Appendix

Reference Information

Up To Date is a CD ROM based reference guide some attendings have. It is a fabulous quick reference that can be easily used during a clinic visit. Unfortunately, we cannot access most of healthlinks.washington.edu and all the lovely resources that it has. You can, however, get individual access to many useful sites such as MDConsult, NEJM, Lancet, by contacting the UW library.

Various reference books are available in attending offices. They are eager to share these resources. In addition, Beacon Hill has a resident teaching file with primary care articles available for copying.

My favorite primary care reference books:

Ackerman. Clinical Atlas of 101 Common Skin Diseases. A little different from Kirkpatrick – gives you 10-20 pictures of each of the most common diseases, so that you get more of an idea of the spectrum of the dermatology.

Goroll. Primary Care Medicine. 2000. Comprehensive text for primary care issues, organized by symptoms (e.g. “Nausea.”)

Greene, Walter. Essentials of Musculoskeletal Care. 2001. A nice concise synopsis of the exam and general approach to common musculoskeletal ailments.

McGee, Steve. Evidenced based physical diagnosis. 2001. Gives you the pearls of physical diagnosis that every UW resident should know.

Fihn, Stephan and Dawn DeWitt. Outpatient Medicine. 1998. More concise than Goroll; less complete but perhaps a better introduction to primary care medicine. Written by UW’s finest.

The Swedish Hospital reference librarian is Cheryl Goodwin (386-6469, cheryl.goodwin@swedish.org.) E-mail her with any questions particularly about references for e-cases.

Patient education literature is available for almost any problem and is a good way to enhance patient care. MA’s can locate most sheets but you should familiarize yourself with them too. PacMed has a number of clinical quick reference sheets that help manage patient data for common disorders such as diabetes, health care maintenance and depression.

Some books that attendings like to recommend to patients:
Strong Women and Men Beat Arthritis by Miriam Nelson, PhD. Putnam books. (Vickie Allen)

Feeling Good by David Burns. (Vyn Reese) For the depressed patient who is motivated and relatively analytical in nature.

Dr. Shapiro's picture perfect diet. (Dena Kennedy) A visual approach to modifying your diet – the visual punch often is a good motivator for change.

 

Some useful medical websites for residents:

Depts.washington.edu/uwmedres
The medicine residency website. PacMed ecases can be found here, as can many primary care handouts.

Healthlinks.washington.edu
The ultimate place to look for medical resources. Unfortunately, most of it is inaccessible from the PacMed computers because of a firewall restriction. However, you can access it from anywhere else in the UW system or at home (once you’ve set up a proxy server).

www.primeanswers.org/primeanswers/
(also found at the top of the healthlinks-care provider toolkit website)
A great initial place to look for answers and patient handouts. From here you can search mdconsult, derm atlases, patient handouts, immunization schedules, prevention guidelines, natural meds, traveler's health.

www.cdc.gov
Resource for traveler's health

Uwgi.org
Practical guidelines on managemznt of basic gi/liver disorders, organized by symptom (e.g. “diarrhea”).

www.orthop.washington.edu
A great resource for patient handouts on rheum and ortho ailments.

 

PALM RESOURCES


http://pbrain.hypermart.net/links.html

This is the single best resource for medical software for the palm. My favorites are:

  • ATPIII Cholesterol guidelines: an interactive and informational tool for diagnosing and treating hyperlipidemia
  • ePocrates – a great pharmaceutical resource – a must have for any resident.
  • Johns Hopkins Antibiotics Guide: a good free alternative to a Sanford guide, if you have room.
  • JournalToGo – when you HotSync your PDA, it will download the latest abstracts on any journal you choose
  • mobileMICROMEDEX – has the same pharmaceutical information as epocrates, but also has toxicology and alternative medicine info. Medicine residents can download this for free if you go instead through the healthlinks.washington.edu site and click on ‘micromedex.’
  • BreastCa: an interactive tool for predicting breast cancer risk; good for reassuring patients.
  • MedCalc and MedMath – calculate most medical equations, including FENa, CrCl
  • MedRules – evidence-based prediction rules for various things, including suspicion for PE or pneumonia risk
  • Skyscape’s 5-minute clinical consult: one of the few things that I paid for. Provides bullets of medical info for most common things.

www.mobilemedica.com
AHA guidelines, including atrial fibrillation, valvular heart disease, secondary prevention of CAD, CABG, chronic stable angina, CHF, pacemakers, and AMI.

www.cyclos.com
The Hi-Note software is a nested memo program; this is what I use to take notes. They have a desktop program too. Well worth the investment if you take a lot of notes on your palm.

www.land-j.com
J-File is a good database program, though it costs money. The databases I have are CSF analysis, Pleural fluid analysis, Synovial fluid analysis, Eponyms, Lab Values.

www.avantgo.com
Multiple channels, mostly nonmedical (e.g. NY Times, seattle.citysearch.com) but also includes a couple of medical journals (Lancet)

www.statcoder.com
Interactive tool for calculating cardiac risk based on the Framingham data.

www.osteoed.org
An interactive and informational tool about osteoporosis risk and treatment, created by UW’s own Mary Laya and Mary Migeon.

www.goldenratiodesign.com: PainSTAT
A calculator for converting among pain medicines

Palmems.com: palmEKG
A rough illustration of various rhythms. Good for teaching medical students.


Intro to the PacMed Computer System (“IDX”) for Medicine Residents

  • There are two interfaces: one is web-based (tends to be slower and more cumbersome) and xterm. Call IS 621-4357 for more information on getting the software.
  • You will get two separate usernames:
    • One is the LAN account (it will be a username like “melissac” or “christophers”), which you use to log into the computers at PacMed, and which you will enter every time your screensaver locks you out.
    • The other is your IDX account (which is something more cryptic, like “MC13”), which you will use to access medical records.

To use the terminal-based interface: double-click on the “IDX-TERM” icon on the desktop.

  • Log in with your IDX account.
  • At the menu, choose “MREC”
  • The computer will prompt you with “Select Function:” Type “1.”
  • Enter the patient’s name in the format LASTNAME,FIRSTNAME (you can input just the first 3 letters and the computer will give you other options), or put in the medical record with a period before it. When you hit enter, a menu of options should appear.
    Note: IDX requires use of all capital letters.

To look up past notes:

  • Hit F for Flowsheets
  • Scroll till you find NOTES
  • Hit V for VIEW
  • Hit E for ENTER CELL
  • Scroll until you have selected the note you wish to view.
  • Hit D for DISPLAY DETAIL.
  • Commands for scrolling are at bottom of screen – B for back, F for forward.
  • F10 kicks you back to the previous list of all notes.

 

  • To look up labs/radiology: two ways.
  • Hit F for FLOWSHEETS
  • Scroll until you find the lab/radiology you want to look up.
  • Hit V for VIEW.
  • This gives you a better idea of the big picture, lab trends or all radiology that has been done.
  • Or: while at the main menu,
  • Hit I for INQUIRY (general)
  • Hit O for ONE SECTION
  • Type in L and hit F10.
  • This gives you all labs in reverse chronological order.
    F10 is like the ‘escape’ key – use it to go back to the previous menu.

 

To add notes: while at the main menu,

  • Hit A for ADD DATA. This will put you into a screen that makes you enter several fields before writing the notes. Use the Tab key to go from one field to the next.
  • For the date, type T for ‘today’.
  • Enter your name (you can use your dictation/pacmed rx 5-digit ID).
  • Enter the attending name that staffed the patient with you (you can use their number).
  • Type PROG (note all caps).
  • Then hit E to go into the entry field.
  • Type your note.
  • Hit F10 a couple of times when you are done.

You can edit notes within 30 days if you typed the original note in, but not if you dictated it. Just hit E on the original menu for EDIT DATA.

 

Call IS (Information Services) for any computer-related questions, including passwords: 621-4357

 

To check your schedule:

  • hit F10 until you get kicked back to the original menu, where you had originally selected “MREC.” Now select “SCH”.
  • When it prompts “Select function,” press “4”.
  • Type your IDX number in, and the date to peruse.
  • When it prompts “Which session for detail?” type PM for an afternoon clinic, AM for a morning one.

HOW TO USE PACMED VOICEMAIL (note: this is different from the voice mail that is provided with your pager)

To leave a message for a voice mail user (indicated by an * in the directory), dial the appropriate number:

Clinic Internally Externally
1101 Madison Clinic 1191 206-505-1191
Beacon Hill Clinic 4191 206-621-4191
Renton Clinic 3126 425-227-3126

During the greeting, enter the desired mailbox number and press “#”. Follow the instructions to leave a message.

To leave a message for a voice mail user who only has a phone mail box (indicated by ** in the directory):

  1. Dial 4191 (internally) or (206) 621-4191 (externally).

  2. During the greeting, enter the mailbox number and press “#”.

  3. Follow the instructions to leave a message.

 



KING COUNTY COMMUNITY RESOURCES

Information and Referral  
Senior Information and Assistance 206-448-3110, 1-800-972-9990
Community Information Line 206-461-3200, 1-800-621-4636
Mayor's Office for Senior Citizens 206-684-0500
Alzheimer's Association 1-800-848-7097
Adult Protective Services 206-341-7660
Transportation  

ACCESS

206-689-3113

(Van service of people with disabilities)

Options

206-553-3060

(Van service and taxi scripts for people age 65+ with limited income)

Medicaid Transportation

1-800-923-7433

Volunteer Transportation

206-448-5740, 1-800-282-5815

(Transportation to medical appointments for people age 60+)

In-Home Assistance  

Home and Community Services/COPES

206-341-7750

King Co Respite

206-448-3110

Eastside

425-899-3200

King Co Volunteer Chore Service

206-324-5247

Meals on Wheels

206-448-5767
Mental Health  

24 Hour Crisis Line

206-461-3222 1-800-244-5767

Geriatric Regional Assessment Team

425-899-3225

Evergreen Mental Health 3 day response

 

Mental Health Professionals

206-296-4013

(Can assist with involuntary commitment)

Community Services Officer

206-684-4790

(Through the police department)

Alcohol and Drug Helpline

206-722-3700, 1-800-562-1240

Domestic Violence Info Line

206-205-5555

Wa State Domestic Violence Hotline

1-800-562-6025
Legal  

Columbia Legal Services

206-464-5911, 1-800-342-3872

Legal information on a variety of issues pertaining to seniors

Senior Rights Assistance

206-448-5720

Information for clients ages 55+ with issues related to health insurance, long term care, social security, end-of-life planning, estate planning, landlord-tenant problems, consumer issues, homeowner concerns, and legal topics. They have a Senior Legal Clinic.

Insurance Information  

Social Security Admin and Medicare

1-800-772-1213

SHIBA

1-800-397-4422

Provides info on health insurance, long-term care ins, and managed care.

Durable Medical Equipment  

Bridge Ministries (Free equipment)

425-828-1431

Wheel Chair Haven (Used equipment – discounted)

253-926-8971

Fall Factors (Reduced grab bars)

206-296-0202
Housing  

King Co Housing Authority

206-574-1100

Section 8

206-574-1300

Seattle Housing Authority

206-615-3340

Housing and Urban Dev (HUD)

206-220-5104

SHAG (Senior Housing Assistance Group provides affordable housing for low and moderate income persons age 62+)

425-228-4100, 1-888-450-SHAG

Home Sharing for Seniors

206-448-5725
Financial Assistance  

Minor Home Repair

206-448-5751

Energy Assistance

206-684-3688

WA Telephone Assistance Program

1-800-483-4100
Community Resource Information Online  

www.seniorservices.org; www.crisisclinic.org; www.nwjustice.org


Directions to PacMed Clinics

PacMed Clinics-Beacon Hill
1200 12th Avenue S, Seattle, WA 98144
(206) 621-4000

From I-5 Northbound: Take the James Street exit (164A) and turn right on James. Continue east on James Street up and over the hill. (James becomes E. Cherry at Broadway.) Turn right onto 12th Avenue. Continue on 12th Avenue (through light at Yesler) to PacMed Clinics-Beacon Hill (large orange brick building). Veer left at light as the street divides around the PacMed campus. Turn right at the sign to “Main Entrance Parking” and park in the garage.

From I-5 Southbound: Take the James Street exit (165A) and turn left on James (the second light). Continue east on James Street, up and over the hill (James becomes E Cherry at Broadway). Turn right onto 12th Avenue. Continue on 12th (through light at Yesler) to PacMed (large orange brick building). Veer left at the light as the street divides around the PacMed campus. Turn right at the sign to “Main Entrance Parking” and park in the garage.

From I-90 Westbound: Exit at Rainier Avenue North. Continue north on Rainier Avenue (straight through the light at Dearborn). Turn left onto Jackson Street. Turn left onto 12th Avenue South and proceed to PacMed (large orange brick building). Veer left at the light as the street divides around the PacMed campus. Turn right at the sign to “Main Entrance Parking” and park in the garage.

From West Seattle: Head east over the West Seattle Bridge/Spokane Street. Exit onto Columbian Way (East). Turn left at the first light (Spokane Street). Turn left again at next light (one small block) onto 15th Avenue South. Continue (north) to Beacon Avenue. At Beacon Avenue, either continue straight on 15th or jog to the left for one block. Travel north to PacMed.

Metro bus routes 36 and 60 also stop right at our door.

PacMed Clinics-1101 Madison
1101 Madison St, Suite 301, Seattle, 98104
(206) 505-1000

From I-5 Northbound: Exit at the James-Madison exit (Exit164A). Continue to Madison Street and turn right. Follow Madison east to Boren Avenue. Turn right at Boren and left at Marion. The entrance to the Marion-Minor garage is on you immediate left. The clinic is on the third, fourth and seventh floors.

From I-5 Southbound: Exit at James Street exit (Exit 165A). Turn left on James and proceed east to Boren Avenue. Turn left on Boren and right at Marion. The entrance to the Marion-Minor garage is on you immediate left. The clinic is on the third, fourth and seventh floors.

PacMed Clinics-Renton
601 South Carr Road, Suite 100, Renton, WA 98055
425-277-3700

From I-5 Southbound & Northbound: Take I-405 northbound (Renton) exit and follow I 405 northbound directions below.

From I-405 Northbound: Take the Kent/Auburn (2A) exit and travel southbound on Highway 167. Take the S. 180th Street exit. Turn left on East Valley Highway and then left on 43rd S.W./S. 180th. Go up the hill to Smithers (third light) and turn right. Parking lot will be on your right hand side.

From I-405 Southbound: Take the Kent/Auburn exit for Highway 167 southbound. Travel south on Hwy 167 and take the S 180th Street exit. Turn left at East Valley Hwy and left onto 43rd SW/S 180th. Go up the hill to Smithers (third light) and turn right. Parking lot will be on your right hand side.

From Hwy 167 Northbound: Take S 180th Street exit. Turn right at light. Go up the hill to Smithers (second light) and turn right. Parking lot will be on your right hand side.


Dictation Guide

Dictating is an art which takes practice to master. It is an important skill learned in residency yet it is not formally taught. It documents patient care, communicates it to other physicians and is the primary determinant of billing. The following is a suggested template for a non-yearly clinic visit. It incorporates efficient communication of data and documents thought process in a format that easily justifies billing. Remember that transcription is a health care cost. Using simple sentences, abbreviations and references to past notes helps keep these costs down.

Medquist #: (206) 493-1311
Dictation ID:
Work type: (1= Stat, 2=H&P, 3=Progress Note, 4=Consultation, 5=Telephone note, 6=Letterhead note)
Clinic location: (11=Beacon Hill, 14=Renton, 30-Madison)

Dictate your name, patient name (spelling both first and last name), PacMed number, date of service, report type and attending name.

Problem List: If one already exists, refer to that dictated note (i.e. See note 5/2/01)
CC: Age, gender and reason for visit.
HPI: Briefly summarize interval if this is a follow up. Include the “seven” components of each complaint.
(character, location, duration, radiation, intensity, precipitating factors, associated symptoms)
If FH and SH are relevant to the problem, document it.
PMH: if relevant.
ROS: Refer to HPI if included there.
Rx: Give name dose and schedule. Make reference to prior note (i.e. see med list 5/2/01) if there are no changes. Accuracy is essential.
PE: Use abbreviations.
Labs/Studies: Note briefly the labs and studies reviewed that are relevant to this visit.
A/P: Active Problems
Health Maintenance
Follow Up
cc: Primary care provider and consultant if relevant.

For example:

Problem List: See 5/2/03.

CC: 55yom with painful foot.

HPI: 2d acute onset swelling/pain/redness in R big toe. Denies F/C/NS/other jt complaints/trauma. 1st occurrence. Enjoyed a banquet of meat, fish, and asparagus 3d ago.

PMH: Htn, CAD, DM.

SH: Born in Phillipines, moved here 15 yrs ago. 2 beers/d.

Meds: HCTZ.

All: none.

PE BP 150/90, P 80, Wt 300. NAD. R 1st MTP swollen, tender, erythematous, with decreased ROM.

Please see written note for full details of the benign remainder of exam.

A: First gout attack for this pt with multiple risks – gender, ethnicity, etoh, dietary indiscretion, hctz. Ddx includes infection, pseudogout, trauma. Also HTN – may have pain component, but goal is 130/80 for a diabetic.

P:

  1. Reviewed dietary precautions.
  2. Prednisone 20mgx5d, ibuprofen prn.
  3. No indication for allopurinol/probenecid yet – if he has recurrence, will do 24hr urine collection for further workup.
  4. HCM – UTD on pneumovax,td,flu; colonoscopy neg 6/2002; declines PSA.

RTC 2wks for BP check and htn med review.


Billing Guide

Coding, or billing, is an important part of medical training that is often neglected. Residents often feel, appropriately so, that there is so much to learn and focus on why spent time on something as trivial as billing? However, billing is essential for any medical service, even non-profit, to remain viable. This includes PacMed, Harborview and the University. For these reasons, PacMed residents learn the basics of billing as part of their training. All billing levels are derived from the dictated note by a highschool or college graduate with no medical experience.

Coding reference chart

The following is a simplified version of the Evaluation and Management coding used for all billing. Its overall organization and finer nuances can be explained in due time by your attending. There is an algorithm used by Beacon Hill attendings to determine what documentation is required to bill for a level three verses a level four visit.

Abbreviated Coding Guide (minimum requirements)

  Level 3 Level 4 Level 5  
# of History elements 1-3 4 4  
# of systems (ROS) 1 2 10  
PMH/FH/SH   1 (3 if new pt) 2 (3 if new pt)  
# of exam bullets 6 12 18