By Dr. A. Carbonell
The reminders are used in order to address quality measures, input from these reminders are pulled into the primary care almanac and EQM data to evaluate your panel therefore it is very important to address these reminders at each visit including nursing interventions.
The way to address reminders at your visit is as follows:
I. While you are editing your note, on the lower left corner of the screen there will be a bar that says Reminders
II. When you click on that reminders bar, all applicable reminders will populate
A. Medication reconciliation must be done every PCP appointment including acute visits
B. =====Use for HIV screen order is always present, this is offered yearly to every veteran
C. All other reminders will change according to the patient, the following are pointers
1. HTN: Recheck BP – BP>139/89 Will present if the patient has a blood pressure checked in any clinic that is above this value, the blood pressure must be rechecked, and the value must be entered, elevated BP must be addressed
2. Vaccine Reminders will populate depending upon their diagnosis and age–this includes shingles, PPSV23, PCV13, HPV, flu (nurses can give flu without an order but all other vaccinations will need an order from the doctor, the order will auto populate when the reminder is addressed therefore I recommend addressing this reminder while you are in the room with the patient)
3. Hepatitis B Serology/immunization will auto populate for all diabetics and people with liver disease or elevated liver enzymes, this will prompt you to test for hepatitis B immunity and offer vaccination if this patient is not immune as Hepatitis B vaccination is indicated in these groups.
4 Heart failure ACE or ARB use will prompt you to order an ACE or an ARB in any patient with a diagnosis of heart failure, you must address this reminder and either order the appropriate medication, document if they are using from a non-VA source or document that it is an non-accurate diagnosis of heart failure to clear the remainder - make sure to remove heart failure from the problem list if the diagnosis is not accurate any longer
5. Non-VA medication update will prompt you to verify if patient is taking any over-the-counter supplements or prescriptions from an outside doctor to prevent medication duplication
6. Avg Risk Colorectal cancer screen - You must address what form of testing you are using for colorectal cancer screening; document results or document if the patient declines colorectal cancer screening through this reminder.
a. Colonoscopy Gap Reminder prompts you to look at the colonoscopy results and document when follow-up is due, this also must be addressed if present with either a new date for colon cancer screening, GI consultation for colonoscopy or GI E consultation to determine new set date if it is unclear
7. Assess statin use – Lipids (CVD/DM) - all patients with CAD should be on high intensity statin and all patients with diabetes should be at minimum on a moderate intensity statin, this reminder will prompt you to either order the appropriate statin or document that patient is getting from an outside provider or document the contraindication (myalgias - this then must be added as an allergy and to the problem list if this is why patient cannot take statin)
8. Foot exam and risk assessment - this auto populates yearly for every diabetic patient, if patient is PAVE 3 they should see the podiatrist for diabetic foot care, and you can also order them diabetic shoes from prosthetics every year and diabetic socks every 3 months if they are interested. If the patient declines the foot exam there is a section to document this within the reminder
9. Flu vaccination refused - this alerts you that the patient declined the flu vaccine, this requires you to readdress it as often the patient will agree to a flu vaccine if the doctor recommends it
10. Use for Incorrect Diabetes Diagnosis – the diagnosis of diabetes automatically creates several reminders (eye exam, foot exam, statin) - if the patient does not have diabetes you will need to remove diabetes from the problem list and use this reminder in order to inactivate all the diabetes specific reminders
D. The following are FYI reminders that only resolve when the issue is addressed
a. Consider thiazide for HTN - FYI only
b. Non- VA Data in Vista Web - this alerts you that the patient sent outside records to the VA and they have been scanned into vista for you to review
c. Diabetic Eye Exam - eye exam must be completed by the eye clinic or you must document the report from the outside eye exam
d. DM A1C >9% or not done - the patient is diabetic and either has not had an A1c completed within the last 12 months for the A1c is uncontrolled and must be addressed
e. INFO: HbA1c >8% - the A1c is above goal and must be addressed
E. The Following are typically addressed by nursing immediately prior to your visit:
1. MOVE! (Weight control) screening
2. Tobacco use screening
3. Alcohol use screening (Audit-C)
4. Depression screening
5. Homelessness/food insecurity screen
6. Hypertension education
7. Foot care education
If the patient presents for a nursing intervention or any other appointment for that matter and you notice any applicable reminders that you would like to address, you must be within an active note (can either make an addendum on the nursing note or make an administrative note if appropriate) and then address the reminder just as you would above