ahlta vitals module training to support tswf nursing service … · 2019-03-21 · ahlta vitals...

“Medically Ready Force…Ready Medical Force”

AHLTA Vitals Module training to support TSWF Nursing Service AIM form

Serial Blood Pressure Check


Purpose of Training

• Standardized usage of the AHLTA Vitals Module.

• Standardized workflow for the documentation of serial Blood Pressures.

• Standardized workflow for the documentation of orthostatic Blood Pressures.

• Meet MHS Coding Guide (4.1.2) recommendations.


Vitals Module: (overview)

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*Cannot use T-Con appointment type(no vitals entry field is available).

B/P & HR reading for each arm must be entered separately into the Vitals module.

Workflow options to recording B/P over time: 1) Recommended is a Single encounter for each day to recorded B/P for each visit (AM/PM) (Walk-in, Same Day)or2) Log all results on paper and transcribe when all B/P measurement are obtained and enter as a single summary visit.


Vitals Module: (overview)

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When recording the Manual B/P readings you must include which arm and type of cuff.

The ellipsis button next to the BP entry field allows you to add appropriate left / right arm and cuff size modifiers.

Record B/P & Heart Rate

Use the “Comments” field to state which serial # (day#) the measurement is for. This will make identifying the appropriate measurements easier when averaging for the final visit.

Click OK to complete.


Workflows B/P entry: (Log or Walk-in)

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Walk-in visits: single day encounters: 1. Leave encounter open from AM to PM B/P measurements. 2. Complete a separate S/O for the AM and PM visit using the TSWF Nursing Services content. (Do Not use the ‘edit S/O’ option)3. Close the note after the PM visit.

To enter multiple reading from a log: 1. From an open Vitals Entry, modify date & time, record B/P & HR click OK

Modify the Date & time using the “Date” button or enter directly. *Time is entered directly in 24hr format must be HH:MM including the “:”

2. Repeat until all readings in the log are recorded.3. Complete TSWF-content in the S/O


Workflows B/P entry: Final Note

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1. Complete the final B/P Measurement. 2. Calculate average B/P measurements.

See link to the downloadable Average B/P calculator in TSWF-Nursing Service AIM form.

3. Complete TSWF-S/O content including the averages.

Options to view B/P values.1. Vital sign entry “Review” tab. This is the only location the Vitals can be edited/corrected, until the note is signed.

Selecting each line will show the comments to see which arm the measurement is for.


Workflows B/P entry: Final Note (cont.)

2. The “Vital Signs Review” in the Health History Folder List. (unable to edit vitals here)

Selecting each line will show the comments to see which arm the measurement is for.


Adding B/P reading to the final Provider’s Note

From the Current Encounter screen, open the Options menu


Adding Serial B/P to the final Provider’s note (cont)

Check the ‘Vitals’ check box and enter the # of days necessary to capture all the B/P reading completed for the serial B/P

Click ‘Ok’


Adding Serial B/P to the final Provider’s note (cont)

All of the vitals for that time period will be AutoCited into the note.

The Provider will need to unselect the ‘Vitals’ in Options during the next Patient’s encounter or the Vitals will continue to AutoCite in all the following patient’s notes.


Presentation of vitals (Note View)

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Note View of vitals in AHLTA using a B/P log (top)

OR view of single day’s measurements. (Bottom)


Documenting Orthostatic Blood Pressures

From an open Vitals Signs Entry, click ‘Display Orthostatic’


Documenting Orthostatic Blood Pressures

To enter multiple reading from a log: 1. From an open Vitals Entry, modify the date & time, record B/P for the appropriate position and click OK.

Modify the Date & time using the “Date” button or enter directly. *Time is entered directly in 24hr format must be HH:MM including the “:”

2. Repeat until all readings in the log are recorded.3. Complete TSWF-content in the S/O


Coding IAW DHA Coding Guide section 4.1.2

The CSS selects the appropriate Diagnosis related to Providers order.

If no Dx exists in the problem list, use the following ICD-10 and always the procedure code.

• Dx code R03.0 “Elevated blood pressure reading, without diagnosis of hypertension”

• Procedure code 2000F “Assessment & Intervention Pressure Measured”

Non-Privileged Providers. The following clinic services are not considered codable events:

• Blood pressure checks per patient request

See the TSWF List Management training to build A/P Diagnosis and Procedure Codes Favorites List in AHLTA (http://www.tswf-mhs.com/support/how-to-videos/)

http://www.tswf-mhs.com/support/how-to-videos/


TSWF Resource Material

The TSWF repository for training/educational materials and updates:www.tswf-mhs.com/


Comments or Feedback

Contact

• Form feedback / discussion forums: https://www.milsuite.mil/book/groups/tswf

• TSWF resources / educational materials: www.tswf-mhs.com

• Local Clinical Systems Trainer (CST)

https://www.milsuite.mil/book/groups/tswf

https://www.tswf-mhs.com/


TSWF Content Management Sub-Working Group

▪ CHAIR - Maj Matthew J Royall▪ ARMY - Dr. Robert Marshall▪ NAVY - CDR Anja Dabelic▪ AIR FORCE - Lt Col Thomas Mahoney▪ DHA – CPT Hudson-Odoi

TSWF Feedback https://www.milsuite.mil/book/groups/tswfTSWF Website http://www.tswf-mhs.com/

https://www.milsuite.mil/book/groups/tswf

http://www.tswf-mhs.com/

ahlta vitals module training to support tswf nursing service … · 2019-03-21 · ahlta vitals...

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