods.
Not applicable - please select two different methods.
Not applicable - please select two different methods.
Not applicable - please select two different methods.
-Additional guidance:
-Using external condoms - use a new condom with each intercourse, pull out before penis gets soft wile holding onto the condom's ring, use a polyurethane condom is allergic to latex, 82% effective with proper use
-Using internal condoms - use a new condom with each intercourse, use extra lubrication as needed, 79% effective with proper use
-Using spermicide - insert more spermicide each intercourse, insert spermicide deep into vagina shortly before intercourse, 72% effective with proper use, may use condoms as well (to protect against HIV/STIs, increase effectiveness)
-Using withdrawal/coitus interruptus method - pull penis out of vagina BEFORE ejaculation, does not work if penis not pulled out in time, 78% effective with proper use
-Using fertility awareness/calendar method - predict fertile days by (1) taking temperature daily, (2) checking vaginal mucus for changes, AND/OR (3) keeping a record of menses; works best if using more than one of these methods; avoid intercourse or use condoms/spermicide during fertile days, 76% effective with proper use
-Using breastfeeding/lactation amenorrhea method - nurse at least every 4 hours during the day and at least every 6 hours at night, must breastfeed exclusively (not bottles/formula/food), no long considered effective once first menses starts or 6 months after childbirth whichever comes first; 95% effective with proper use
-If using emergency contraception pill method - works best the sooner it is taken after unprotected intercourse, can take pill no more than 5 days after unprotected intercourse, if pack contains 2 pills then take both pills together, can get some brands without prescription, 58-94% effective with proper use
-Breast CA screening with imaging
F 50-79yo or higher risk based on shared decision making
-
patient declined
patient requested
ordered
not indicated for patient at this time
-BRCA risks assessment tool
assessment tool website
- per risk tool
risk lower than average
risk average
risk above average
-Breast CA primary prevention with medication
-
patient declined
patient accepted/agreed
ordered
-GC and Chlamydia screening
F under 24yo or high risk behavior
-
patient declined
patient requested
ordered
not indicated for patient at this time
-DM screening
M/F 40-70yo or other risk factors
with FPG/A1c -
patient declined
patient requested
ordered
not indicated for patient at this time
-Falls Prevention exercise interventions
M/F >65yo with increased risk(s)
-
demonstrated
provided handout
not indicated for patient at this time
-Folic Acid supplementation of 0.4-0.8mg daily
F of reproductive age and capability
-
not indicated for this patient
provided information
patient agreed/accepted
ordered
gave info about OTC options
patient declined
-Healthy diet and physical activity counseling
M/F overweight/obese or other CV risks
-
patient declined
patient agreed to discuss
discussed with specific mutually agreeable recommendations given
not indicated for patient at this time
-Hepatitis C virus screening
M/F ages 18-79
-
patient declined
patient requested
ordered
not indicated for patient at this time
-HIV PrEP
M/F at high risk of HIV acquisition
HIV high risk criteria for PrEP
(1) MSM & sexually active with 1+ of:
-sexual relationship with partner with HIV
-inconsistent use of condoms during receptive/insertive anal sex
-had STI with syphilis, GC, or Chlamydia within past 6 months
(2) F Heterosexual, sexually active with 1+ of:
-sexual relationship with partner with HIV
-inconsistent use of condoms with partner with unknown HIV status AND high risk for HIV (eg. injects drugs, MSM)
-had STI with syphilis or GC within past 6 months
-
patient declined
patient requested
ordered
not indicated for patient at this time
-HIV screening
M/F 15-65yo at increased HIV risk
-
HIV high risk activities:
-MSM
-Injection drug use
-Anal sex without condoms
-Vaginal sex without condoms AND 1+ partner of unknown HIV status
-Exchanging sex for drugs/money
-Previous STIs or sex with partner with STI
-Sexual partner with HIV or partner at high risk for HIV
-Requesting testing for other STIs
low risk (no risk factors)
no testing ordered
risk factors present and testing recommended
patient agreed to testing
testing ordered
patient declined testing
patient requests testing
-Lung CA screening with Low-dose Lung CT
M/F 50-80yo, 20 pack-year hx, current or quit 15yrs ago or less
-
not indicated
patient declined
patient accepted/agreed
ordered
-Obesity counseling and multicomponent behavioral interventions
M/F, obese
- reviewed BMI,
patient declined discussion
patient agreed/acknowledged
discussed multicomponent behavioral intervention options
provided patient handout
patient referre for multicomponent behavioral interventions
MCBIs are programs with group sessions 12+ in first year that-
(1) help patients make healthy eating choices
(2) encourage patients to increase physical activity
(3) help patients monitor their own weight
-Skin cancer behavioral counseling
M/F 24yo or younger with fair skin/high-risk skin type
-
patient precontemplative
patient contemplative/accepted
provided education/handout
-Osteoporosis screening with BMD testing
F >65yo or postmenopausal, or risk of major osteoporotic fracture greater or equal for >65yoF
-
not indicated
patient declined
patient accepted/agreed
ordered
-STI counseling
M/F adolescent/adult at increased risk for STI
- provided information about
what STIs are
how STIs are transmitted
behaviors that increase risk of transmission
condom use
safe sex practices, problem solving, and goal setting
-Statins for primary prevention of CVD
M/F 40-75yo, 1+ CVD risk factors AND 10%+ CVD event risk
-
not currently indicated for patient
patient agreed/accepted
patient declined
patient already taking
ordered
refilled
-Colorectal cancer screening
M/F 45-75yo or high risk
-
patient uptodate
patient declined
patient accepted/agreed
referred for colonoscopy (q10yrs)
ordered FIT-DNA (q3yrs)
ordered FIT (annual)
referred/scheduled for flexible sigmoidoscopy (q10yrs) and FIT (annual)
ordered CT colonography (q5yrs)
-Discussed the following vaccinations based on CDC recommendations:
CDC Adult Immunization Schedule
-Influenza Vaccine, annually
≥19yo
-
≥19yo for inactivated (IIV) or recombinant (RIV); 19-49yo for live attenuated (LAIV)
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Tdap/Td q10yrs
≥19yo, either Tdap or Td acceptable, ensure ≥1 Tdap
-
patient uptodate
patient declined & will continue to address each visit
patient accepted
Td to be given at today's visit
Tdap to be given at today's visit
-Measles/Mumps/Rubella Vaccine
19-64yo, 1 dose for all; for healthcare workers 2 doses ≥4wks apart
-
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Varicella Vaccine
19-49yo
-
2 doses 4-8wks apart
if no evidence of immunity or healthcare worker
evidence of immunity, no vaccination required
↑ evidence of immunity:
-U.S.-born before 1980 (except for pregnant women and health care personnel
-documentation of 2 doses varicella-containing vaccine at least 4 weeks apart
-diagnosis/verified hx of varicella or herpes zoster infection by a health care provider
-laboratory evidence of immunity or disease
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Zoster/Shingles Vaccine
≥50yo
-
Zoster recombinant (Shingrix) 2 doses 2-6mos apart (≥4wks min)
preferred, ≥50yo
Zoster live (Zostavax) 1 dose
if Shingrix not feasible, 60-65yo
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-HPV Vaccine
≤26yo recommended, 27-45yo with shared decision making
-
3 doses at 0,1,6mo interval (≥4wks #1-#2, ≥12wks #2-#3, ≥5mo #1-#3)
if ≥15yo at initial vaccination
1 dose
if 9-14yo at initial vaccination and had 1 or 2 doses less than 5mo apart
series complete
if 9-14yo at initial vaccination and had 2 doses ≥5mo apart
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Pneumococcal Vaccine
≥65yo or 19-64yo with specific conditions
-
PPSV23 1 dose (recommended)
also PCV13 1 dose (with shared decision making, will give PCV13 + PPSV23 ≥1yr later)
↑ ≥65yo without risk factors -or-
≤64yo with chronic heart/lung/liver disease, diabetes, alcoholism, cigarette smoking
1 dose PCV13 + PPSV23 #1 ≥8 wks later + PPSV23 #2 ≥5yrs later
↑ ≥19yo with CSF leak or cochlear implants or immunocompromised by:
-congenital or acquired immunodeficiency (ie. B/T lymphocyte deficiency, complement deficiencies, phagocytic disorders, HIV infection)
-chronic renal failure, nephrotic syndrome
-leukemia, lymphoma, Hodgkin disease, generalized malignancy
-iatrogenic immunosuppression (ie. drug or radiation therapy)
-solid organ transplant
-multiple myeloma
-anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies)
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Hep A Vaccine
≥19yo if desires or at risk
-
Hep A risk factors:
-Chronic liver disease (e.g., persons with hepatitis B, hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, ALT or AST level greater than twice the upper limit of normal)
-HIV infection
-Men who have sex with men
-Injection or noninjection drug use
-Persons experiencing homelessness
-Work with hepatitis A virus in research laboratory or with nonhuman primates with hepatitis A virus infection
-Travel in countries with high or intermediate endemic hepatitis A
-Close, personal contact with international adoptee (e.g., household or regular babysitting) in first 60 days after arrival from country with high or intermediate endemic hepatitis A (administer dose 1 as soon as adoption is planned, at least 2 weeks before adoptee’s arrival)
-Pregnancy if at risk for infection or severe outcome from infection during pregnancy
-Settings for exposure, including health care settings targeting services to injection or noninjection drug users or group homes and nonresidential day care facilities for developmentally disabled persons
2 dose series (Havrix/Vaqta)
Havrix 6-12mo apart, Vaqta 6-18mo apart
HepA/HepB (Twinrix) 3 doses
≥4wks #1-#2, ≥5mo #2-#3
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Hep B Vaccine
≥19yo if desires or at risk
-
Hep B risk factors:
-Chronic liver disease (e.g., persons with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, ALT or AST level greater than twice upper limit of normal)
-HIV infection
-Sexual exposure risk (e.g., sex partners of HBsAg-positive persons; sexually active persons not in mutually monogamous relationships; persons seeking evaluation or treatment for a sexually transmitted infection; men who have sex with men)
-Current or recent injection drug use
-Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAg-positive persons; residents and staff of facilities for developmentally disabled persons; health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids; hemodialysis, peritoneal dialysis, home dialysis, and predialysis patients; persons with diabetes mellitus age younger than 60 years and, at discretion of treating clinician, those age 60 years or older)
-Incarcerated persons
-Travel in countries with high or intermediate endemic hepatitis B
-Pregnancy if at risk for infection or severe outcome from infection during pregnancy. Heplisav-B not currently recommended due to lack of safety data in pregnant women
Heplisav-B 2 dose series
≥4wks apart
Engerix-B or Recombivax HB 3 dose series
0,1,6mo (≥4wks #1-#2, ≥8wks #2-#3, ≥16wks #1-#3)
HepA/HepB (Twinrix) 3 doses
≥4wks #1-#2, ≥5mo #2-#3
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-Meningococcal Vaccine
≥19yo with certain conditions
-
MenACWY (Menactra/Menveo) 1 dose
↑ First-year college students who live in residential housing (if not previously vaccinated at age 16 years or older) and military recruits
MenACWY (Menactra/Menveo) 1 dose initially and q5yrs (if risk remains)
↑ Travel in countries with hyperendemic or epidemic meningococcal disease, microbiologists routinely exposed to Neisseria meningitidis
MenACWY (Menactra/Menveo) 2 dose series ≥8wks apart and q5yrs (if risk remains)
↑ Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use
MenB-4C (Baxsero) 2 dose series (≥1mo apart), booster in 1yr then q2-3yrs
MenB-FHbp (Trumenba) 3 dose (0,1-2mo,6mo) or 2 dose (≥6mo apart) series, booster in 1yr then q2-3yrs
↑ special situations:
-Anatomical or functional asplenia (including sickle cell disease), persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use
-Microbiologists routinely exposed to Neisseria meningitidis
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
-HIB type B Vaccine
≥19yo with certain conditions
-
HIB-B 1 dose (preferably 14d prior to elective splenectomy
↑ anatomic/functional asplenia
HIB-B 3 dose series (each ≥4wks apart) 6-12mo after successful transplant (regardless of prior HIB vacc)
↑ hematopoietic stem cell transplant
patient uptodate
patient declined & will continue to address each visit
patient to receive at todays visit
Additional issues discovered/addressed:
none
speech input
DISPOSITION
-Followup:
routine f/u visit not indicated
day(s)
week(s)
month(s)
with PCM
with unit provider
f/u free text
-Explained the above assessment and plan to patient who:
acknowledged understanding and intent to follow through with plan
desires second opinion
coding blurbs
-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
-Laboratory results as displayed were reviewed and interpreted
-Radiologic study results as displayed were reviewed and interpreted
-Radiologic study images which results are displayed in note were reviewed and interpreted
-Pap smear was performed and sample collected at today's visit, sample to be sent to lab for analysis
Virtual Encounter Verbage
*
- Spent
minutes via
realtime audio/video communication
voice-only/telephone
asynchronous secure text messaging
involving obtaining/reviewing history,
conducting visual exam
discussing test results
discussing workup
discussing above plan
patient education
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