General
DAY ONE ADVICE
Look over your EPIC schedule for the week to get a sense of when you will have clinic and see patients.
Note that your schedule is subject to change based on cancellations and add-ons, so it is best to always check your schedule again the morning before your clinic.
Chart review patients and pre-write notes for your next clinic session. Patient records will be available either in EPIC, in a hard copy in your mailbox, or emailed to you via PDF.
For afternoon clinics (Mon, Tues, Thurs, Fri), you should go to clinic directly after lunch conference.
For morning clinics, (Wednesday), you should arrive at least 15 minute before your first scheduled visit.
Familiarize yourself with the “dot system” outlined below so you know when you should call your patient back to be seen.
Familiarize yourself with policies regarding staffing patients with attendings. This varies between PGY level and patient visit types.
KEY CONTACT PEOPLE
Kara Stevens, RN - Clinic nurse manager
Dr. Marcella Wozniak - Clinic director
Jasmine Herndon: Clinical Business Manager JaHerndon@som.umaryland.edu
AAs for the general neurology clinic:
Primary: Ashley Kaufman, AKaufman@som.umaryland.edu
Gregg Davis, GDavis@som.umaryland.edu
Hannah Diggs, hannah.diggs@som.umaryland.edu (Only if Gregg or Ashley are not available)
AAs can help with any patient needs such as the following:
Sending out orders/referrals/After visit summary
Setting up follow up appointments
Setting up hospital discharge appointments
Route letters to then to mail to patients
Scanning outside records into EPIC
There is a lot of info to remember about patient care, notes, and how the whole system works. If in doubt, ask!
SCHEDULE
Your whole clinic schedule will be known from the beginning of the year. The Attending schedule is also known in advance (but sometimes changes)- which can be important when patients need to be seen by subspecialty attendings. The attending schedule can be found on EZcall.
There will be no continuity clinic during inpatient service months. As per ACGME requirements, residents will have at least 40 continuity clinics each year and will not have more than 6 weeks between clinic sessions. During some rotations, residents will have continuity clinic one afternoon per week. Residents will have some clinics during 1-week Clinic blocks, with one continuity clinic session per day.
1-week Clinic blocks:
5 sessions of your continuity clinic: Mon, Tues, Thurs, Fri Afternoon; Wed Mornings
Wed Afternoons Grand Rounds
4 mornings (Mon,Tues, Thurs, Fri)
2 mornings: Subspecialty clinics (with priority given to Movement Disorders morning clinics)
2 mornings: Administrative time (finish clinic notes, call back patients, read about complex patient, prepare grand rounds case conference, etc.)
RESIDENT CLINIC GROUP PRACTICE AND SCHEDULING
Resident Clinic is scheduled for a maximum of 8 patient-slots per clinic ½ day. A follow up patient takes up ONE patient-slot (30 min) and a new patient occupies TWO patient-slots (1 hour).
Clinic runs from 1245-445 PM. The standard schedule template is 3 new patients and 2 follow-up patients or 2 new patients and 4 follow ups. However, if slots are open and there is a need for appointments of another type, these slots may be divided or combined.
PGY2 residents will be given more time as they are learning the system and must staff every patient:
July-September: 3 patients
October onward: Number of patient slots will gradually increase for PGY2s as the year goes on
PATIENTS
Your patient population derives from 2 different sources: the community and the hospital. Patients can be scheduled with you from outside physicians or even self-referred.
For billing purposes: A “new” patient has never been staffed by a UMMC attending neurologist in the past 3 years. Any patients seen or staffed by attending in past 3 years is a follow up for billing purposes (even though they may be new to you and new to ambulatory clinic).
STAFFING PATIENTS WITH ATTENDING
Requirements for staffing patients differs based on PGY level of resident and visit type.
PGY-2 Residents - All patients, regardless of visit type, must be seen by the attending. After seeing your patient, present the case to your attending. The attending will then see the patient with you.
PGY-3/4 Residents – The goal is for all patients to be seen by the attending. However, if required to maintain clinic workflow, some patients may be discharged from clinic without seeing the attending, with the following parameters:
Initial visits (aka new patients) - Must be seen by the attending.
Follow-up visits
When done evaluating the patient, check to see if the clinic attending is available for staffing. If the attending is not immediately available and you have another patient waiting to be seen, the patient may be discharged without seeing the attending IF you feel that the problem is straightforward, and you have a good treatment plan in place. For complex patients or those who come with a new problem, wait to staff with the attending.
For any patients that were not seen by the attending, you must present these cases to the attending later in the day. This can be done in between your patients or after you are done seeing patients.
HOSPITAL FOLLOW-UP APPOINTMENTS:
We are trying to improve patient continuity of care and transitions from hospital to clinic by informing patients of their follow-up appointments prior to discharge whenever possible (this applies to patients on the neurology service AND consults seen in the ED or on other services). DO NOT just ask the patient to call the clinic for an appointment, use the method below to arrange appropriate follow-up.
Having just cared for the patient, you know when they should need follow up. Discuss who on the team will be primary neurologist going forward (junior resident, senior resident, attending). Providers who already know the patient should maintain “ownership” for continuity. They can be scheduled for a quick hospital follow-up with another provider if primary not available, and then follow-up with primary for future appointments. You can set up both the hospital follow-up and the appointment in a couple months at the same time.
During the weeks after an inpatient rotation, residents will have some clinic appointments on hold for hospital follow-ups. Look ahead at your schedule to determine when these are so you can help facilitate getting discharge patients into those spots.
1. Send EPIC message to both Ashley Kaufman and Gregg Davis with the patient’s name in the subject. There is a smartphrase that will cue you for the required information: .UMHNEUROAPPREQUEST (you can delete sections that are not relevant).
2. For patients going home: schedule rapid hospital follow-up AND follow-up with primary neurologist who will continue to follow longer term if appropriate
a. Rapid hospital follow-up appointments: Patients with acute neurological problem discharged from hospital to home should have follow up appointment in neurology clinic in 7-10 working days. The goal of this appointment is to prevent readmissions to the hospital. You should make sure that patients understood discharge instructions and discharge medication list and have been able to obtain meds and arrange for other follow-up appointments if needed. Patients should then subsequently follow-up with their Primary Neurologist.
b. For stroke patients going home: Coordinate with Devin Williams, patient navigator, who will also work on discharge planning.
3. For patients going to rehab: request follow-up in a couple months with primary neurologist
RETAINING PATIENTS
When you see interesting or complicated patients you should try to keep them in your clinic. That said, one benefit of a tertiary care center like UMMC is the availability of experts in various subspecialties. If you think subspecialty expertise would be helpful, you have several options:
Try to schedule patient with you in clinic on a day when an attending of that specialty is the clinic attending. You can see the attending schedule for clinic on EZcall and specify a date when you message Ashley.
Discuss the patient with one of the other attendings who is in clinic that day (if they have time).
Email or discuss the patient with an attending outside of clinic hours and then follow-up with the patient regarding any recommendations.
Schedule the patient for a one-time visit with the subspecialty attending; afterwards they can follow with you (or, in some cases, with the attending)
REFERRING YOUR PATIENTS TO A SUBSPECIALTY CLINIC
When you see interesting or complicated patients you should try to keep them in your clinic. That said, one benefit of a tertiary care center is the availability of experts in various subspecialties. If you think subspecialty expertise would be helpful, you have several options:
For PGY3/4- if you see a complex patient as an initial, you should formally staff with the clinic attending, but can contact a subspecialty attending after clinic to discuss the case. For subsequent follow ups, you may ask that subspecialty attending to formally staff with you. If you feel that the patient should be seen and examined with the attending (ex. movement disorder, neuromuscular), you should try to schedule follow up on a day when an attending of that subspecialty is staffing resident clinic (attending schedule available on EZcall). Alternatively, you can coordinate with the attending's administrative assistant to coordinate a time outside of normal clinic hours to see the patient together.
For PGY2s- if you see a complex patient as an initial, you should formally staff with the clinic attending, but can contact a subspecialty attending after clinic to discuss the case. Since your follow ups are to be staffed in real time, subsequent follow up appointments with the patient should be coordinated with the subspecialty attending. You can either do this by determining when that attending is staffing resident clinic next, or Ashley can help to coordinate a follow up time with the attending's administrative assistant.
If you are having difficulty coordinating a time to see a patient with the subspecialty attending, you can try to have the patient scheduled in the attending's clinic by reaching out to that subspecialty clinic admin and requesting the first available appointment. You should let the attending know that you would like to continue following the patient after this visit.
Here is a list of clinic admins for each subspecialty department for help when you want to refer a patient to a subspecialty clinic. For divisions with multiple admins, it is suggested that you email all of them to get the first available appointment unless there is a specific attending you want the patient to see.
DOT SYSTEM
WORKFLOW WITH MEDICAL ASSISTANTS
After your patient arrives, your patients should be triaged by medical assistants (MAs) before you see them. The MAs will do the following in their triage process:
Document chief complaint
Verify allergies and perform a medication reconciliation
Take vitals
Perform health screens for home safety, fall risk, and depression
The MAs use the “dot system” in EPIC to indicate where they are in their workflow. The dot appears in the far left column in your EPIC patient schedule
If no dot is present, it means the patient has not been taken back by the MA yet
White Dot: Patient has begun meeting with the MA for their triage process
Blue Dot: Patient has completed the triage process with the MA and is ready to be seen by provider
Green Dot: Provider changes dot to green when starting their portion of the appointment
Red Dot: Provider changes dot to red when the appointment is completed
MOCA EXAMS
If you anticipate that your patient requires a MOCA exam, use the dot system to change the patient’s dot color to black at the beginning of clinic. This will signal to the MAs to perform a MOCA during triage.
If a patient arrives late or if you are running behind, you can coordinate with the MAs to see if it is okay for you to take your patient back to see before they do their check-in process. If this occurs, remember to take the patient back to the MAs for their vitals and health screenings.
Information relating to EPIC
NOTES
You are expected to write your notes within 24 hours after seeing each patient (maximum acceptable time = 48 hours). Note should be forwarded ASAP to attending for co-signature. Encounter cannot be closed completely until the attending signs.
Note templates are available on this “Helpful smartphrases” document. It can be really helpful to ask attendings or other residents if they have any other smart phrases that may be useful to you - why reinvent the wheel? You can add yourself to another user's smartphrase access list, or you can copy it to your own list.There are many different ways to write your notes. You probably already have some things that you like. Feel free to look around, discuss with other residents or attendings, to find what works for them and what works for you. Ex: some people like a copy and pasted (make sure it is clear what is copy/pasted and what is new info!) section on "past medical info" or "past testing" in their HPI. Some people will bold any pertinent positives/negatives in their exam, and highlight positives in one color, negatives in another. Using the speech to text dictation system can be very helpful; spending some time learning to use the system can save a lot of time later.
In the “Wrap Up” section of the encounter, you can select providers to route your note to. Make sure your note is complete before you make this selection.
CONTACTING PATIENTS
You can use patient reminders in Epic ("Reminder" tab at the top of the screen) to send yourself a scheduled message so you remember to check up on important testing and follow up. The tip sheet can be found here (accessible on campus).
You can send the reminder to pools, admins, or other providers in the care team.
You can delay when the reminder will be sent or set an expiration date for it.
Always use Doximity dialer, Google voice, or a similar app to disguise your phone number to call your patients. Do not use the team room phones.VACATION
Your patients might still need your help while you are on vacation. The VA LP resident is the default to cover your EPIC inbox while you are away. You must set your inbox for coverage:
On the top of your inbox click the "out" button, create a "new" out event:
Choose the dates you will be away, and to whom your messages will be forwarded (you should also put a vacation message on your email during this time as well):
CLOSING ENCOUNTERS IN EPIC AND AVOIDING THE RED REPORT
Writing your notes and signing your encounters is the best way to stay off this list, but sometimes you can end up on it even though did just that.
The Red Report is a monthly report for our entire department regarding encounter closure compliance (i.e. the note writing naughty list). Periodically you will be sent a list of encounters from this report. Please try to close each encounter
Two things you can do to avoid a large portion of these unclosed encounters are:
1. Make sure you “change provider” to yourself when covering clinics
· If you swapped or are covering clinics with someone else, you must change yourself to the provider for the patient in the EPIC schedule
· Do this by going to the EPIC schedule for the day and click “change provider”
· If you don’t do this, the encounter cannot be closed by your attending
2. Make sure your inbox doesn’t have a “chart cosign” subfolder
· This folder naturally should not occur for residents
· This folder will appear if your attending replies or forwards your chart cosign request back to you. Epic is dumb and this prompts it to reassign you yourself as the cosigner
· If you see yourself on the red report where you yourself are the assigned cosigner, this is probably what happened
· Fix this by forwarding back the encounter in the “chart cosign” folder back to the right attending
If there are other issues that prevent it from closing, please reach out to Dr. Sarah Fredrich sfredrich@som.umaryland.edu. Depending on the case, she may redirect you to the help desk helpdesk@umm.edu or other EPIC staff (Kulah Davis kdavis5@umm.edu Sara Lattanzia slattanzia@umm.edu)
GUIDE FOR HOW TO SAVE EPIC ORDERS TO PDFS AND HOW TO ATTACH THEM TO MYPORTFOLIO MESSAGES
Dr. Jin put together this helpful guide. He uses it to send orders to patients via secure e-mail or MyPortfolio along with Doximity fax for records and orders to insurance companies / testing centers. You will find it particularly helpful though when a patient needs to get an order quickly or if there are snafus on the administrative side.
OUTPATIENT BILLING CODE TIPS
1. New vs. Follow-up encounter codes: In the clinic, the attending physician is going to bill physician fee via FPI Neurology using the Level of Service tab. If a patient has been previously seen by any attending billing via FPI neurology in the past 3 years, the patient is billed as a follow up (99212 to 99215).
So even though "new" to clinic and "new" to you and attending, it is still follow up for Level of Service billing. So all hospitalized patients staffed by neurology faculty and all rehab patients seen by UMROI neurologists will be follow up encounters for professional fee billing.
2. Stroke ICD-10 codes: The acute stroke codes (ICD 10 I63.xxx) are only used during the initial or acute ischemic stroke presentation.
So when patient comes to clinic follow up, you are going to use Sequelae of stroke codes (I69.3xx). If patient does not have any residual stroke deficits, you would use Z86.73 Personal history of TIA and cerebral infarction without residual deficits.
3. This is free web site were easier to look up and see official definitions of codes. https://www.icd10data.com/
4. In Epic you can choose a code and then have a display name that is incorrect. See this all the time where "name" is cerebellar stroke but they are using I63.9 (ischemic stroke not otherwise specified) instead of I63.x4x (ischemic stroke due occlusion of cerebellar artery).
5. See also Documentation Guidelines and Epic tips page [link: https://marylandneurology.squarespace.com/epic-documentation-tips] for additional information regarding documentation requirements for billing compliance (ideally could link directly to that section of the page)
Miscellaneous Information
UTILIZING INTERPRETER SERVICES
Communicating with patients in their preferred language is a basic patient right and a Joint Commission requirement.
Find out if your patient or surrogate decision maker requires an interpreter on the left hand side of their EPIC page
If you are bilingual in the patient’s preferred language, you can provide language concordant care to obtain consent.
If you are not bilingual in the patient’s language, you may not use a family member, guest or other UMMC employee to interpret. You must obtain either a hospital-based Qualified Medical Interpreter or a Qualified Medical Interpreter using the Video Remote Interpreter device (VRI) or the Interpreter phone to obtain consent.
a. Telephonic interpreter: 8x5452
b. Video Remote interpreter: Page TALK (8255)
c. In-person interpreter: Page TALK (8255)
Print the appropriate consent form from FormFast
Speak directly to your patient or surrogate decision maker in short but complete sentences. Pause to allow the interpreter to interpret.
There are 2 lines underneath the provider’s signature line on the consent form. Check the appropriate box. Write the interpreter’s name and/or interpreter # given when using technology.
a. __ Healthcare provider is bilingual and provided language concordant care for consent
b. __ Interpreter used: Name or interpreter # _____________________
COMPETENCY BASED GOALS AND OBJECTIVES
Patient Care and Medical Knowledge:
Evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.
Appropriately order and interpret neuroimaging studies.
Interpersonal and Communication Skills:
Counsel patients and families regarding diagnosis and treatment, discuss goals of care, and negotiate conflicts among family/patient and the treatment team.
Clearly and completely document patient care in a timely fashion.
Practice-Based Learning and Improvement
Review literature to incorporate evidence-based medicine in patient care.
Incorporate feedback and develop a learning plan.
System-Based Practice
Be able to use non-technical terms to explain procedures, such as EEG/EMG.
Be able to appropriately request consultations from neurologic subspecialists.
Last Updated: October 2022