Ambulatory Comprehensive Intake PowerForm

Ambulatory Comprehensive Intake PowerForm

Follow the steps below to document a comprehensive patient intake:

1. Navigate to the AMB Primary Care Workflow within the Provider View.
2. Select the Vital Signs Component.
3. Click the down arrow.
4. Select Ambulatory Comprehensive Intake to open the PowerForm.

Intake Summary

Intake Summary documentation requirements may vary based on the practice. Follow practice guidelines for documentation.

Patient Summary

1. Chief Complaint: Enter the patient stated chief complaint.
2. Communication Preference: Select or update as needed. This is required to be selected for patient invitations.
3. History of Present Illness Nursing Note: HPI is optional and should be used only as directed by the practice.

Vitals

1. Blood Pressure: Document systolic/diastolic pressure.
2. Pulse Rate: Document beats per minute when auscultated or palpated. Document Heart Rate Monitored when a machine is used to record beats per minute.
3. Respiratory Rate: Document breaths per minute.
4. O2 Sat: Document oxygen saturation.
5. Temperature: Document as oral, temporal, or tympanic.
6. Heart Rhythm: Document the patient's heart rhythm.
7. Pain Scale: There is a drop-down list to select a specific scale. After scale selection, a pain level can be documented. Additional comments may be entered in the free textbox.

Note on Blood Pressure: If BP is greater than 140/90, repeat after 5 minutes or longer. Document on Vital Signs and Measurements form.

Blood Pressure Source Options: Left arm w/ BP machine, Left leg w/ BP machine, Right arm w/ BP machine, Right leg w/ BP machine, Left arm, manually, Left leg, manually, Right arm, manually, Right leg, manually, Left arm, palpated, Left leg, palpated, Right arm, palpated, Right leg, palpated.

Measurements

Measured and Non Measured Height and Weight fields are available for documentation. Enter the information in the correct field. Measured Height and Weight must be entered yearly. Both Height and Weight need to be measured to calculate a Body Mass Index (BMI).

Fields include: Weight Measured, Waist Measured Circumference, Height/Length Measured, BMI Measured, Weight Non-Measured, Height/Length Non-Measured, BMI Non-Measured, Pre-Pregnancy Weight Non-Measured.

Depression Screening

Select the PHQ-2 and PHQ-9 section to document depression screening and calculate a score. If the PHQ-2 score is greater than 0, the PHQ-9 needs to be completed to calculate a Severity Score. Documentation requirements may vary based on the practice. Follow the practice guidelines for documentation.

The PHQ-2 and PHQ-9 Depression Screening Question asks about the frequency of problems like 'Little Interest or Pleasure in Doing Things' and 'Feeling Down, Depressed or Hopeless' over the last 2 weeks, with options like 'Not at all', 'Several days', 'More than half the days', and 'Nearly every day'.

Allergies and Medications

Review of allergies and medications are required at every patient visit. The review can be done from the Ambulatory Nursing Workflow or Ambulatory Comprehensive Intake PowerForm.

Allergies:

1. Click + Add to add an allergy to the list.
2. Select a current allergy on the list, then click Modify to modify an existing allergy.
3. When the allergy review is complete, click the Mark All as Reviewed button.

Note: If the allergy review is done on the Intake form, the Complete Reconciliation button in the Allergies component on the AMB Primary Care Workflow will need to be clicked for meaningful use credit.

Medications:

1. Click Document Medication by Hx to begin the medication review. Medication compliance is required when reviewing medications.
2. Click + Add to add a medication order.
3. When the medication history is completed, the Meds History Reconciliation is performed.

Medication display options include 'All Active Medications' and 'All Inactive Medications 24 Hrs Back'.

Social History

Social History is required to be reviewed at every patient visit. This includes documenting at a minimum, tobacco status for meaningful use and safety-home and environment information for rural health clinics. Follow practice guidelines for additional social history documentation.

The form prompts providers to ask about sexual orientation and gender, offering written options if the patient is confused.

Instructions for making changes include right-clicking to 'Add' or 'Modify' documentation.

Key fields include Category (e.g., Tobacco), Details, Last Updated, and Last Updated By.

Family History

Family History is required to be reviewed at every patient visit. This history review includes first-degree relatives: parents, siblings, and offspring. Positive and negative pertinent information should be documented.

1. Click + Add to add and/or modify any health history for a family member.
2. The display drop-down allows for different viewing options.
3. Once the Family History review is complete, click Mark all as Reviewed.

In the Add Family History screen:

1. Family members are listed at the top. Left-click on the relationship name to enter names and demographics. Right-click on a family member to remove.
2. Click the Add Family member drop-down to add a family relationship.
3. Click the QuickList magnifying glass to search for and create a list of histories not found in the General Family History list.
4. Selecting 'negative' here will document a negative history for the selected condition for all family relationships listed.
5. Click in the white or blue column under each family member to document a negative or positive history.
6. Click on Add Group to add additional groups of histories for review.
7. Once complete, click OK.

Obstetrical History

Obstetrical History section is available for documentation of pregnancy information. It includes fields for Delivery/Outcome Date/Time, Gestation Weeks, Pregnancy Outcome, Length of Labor, Gravida/Para, and details on Fullterm Para, Preterm, Abortions, and Living Child.

Procedure and Surgical History

Procedure and Surgical History is required to be documented at a patient's initial visit and at least yearly thereafter.

1. Click + Add to add a procedure/surgery to the history list.
2. Click the Mark all as Reviewed button when the review is complete.

The display can be filtered by 'Active' procedures.

Problems and Diagnosis

In the Problems and Diagnosis section, it is required to document patient-stated medical problems at every visit. In this window, Problems and Diagnoses can be added, updated, and converted.

1. Diagnosis: The problem being addressed at the current visit.
2. Problems: Lists documented chronic conditions that stay with the patient across all encounters.
3. After selecting a condition in the Problems list, click Convert to add it as a Diagnosis (Problem) being addressed this visit.
4. Click Mark all as Reviewed when done.

The interface allows adding, modifying, and converting problems, with fields for Priority, Condition Name, Clinical Dx, and Vocabulary (e.g., SNOMED).

Infectious Disease Risk Screening

This section is available for documentation of Infection History, Infectious Disease Risk Factors/Symptoms, Tuberculosis Risk Factors/Symptoms, and several other family member and travel history information.

Includes sections for Infection History (e.g., Chickenpox, Chlamydia, Gonorrhea, HIV Exposure), Infectious Disease Risk Factors/Symptoms (e.g., Chills, Fever, Headache), Hepatitis B/C descriptions and vaccination dates, and Recent Travel History.

Psychosocial and Spiritual

This section is used to document stressors, coping and support, as well as spiritual and religious preferences.

It includes Psychosocial Screening with options for Family illness, Family problems, Finances, Hospitalization, Sexual orientation, and Body image. Coping and Stressors are also documented.

Spiritual preferences include options like Amish, Catholic, Buddhist, Hindu, Jewish, Muslim, Protestant, and 'Other', with fields for 'Do You Receive Comfort From' and 'Emotional Support Available'.

Conley Fall Risk Scale

The Conley Fall Risk Scale section is available to score patient risk for falls.

It assesses factors like History of Falling in Last 3 Months, Impaired Judgment/Lack of Safety Awareness, Agitation, Impaired Gait, and Dizziness/Vertigo. Each factor contributes to a Fall Risk Score, with a patient considered at risk if the score is greater than or equal to 2.

Instrumental ADL Adult

The Instrumental Activities of Daily Living section is available to document levels of independence.

Activities listed include Meal Prep, Writing, Keyboarding, Phone Use, Money Management, Grocery Shopping, Clothing Care, Light Cleaning, Heavy Cleaning, Community Transportation, Community Mobility/Safety, Care of Others, and Medication Management. Independence levels can be marked as 'Complete independence', 'Modified independence', or 'Supervised'.

Education Needs

Educational Needs section is required for documentation, indicated by a red asterisk, and may include education needs and learning style preference for the patient and/or family.

1. Barriers to Learning: Required to be documented at every visit. Options include None evident, Acuity of illness, Cognitive deficits, Cultural barrier, Desire/Motivation, Difficulty concentrating, Emotional state, Financial concerns, Hearing deficit, Language barrier, Literacy, Memory problems, Vision impairment, Other.
2. Patient/Family Learning Style Preferences: Where patient and family preferred learning styles can be documented. Multiple styles can be selected (e.g., Demonstration, Printed materials, Verbal explanation).
3. Patient/Family Education Needs Comments: A free text box for any additional comments.

Healthcare Decision Maker - Amb

The Healthcare Decision Maker section is used to capture information regarding healthcare decision making, Guardian, and Advance Directive/DPOAH for the patient.

It asks if the adult patient or pediatric patient representative is able to answer questions, and if the patient has a Guardian or an Advance Directive/DPOAH, with options to document their presence and provide copies.

Interpreter Services

Interpreter Services section is available for documentation of Interpretation Type, Agency, and Modality.

Interpretation Types include In-person, Telephonic, Video, and Patient declined. Interpretation Reasons and Interpreter Agency Name can be documented. Modality options include On-site interpretation, Video remote interpretation, and Telephonic interpretation.

Review of Systems

Review of Systems section is available for documentation for clinical staff that perform this review.

It covers general symptoms (e.g., Weight Change, Difficulty Sleeping, Fever, Fatigue) and Head and Neck symptoms (e.g., Visual changes, Dizziness, Double vision, Sinus problems, Trouble hearing). Responses are typically Yes/No.

Signing the Form

When documentation is done, click the green checkmark ✔️ on the top of the PowerForm to sign and complete the Ambulatory Comprehensive Intake.