Can I do that❓
Who does that? 🙋♀️🙋♂️
Should I do that? 👩🎓👨🎓
What is that?
How to Make it Happen 👨🍳
But Do You Know Your Attendings?
100
One of our NPs sees your RCT colleague's patient for a NAC visit. They CC the chart to your colleague with an FYI that the patient mentioned they want to discuss getting evaluated for ADHD at their upcoming annual. They ask that you let your resident colleague know about this. Can you do that? 3 options please!
sure! multiple options:
1) postpone the CC'd chart in their inbox until 1-2 days before the RPV
2) set a reminder dated for 1-2 days before (make sure to put the patient's name on the Reminder!)
3) send them a staff message and forward date it for when they're back on ambulatory.
100
A patient sends in a mypennmedicine message saying they are having new knee pain and swelling after playing pickleball over the weekend. How do I bring them in for a visit?
route the encounter to your nursing pool! Remember that nurses help schedule acute/urgent visits (usually within a week). Anything longer/not urgent should go to the PSA pools
100
A patient comes into the office and their blood pressure is 160/90. They say they "always run high" in the office. Should I repeat it? If so, what's the proper technique?
Of course! Best to let the patient sit for a few minutes before repeating.
Ideal blood pressure technique:
-check over bare skin
-use an electronic, calibrated cuff when able
-feet flat on the ground
-arm at heart level
-cuff fits properly
-not talking at the time
100
RCT
Resident Care Team - this is your cohort of interns/residents that crosses ILM groups! You share a supervising attending and you will cross cover each other's inboxes
100
A patient with diabetes mentions at an office visit that their insurance no longer covers their long-acting insulin. How do you find what might be on their insurance formulary?
2 options:
1) look up the formulary online!
2) route your question to the PRESCRIPTION pool who can either search the formulary for you or call the insurance company to find out
100
This PIMUC attending and known whiskey connoisseur picked their drink for the taste and the inspirational message. In their own words, it reminds you that "you can get a lot out of life with very few ingredients, and still have significant complexity and spice"
Dave Aizenberg - Old Fashioned with Chili Bitters
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200
A 25 year old healthy patient comes in for an annual visit without any acute concerns. You review any updates in medical/family history since last OV and order STI screening per their request. The patient asks if this can be billed as a preventative visit. Can you do that?
Yes! A preventative visit is for those not on medicare who come in for a visit where you don't manage any new problems. Since this is simply a review and ordering routine screening tests, many insurance companies will not charge a copay for this visit.
Bill this one as a PREV visit - can search that in the billing bar or type 993__ which is the starting code for all of the preventative visits (as opposed to 992 for established visits)
200
You see a patient during the week with UTI symptoms and prescribe an antibiotic for cystitis. You counsel them that they should call the office if their symptoms worsen. Who might they reach if they call?
During the day? they will likely hit the option to speak to a nurse but that stops at 5pm
After hours? The operator will route them to Penn Medicine On Demand for a video visit with an APP. This is billed to their insurance.
200
A patient calls us saying she tested positive for COVID. She will be out of work for a few days and needs a letter to send to her job stating that she's excused. Should I do that? If so, how do I do it?
2 options:
1) Your route the encounter to your nurse pool to ask them to draft the letter and send it on to the patient. they will usually send it back to you to proofread
2) You write it! To do that, go into the "letters" tab of the telephone encounter. you can look for letter templates for Cooper (search PCS) or PIMUC (search PIMA) so that it has our letterhead. If the patient has MyPennMedicine, the letter can be sent to them through the portal so they can print it! If not, you can ask the nursing team to call the patient for a fax number and/or if they plan to pick it up.
200
PSA (not the lab test)
Patient Service Advocate - these are our front desk staff that help with check-in and check-out (among other things). They do not have any medical training so do not ask them to deliver patient information. You SHOULD ask them to schedule any ROUTINE (not urgent) appointment, provide phone numbers for specialists, etc.
200
You are finishing your note at the end of a busy clinic day and are dismayed to find that you can't sign it because your attending left a *** variable in the note! drats! How do you make that go away so you can sign your note?
tell them! PennChart message, find them in person, carrier pigeon, snail mail, text, etc.
wrong answer: DO NOTHING! attendings do not get an "open visit" notification for our attestations to your notes so we won't know unless you tell us!
200
This attending is primarily based at PIMUC, but pops into Cooper from time to time. They chose a drink that is reliable, enjoyed by most people, and is mostly sweet thanks to the mint, but if you put a little too much lime in it it can get sour quickly!
Lauren Mechanic - Mojito
300
Fall is still a season🍁🍂!
You are meeting with a 70-year-old patient who is hoping to get all of their fall vaccines at this visit. They would like the updated covid booster, a high-dose flu shot, as well as the RSV vaccine since they heard about that on TV. Can you do that?
Sort of! This question is about what vaccines we have in the office. 💉💉
COVID- we used to! But no longer. Ask your preceptors if we have the updated booster
High-dose flu - absolutely! immunization room for PIMUC, in the exam room for Cooper
RSV - we don't have it (yet?)! patients who are eligible should be instructed to get it at their pharmacy.
300
A patient sends in a mypennmedicine saying that they are starting a new job! They need tuberculosis screening and a form to be completed. Who can you ask to help with that?
Exciting!
Both clinics have nurses that help with forms! we tell patients 10-14 days although it is often quicker.
PIMUC- if not done already, route encounter to P PIMUC FORMS POOL so that our nurse can start the form for you.
Cooper- route this to the nurse pool!
For the tuberculosis testing, you have options! the patient can come in for a PPD (can route that to the nursing pool or ask the forms nurse to bring them in for the PPD in the above encounter) or order a Quantiferon Gold! If you order the QFT, you can reply to the patient to let them know the order is in.
300
A patient with severe osteoarthritis uses a cane for ambulation. Their family member at the visit asks for a walker to help the patient feel safe outside the house. Should you order that?
No! For some patients DME needs to be signed by an attending, but in our practices our nurses are the DME wizards! They can help you with the appropriate documentation for coverage, pend the order to the appropriate DME company, and can discuss any specifics with the patient.
Create a new telephone encounter and route it to your nursing pool!
300
NAC
Nurse Access Center- these are (usually) off-site nurses who triage phone calls for the practices when a patient calls in and requests to speak to a nurse. They will triage the patient's call, offer medical advice, and facilitate an appointment (if appropriate).
They are (usually) NOT part of our practices so they cannot help with any additional clinic needs. As a result, DO NOT REPLY TO THEM! You will see a red banner at the top that reminds you not to reply to them. If you need anything communicated to the patient after you get a NAC call, please send to the in-office nurse pools (p pcs blue nurse, p pcs red nurse, p pimuc orange nurse, p pimuc yellow nurse)
300
You order labs on a 27 year old patient who is in the office for fatigue. Her labs reveal a hemoglobin of 8.9 with an MCV of 75. You want to add on iron studies so the patient does not have to return to the lab. How do you do that?
Yes! the lab keeps the samples for 3 days so it's important to know both options:
2 options:
1) order the labs and route the encounter to the nursing pool asking them to fax the add-ons
2) have you seen the awesome 3701 Wiki? if you're not already added onto it, make sure you do! Within the wiki you can find a smartphrase walking you through how to add them on yourself!
300
Much like a quick hit of caffeine, this Cooper attending describes themself as "to the point" at first, but definitely helps to facilitate a good time! Some might call this one a Powerful Drink ;)
Amber Bird - Espresso shot
400
You're meeting with a patient with recurrent falls who you think would benefit from a home safety evaluation. Is that a thing you can do? Tell me how you might do that (2 ways)
Yes!
1) Consult to Penn Medicine Home Health! in the order you can put in home safety eval
2) arrange it through the Philadelphia Corporation for the Aging (PCA)! Go to their website and fill out the brief online form.
400
A CC'd chart comes into my colleague's inbox from an obgyn. At the top of the note they sent a comment saying that the patient's BP was high and they wanted to let us know. The patient is coming in to see their PCP in a month. I want the patient to come in in the meantime to get a BP check. Who does that? I want 3 answers
1) Message the nurses asking them to bring the patient in for the RN BP Clinic - the nurse will check their pressure and talk to them for a bit about compliance with meds. they will route the PCP the encounter to decide if any med changes are needed and they can call the patient back
2) Have them see the pharmacists! can accomplish this through PPIC order, asking the PSAs to schedule, or routing to the pharmacy pool (GIM PHARM 6/7)
3) bring them in to see a provider! that can be you, another resident, or one of the NPs. Message the PSAs since this is more routine.
400
A patient gives you FMLA paperwork at an office visit. They are hoping you can complete it ASAP. Should you do that? What's the process for forms in the office?
No!
In most cases (unless it's something easy like a permit form), you should send the form through the forms process in the office. Do not take the form from the patient and instead ask them to give it to the front desk - they will attach the appropriate paperwork and ensure it ends up with our nurses who will copy it, fill out what they can, and then give it to you to finish.
We tell all patients to expect a 10-14d turnaround for forms.
400
LPN (and what they can and cannot do)
LPN- this is a Licensed Practical Nurse.
They have undergone ~1 year of medical training. They can administer vaccines and communicate medical information. In our offices they also help with forms, refills, prior authorizations. They DO NOT administer meds, put in IVs, or do significant triage.
400
I am meeting with a 37-year-old patient with a BMI of 33 who is requesting to start weight loss medication. You do not identify any contraindications and after discussing options you decide a GLP-1 to be the best fit. How do you make that happen?
Most of the time, you should send the prescription to the PCAM pharmacy. They have a larger supply than most retail pharmacies, more staff to help with insurance and patient communication, and they will mail it to the patient!
Ultimately you are going to rx what the insurance covers, but if you don't know that info and want to send a med that they have in stock, you can find that out by using the Incretin Analog dotphrase (.incretinanalogsupply)
400
This attending can also be seen in both clinics. Like their fizzy beverage of choice, they identify as bubbly, only slightly bougie, generally palatable, and maybe a bit ~spicy~ to some.
Nichole Smith - Pamplemousse LaCroix
500
You are seeing a patient for vaginal discharge and pelvic pain. After doing a pelvic exam and sending office a cervical swab you want to give the patient antibiotics for PID. Can you do that in the office? If so, how?
Yes! we have ceftriaxone in the office. You should prescribe additional antibiotics (in this case doxy and metronidazole but that's not the point of the question). Order 500mg ceftriaxone with the SYRINGE icon (which represents a clinic administered med) and either go find the nurse (Cooper) or page the immunization pager and send the patient down to the room (PIMUC) .
500
You are seeing a patient for an HDV after a complex hospitalization where they underwent a below the knee amputation for a diabetic foot wound. They are home now but they live alone and have multiple appointments they are trying to coordinate. The patients family is working on installing grab bars and other DME. Who in the office can help coordinate care for this medically complex patient?
Nurse Care Manager! Each practice has a nurse who can provide longitudinal care management for patients (usually ~6 months)! This involves proactive outreach to the patient and serves as another layer of support to ensure this vulnerable population gets the care they need.
PPIC consult!
500
You are seeing a 23 year old patient with a history of ADHD for an NPV. She recently moved here for grad school and wants to transfer her longstanding Adderall prescription to our clinic. Can you (and your preceptor) do that? Who could you ask for help?
Yes, if clinically appropriate! ADHD absolutely can and should be evaluated/treated by PCPs, sometimes in conjunction with psych. For patients on stable doses, any attending with a DEA license can help you refill. For complicated new starts or questions it can often be helpful to E-consult psychiatry. Check out the Clinic Wiki dotphrase .HOWTOECONSULTPSYCH for details!
500
Medicare Wellness Visit
This is a special visit for patients on Medicare that is supposed to be free. The recommendation is once per year and is meant to be a REVIEW rather than an action-based visit. Items to review include mood, memory, hearing, advance care planning, pain, etc.
Look to see if the patient has filled out the MWV questionnaire in advance. If not, go over it with him! It has questions about ADLs, iADLs, etc. Then use the smartset to get it into your note.
You CAN address problems at the visit but it needs to be billed differently - talk to your attendings about this.
500
A patient sends in a message asking you to fax a new PT order to their physical therapist so they can continue their rehab. How do I make that happen? 2 answers :)
Option 1) Sign the PT order and ask the nurses to fax to the PT place
Option 2) if the patient can provide the fax number, you can e-fax it! order the PT order and then create a letter. you can put the fax # in the address:
then in the "Choose Letter" section, instead of picking a letter template you can select "MPM Order Requisitions for Current Encounter" and it will pull anything you ordered (in this case the PT script) into the letter!
Hit Send Now and it will e-fax the order!
500
This primarily Cooper-based attending identifies with a drink that's dry, complex, and sophisticated but still a little sweet. In ambulatory education and in life, they like to get the final Say!
Patrick Sayre - The Last Word
