Penn Family Care Policies and Resources

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Precepting Policies

PFC Schedule Template for Residents

Phone List for Presby/HUP/CHOP

Epic Smart Phrases

Office Instructions

1. Colonoscopy
   1. Order Colonoscopy in EPIC. Print and Sign order sheet.
   2. Fill out Colonoscopy Questionnaire in EPIC. Print and Sign.
   3. Patient should obtain referral from Front Desk if required by pt’s insurance
   4. Patient must take EPIC orders and referral to GI
2. Depoprovera
   1. Write prescription for depo with appropriate amount of refills to be taken to pharmacy by patient
   2. Patient should bring depo to lab at PFC to be given
   3. For refills, have patient fill at pharmacy on way to office for scheduled shot
3. EPIC messaging instructions
   1. Pools
      1. “P PFC” in the TO box
      2. Allows messages to be sent to groups of people in each pool
      3. If any provider "done"s it, it is removed from all boxes
   2. Classes
      1. "C PFC" in the TO box
      2. Use class messages when people want to send something to be seen by all
      3. Each person has to "Done" it individually to remove it from their box
      4. Should not be used unless every person needs to see the message
4. Epic Result Pools
   1. Time sensitive results should be responded to by the physician checking the pool if the pmd is not immediately available.
   2. Non-urgent results can be “done’d” out of the shared result pool box.
   3. Non-urgent results do not need to be forwarded to the ordering physician. The ordering physician will already be receiving a copy of the result.
   4. Exception to “c” above: results from lab visit only tests should be forwarded to the pmd as they may not receive a copy from these tests.
   5. Weekends: time sensitive results from all physician team pools (Blue, White, Red, Green) should be checked and responded to appropriately.
5. Forms
   1. General
      1. During office visit: completing forms is considered part of the work of the visit; ideally done during the visit.
      2. Outside of visit: there is a $20 fee to be paid when the form is dropped off.
      3. Office policy is not to do refills, give referrals, or otherwise provide service to patients with no visit for a year. May give one month supply of medicine while patient is making appt to be seen.
      4. If the form arrives with no notice that a fee was paid, you may either complete it, or return it (completed or not) to the front with a note that patient needs to pay form fee.
      5. Once fee is paid, we are obliged to complete the form and return it in a timely fashion (ideally a day or two)
      6. Patient's need for utilities, inability to work, etc. is provider’s decision.
   2. Requests for records
      1. Patient, physician or patient's attorney requests are generally completed at no charge.
      2. Indicating what records you feel should be provided (e.g. date range, progress notes, appropriate labs, xrays, consultants' letters, etc.) will help staff carry out these requests.
   3. Social Security Disability Forms
      1. Generally given option of a dictated report, completing forms, or providing records. The third of these is often most efficient.
      2. They allow a payment for duplication of records
      3. The amount should be marked on the invoice (there is a space for this), and it should be signed and placed in the record request bin on 6th floor.
   4. Life insurance Forms
      1. Request for records should be placed in records request bin
      2. Record reproduction fees up to $50 are generally allowed
      3. General request of $50 for patients with more extensive records; somewhat less for patients with simple records.
   5. "Subpoena" from courts
      1. Includes requests for records from attorneys opposing our patients in law suits.
      2. Best practice is to check with the patient if they give us permission to provide the record. If the patient consents the records are sent.
      3. The court may allow a fee for duplication; we should charge up to $50 if allowed
      4. If the patient does not consent to release, then their attorney needs to file a motion with the court blocking the request.
6. IUDs/Colpo ordering
   1. Patient must get insurance clearance PRIOR TO appointment for IUD insertion
   2. Once cleared, ask nurses for IUD
   3. Code for both procedure and device in EPIC
7. Laboratory Policies
   1. Communication regarding Missed Blood Collection
      1. The phlebotomist will contact (by pager or phone) the ordering physician or his/her designee regarding the fact that a specimen could not be obtained.
      2. This communication will occur for any missed specimen whether the order is STAT, Routine, or Blood culture.
      3. For the Early AM round; if, after 3 attempts, the phlebotomist is not successful in collecting blood, that information is conveyed to the ordering physician or his/her designee
      4. For the Early AM round: if a patient is not in the room for the collection round, that information will also be conveyed to the physician as well as the fact that a phlebotomist will return at 11 am to collect the specimen.
      5. For the 3PM and 7:30 PM Rounds: if the phlebotomist is unsuccessful, then the physician who ordered the test will be paged and notified.
      6. For STATS and Blood cultures: if the phlebotomist is unsuccessful, then the physician who ordered the test will be paged and notified.
8. Legal Requests
   1. If requested by lawyer, may respond stating will consider preparing narrative report for fee (Dr. Nicklin: $200 for preparation of the report; $300-$350 if complicated).
   2. Payment should be received in advance
   3. If receive payment, can block office hours to prepare
   4. Residents should review with medical director, or another attending, and get cosigned.
   5. If you provided care, you are required to provide an appropriate record.
   6. You are not required to provide a narrative summary; law firms should pay you for it.
   7. Depositions: Should bring a check sufficient to cover the time they estimate it will take. Same principles involved. (Dr. Nicklin’s fee: $250/hour)
9. Narcotic Prescribing Guidelines (see contract smartphrase language here - Narcotic Contract Language)
   1. Because of issues around habituation, dose escalation, and diversion, one doctor needs to regulate and supervise chronic narcotic prescribing for each patient - it cannot be a shared activity among the doctors in the practice.
   2. Our office policy is that 100% of the patient's prescriptions for chronic narcotics must be provided by one doctor, and one doctor only.
   3. If the patient runs out, and her doctor is away for a week, he/she will need to wait for her doctor's return.
   4. No narcotics should be provided by any other doctor, or by the residents covering nights and weekends.
   5. If the patient calls in for a refill of narcotics, the message will be sent only to their one doctor, and the patient may not hear back for some time. To avoid frustration for the patient, and the practice, he/she should be told to make regular appts with the doctor prescribing narcotics in the practice, and the provider must write for enough narcotics at that visit to last until the next scheduled visit.
   6. Monthly visits will often be required. The patient should understand if they no-show for a visit, it will result in their running out while waiting for the next visit, so the patient should make every effort not to no-show.
   7. Initiating a plan to use chronic narcotics for pain control should start with a long conversation with the patient, including discussion of the management of the chronic pain, issues around addiction and abuse which are always a concern with these drugs, and how we will monitor for problems.
   8. The patient should understand that successful use of these drugs requires a strong partnership between the patient and ONE physician in our office. At the end of this initial visit, depending upon the symptoms and the relationship with the physician, the doctor may prescribe narcotics, or may suggest other approaches.
   9. We generally favor other modalities than narcotics for the management of chronic pain (e.g. PT, trigger pt injections, tricyclic antidepressants, TENS units, non-narcotic analgesics), because of the problems with habituation and abuse with narcotics.
   10. If the decision is made to prescribe narcotics, reviewing this policy with the patient, and having them repeat back the key elements of it, is important. There should be great clarity about the fact that the pills being provided are to last to the next appt, and that if they lose the prescriptions or medication, they will not be replaced before the next regular interval. Patients should schedule the follow up appt when they anticipate getting their next prescription before leaving the office.
10. Orthopedic/Sports Medicine Supplies
    1. Order orthopedic supply
    2. Ask MA to retrieve item from 6th floor supply room
    3. Fill out supply form including patient’s insurance info
    4. Patient needs to sign supply form
11. Radiology
    1. Order study in EPIC. Be sure to specify With or Without Contrast
    2. Print and Sign order sheet
    3. Patients go to Front Desk for Referral if required by insurance plan
    4. Patients schedule own study if able. General scheduling numbers - HUP 215-662-3000, Presby 215-349-5454
    5. Physician should call department personally if study STAT or urgent
    6. Patients should take epic order sheet and referral if needed to radiology
12. Referrals
    1. Consultants/Specialists
       1. Order referral in EPIC
       2. Patient just needs phone number for office to make appointment
       3. Patients go to Front Desk for Referral if required by insurance plan
       4. Patient should take referral to appointment. Do not need order sheet.

Clinical Reference

1. Coding
   1. Preventive visit requirements: hpi, pmh, psh, soc, famhx, 9 system ros, 10 system exam
2. Coumadin Dosing Guidelines (based on INR 2 to 3)
   1. less than 2
      1. 1. Increase weekly Coumadin dose by 5 to 20%
   2. INR 3 to 3.5
      1. Decrease weekly Coumadin dose by 5 to 15% or
      2. Maintain same dose and recheck in 7 days
   3. INR 3.6 to 5.0
      1. Consider withholding one Coumadin dose
      2. Decrease weekly Coumadin dose by 10 to 15%
   4. INR 5.0 to 10.0
      1. Withhold 1 to 2 Coumadin doses
      2. Decrease weekly Coumadin dose by 10 to 20%
      3. Indications for Vitamin K
         1. Risk of bleeding: Vitamin K 1 to 2.5 mg PO x1 dose
         2. Surgery in 24 hours: Vitamin K 2 to 4 mg PO x1 dose
   5. INR exceeds 10.0
      1. Hold Warfarin
      2. Vitamin K 3 to 5 mg PO x1 dose
      3. Monitor INR daily and consider repeating Vitamin K
      4. Anticipate significantly lower INR within 24-48 hours
   6. Serious or Life-threatening bleeding (esp. INR >20)
      1. Replace Clotting Factors
         1. Vitamin K 10 mg by slow IV infusion
         2. Fresh Frozen Plasma (FFP) 15 ml/kg
         3. Prothrombin Complex Concentrate (PCC) 50 U/kg
         4. Recheck INR at 6 hour intervals
         5. Consider repeating Vitamin K at 12 hours
3. Immunizations
   1. Immunization info at www.immunize.org including VIS's, CDC statements, much more
   2. Philadelphia Childhood immunization registry 215-685-6784 https://kids.phila.gov
   3. CDC immunization website: http://www.cdc.gov/nip/recs/child-schedule.htm
      1. Anthrax - IM
      2. DTAP - IM
      3. Hep A - IM
      4. Hep B - IM
      5. Hib - IM
      6. Influenza - IM
      7. Meningococcal - SQ
      8. MMR - SQ
      9. IPV – SQ for kids, IM for adults
      10. Prevnar – IM
      11. Pneumovax - IM
      12. Rabies - IM
      13. Smallpox - IM
      14. Td - IM
      15. Tdap - IM
      16. Varicella - SQ
      17. Yellow Fever - IM
4. Insurance
   1. Capitated
      1. Keystone Mercy
      2. Keystone East
      3. Health Partners
   2. Fee for Service
      1. Personal Choice
   3. PACE criteria
      1. Insurance @ $1200/month
      2. PA residents > 65 yo
      3. Pharmaceuticals > 65 yo 80% cover by pt
5. Pap smears
   1. Management Guidelines: www.asccp.org