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VA CLINICs

The VA Clinic rotation is designed to provide exposure to multiple different subspecialty outpatient clinics. Afternoon clinic is staffed by the 3 residents assigned to each of the following services: VA Senior, VA Clinic and VA LP. Each clinic has a focused subspecialty including Neurodegenerative, Epilepsy, Neuromuscular, Multiple Sclerosis or Stroke and will have oversight by attendings who are experts in these fields.

‍DAY 1

  • Make sure you have VA access. If you do not have remote access at home, consider calling for a PIV exemption to be able to access charts from home.

  • Also make sure you have completed TMS training for VVC (video visits).

  • Check which resident is on VA LP- if it is a PGY2 who is not signed off to independently perform LPs, you will be responsible for supervising their VA LPs on Fri.

  • You should have received an email from Renee or Latasha with the clinic schedule for Monday afternoon. If not, reach out to one or both of them: latasha.haire@va.gov, renee.hall2@va.gov. This email should also list the supervising attendings for that day.

  • Go to the VA team room right after midday didactics. You may check VetLink to see when your assigned patients have checked in, or the MA for that day will come to the team room and let you know.

TEAM STRUCTURE

Subspecialty Attending(s): Responsible for staffing all patients. Should be available to physically see all patients with PGY2s, all new patients, and any patient for whom there is concern about management.

Residents: Responsible for evaluating and managing all patients but will typically be responsible for seeing follow up patients. Prior to seeing each patient you should review their chart to determine the disease process that is being treated (reminder while patient may be listed as in the stroke clinic they may have neuropathy or seizures etc) as well as the plan that has been established. Each clinic note should end with a concise plan for which studies should have been completed and need follow up as well as potential next steps in evaluation and management.

‍There are typically 3 residents assigned to VA Clinic as described above, as well as any rotators. All should be expected to see and evaluate a similar number of patients. However, the VA Senior may occasionally be pulled away from clinic for more urgent inpatient consults (details for triaging provided under VA Senior guidelines) and so it is expected that the VA Clinic and LP resident will work together to see all patients in a timely and efficient manner. The VA Senior will be responsible for working with the case managers to help manage the flow and triage of clinic.

All new patients seen will need to be staffed and seen with an attending prior to being sent out of the clinic. For follow up patients the PGY-2 (and any additional providers) is expected to present each case to the attending prior to their leaving the clinic. PGY-3 residents may send follow-up patients out of the clinic and present the cases at the end of clinic or when the attending is free. When in doubt about a patient’s working diagnosis or management, please discuss with an attending before sending the patient out from clinic.

Students: Students may join a resident or attending and should be encouraged to do at least part of the evaluation on their own when possible.

SCHEDULE

In VA subspecialty clinic on Mondays, Thursdays, and Fridays, residents will see patients as assigned and staff them with the attending. The assignments should go out via email either the day before or the morning of clinic. ‍Afternoon clinics begin at 12:30 PM and you should report as soon as Midday Didactics have finished.

Some weeks, there will also be a clinic on Thursday morning. You should check with the admin staff or check the clinic schedule in CPRS (see below) to see if this clinic is taking place.

You will also have at least one weekly continuity clinic scheduled at Frenkil during VA clinic. This will be Tuesday afternoon, Wednesday morning, or both.

‍All residents are expected to be at Morning Report (each day during the summer, Tue/Thu the rest of the year) at 7:45 AM, and at Midday Didactics at 11:30 AM (12:30 AM on Wednesdays).

PATIENT FLOW

Patients arrive to the clinic and check in at the 4A desk. The MAs will room the patients and either call or come to the team room to alert the residents that a patient has arrived.

If you have a telephone or video visit, you may call the patient from an exam room at the stated time.

When the patient’s visit is completed there is an instruction sheet that should be completed and handed to the patient with any plans for follow up testing, management changes and follow up. Residents are encouraged to determine patient need for follow up. With many stable disease processes (ie prior stroke, diabetic neuropathy, migraine etc) that have had completed work up and do not require a specialist, patients should be discharged back to care of their PCP to return only as needed for additional consultation.

Scheduling follow up visits for a patient should be completed by placing an order for “Return to Clinic” with the specified time frame for their return. Patients will receive a letter when it is time to schedule their next visit.

 

NOTES AND DOCUMENTATION GUIDELINES

Clinic notes should all use the templates provided in CPRS. Please speak with Liz or one of the senior residents for help finding and saving our shared templates. These templates have multiple fields that will autopopulate for you to include information such as PMH, Current Medications, Vital Signs and labs. 

**You will need to add the patient data object for Medication Reconciliation to your template for each patient.**

Currently, the clinic is designed as a non-continuity clinic and so you will not necessarily be evaluating any patient a second time in the future. This means that your notes must be very clear in order to ensure appropriate and fluid care for our patients. Each note, especially for follow ups, should concisely identify the course of the patient’s neurologic disease and management. A clear “Assessment and Plan” should be written describing your impressions and thought process for any testing or treatment planned. It is also helpful for your colleagues if you provide a bulleted version of the plan for follow up as well as including a plan for the next visit.

When you begin a note, you will identify the attending that will co-sign your note. You can change this later if needed. After a note has been signed you can right-click the note and select “Identify Additional Signers” in order to add a case manager or PCP that should be notified of your recommendations.

After signing your note, CPRS will take you to the billing page where a level of care, diagnosis and service connection must be completed. The encounter will not be able to be closed without this information.

REQUESTS FOR RESPITE CARE

For inpatient or in home respite---service connection does matter for inpt respite.  Also, patients cannot have been in acute care within 30 days before a respite stay. 

Inpatient respite is done in the CLCs and is NEVER guaranteed because it depends upon what their bed availability is at the time respite is needed (they CAN cancel it last minute and the family has to be prepared for that possibility).  In home respite is HHA service offered for expanded hours for up to 30 days per calendar year.

Usually the SW (typically PACT SW or the primary SW working with the patient) enters those requests and communicates outcomes/feedback to the family.

For in-home respite services it is Nicole Trimble and Nicole Kaiser that would be points of contact and a Community Care In-Home Respite consult has to be entered.

If appropriate for inpatient respite consideration, a GEC screening consult needs to be entered.

TIPS

Clinic Schedules are available in CPRS. After logging in, a box will appear in the center of the screen where you can search for patients and see notifications. In the upper left corner of the box there are various lists you can select. Click the one for "Clinics". Search for "BT Neurology _____ (stroke, seizure, degenerative, etc) for the follow up patients. New patients are scheduled under "BT Neuro New/____".

If you have any questions or need help, Abuche or the various case managers are your best resource.

‍If ordering a MRI, you must complete a checklist or the study will not be scheduled. Go to “BT Add new orders” on the left side menu, and click #37 “MRI.” Once you submit the information, the MRI order will pop up and you can fill it out and sign it.

When ordering consults, please read everything before signing the order! Some services will require certain tests to be performed before they will even consider seeing the patient. Also, there may be some information you are required to fill out at the bottom of the order.

Non-formulary medications require a consult, along with a justification for why the formulary medication is not being requested. These can often get rejected if not correctly worded or filled out. If approved, they are given for 30 days.

For controlled substances, a VA badge is required along with a PIN number.

There is a VA-LP clinic to schedule patients if one is needed. They are done every Friday. Please clearly list in your note what labs you would like sent on the CSF and make sure that CBC and coags are done prior to the patient being scheduled.

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GOALS & OBJECTIVES

  • Be able to evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.

  • Appropriately order and interpret neuroimaging studies.

  • 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.

  • Incorporate feedback and develop a learning plan.

  • Review literature to incorporate evidence-based medicine in patient care.

  • Develop appropriate differential and initiate further diagnostic testing and management for movement, neuromuscular, cognitive/behavioral, demyelinating, seizure, neuro-oncologic, and neuropsychiatric/somatofoam disorders, along with headache and neurologic manifestation of systemic disease.

  • Be able to appropriately request consultations from neurologic subspecialists.

  • Be able to use non-technical terms to explain procedures, such as EEG/EMG.

Last Updated: August 16, 2021