1. PPD Clinical Reminders Documentation Wanda Hooper, RN - Infection Control Edith Horn - IT Specialist Lindy Stem - Nursing ADPAC VA Tennessee Valley Healthcare System LGS 2007

2. Introduction New PPD Reminders (NSG PPD Screen/Read and PROV PPD Greater/Equal 5mm) will be available in CPRS beginning October 15, 2007. All PPD templates and titles (PPD Skin Testing title/template, PPD Test Results (TP) title/template, Tuberculin (TB) Skin Test (TP) title/template, PPD Test Result template in Shared Template drawer, PPD documentation within the Chattanooga Nursing template found in the Test Template drawer) will be inactivated on October 15, 2007.

3. LGS 2007 Why Change? This change is being made in order to implement a system wide standardization of documenting PPD tests and results. Further it will assist clinical staff in being better able to locate PPD test results within the patient record in CPRS.

4. LGS 2007 NSG PPD Screen/Read Reminder Description This reminder will activate if patients are currently on one of the LTC units at Murfreesboro or have a diagnosis noted as being high risk for TB. It will not activate for patients who have previous positive PPDs documented. Once the PPD is given, nursing staff will need to read the PPD within 48-72 hours. If the millimeters of induration are 0-4mm, the nursing staff document the date read, reading (millimeters in induration) and the site description. If the millimeters of induration are 5mm or greater, the reminder is resolved and the PROV PPD Greater/Equal 5mm reminder is activated for the provider to resolve.

5. LGS 2007 Getting Started When a patient presents with the NSG PPD Screen/Read reminder due, the nurse will begin to answer the reminder by using the note title, SKIN. This note template will include the dialog for the PPD Screen/Read reminder.

6. LGS 2007 Click the NSG PPD Screen/Read Checkbox NSG PPD Screen/Read Click on the check box to begin documenting the PPD test.

7. LGS 2007 The Following Dialog Appears Remember: GEC/LTC units MUST use the “TWO-STEP” method for PPD skin testing the FIRST time. SUBSEQUENT annual tests are to “One-Step.”

8. LGS 2007 Using the TWO-STEP Process in the GEC/LTC Areas The nurse selects INPATIENT PPD Click on Step One PPD GIVEN Select appropriate site Document Lot # and Expiration Date. Click the Finish button Sign the progress note

9. LGS 2007 Read STEP ONE PPD Read the PPD with 48-72 hours Make a new note using the IMMUNIZATION/SKIN Test note title Click on the Reminder button and find the NSG PPD Screen/Read Reminder Click on PPD READ/RESULTS BY SCREENING STAFF Click the appropriate button and provide the required information Click on the Finish button Sign the note

10. LGS 2007 PPD STEP TWO Complete STEP TWO within 1-3 weeks if STEP ONE was negative Make a new note using the IMMUNIZATION/SKIN Test note title Click on the Reminder button and find the NSG PPD Screen/Read Reminder The nurse selects INPATIENT PPD Click on Step Two PPD GIVEN Select appropriate site Document Lot # and Expiration Date. Click the Finish button Sign the progress note

11. LGS 2007 Read STEP TWO PPD Read the PPD with 48-72 hours Make a new note using the IMMUNIZATION/SKIN Test note title Click on the Reminder button and find the NSG PPD Screen/Read Reminder Click on PPD READ/RESULTS BY SCREENING STAFF Click the appropriate button and provide the required information Click on the Finish button Sign the note

12. LGS 2007 Additional Notes GEC/LTC units MUST use the “TWO-STEP” method for PPD skin testing the FIRST time. SUBSEQUENT annual tests in GEC/LTC are to be “One-Step.” Areas outside of GEC/LTC use the ONE STEP Process

13. LGS 2007 PPDs in the OUTPATIENT Areas When a patient who requires PPD testing presents to the Outpatient area, the nurse selects from the above options (OUTPATIENT PPD DONE W/OTHER VISIT ONLY or OUTPATIENT PPD DONE STANDALONE VISIT) in order to appropriately document workload. For the most part, the PPD will be done in conjunction with another visit.

14. LGS 2007 PPD Screen Test Given Be sure to document site and Lot # & Expiration date.

15. LGS 2007 Other Options in Answering the Reminder PPD DONE PREVIOUSLY PPD DECLINED PPD DEFFERRED PPD ALLERGY PATIENT REPORTS PREVIOUS PPD CONVERSION Note: Some of the above option selections require additional information before the reminder can be completed.

16. LGS 2007 Completed Progress Note The above is what the progress note will look like when the PPD has been administered in the Outpatient area.

17. LGS 2007 The PROV PPD Greater/Equal 5mm If the millimeters of induration are 5mm or greater, the NSG PPD Screen/Read reminder is resolved and the PROV PPD Greater/Equal 5mm reminder is activated for the provider to resolve.

18. LGS 2007 Provider Resources The reminder begins with web links to resources for the provider such as factors affecting treatment decisions and a guide on targeted TST and Treatment of LTBI.

19. LGS 2007 Answering the Reminder Click on the check box “PPD Read by Provider” Click on appropriate OUTPATIENT or INPATIENT button If Chest X-Ray is ordered, an order dialog will appear for the provider to place the order in CPRS. If no Chest X-ray is ordered, a comment is required.

20. LGS 2007 Important Notes If a Chest X-ray is ordered, the PROV PPD Greater/Equal 5mm will remain due until the Chest X-Ray and Treatment Plan are documented within the reminder dialog. This means that once the results are available, the provider goes into CPRS and within the clinical note, clicks on the reminder button and enters the results and any treatment plan through the PROV PPD Greater/Equal 5mm reminder. Once this is done, the reminder is resolved.

21. LGS 2007 Finding PPD Data in CPRS Click on the Reports tab in CPRS Click on Clinical Reports Click on Outpatient Encounters / GAF Scores Click on Skin Tests The Report looks like the one below:

22. LGS 2007 Additional Assistance For questions regarding administering PPD tests or clinical guidelines, contact: Wanda Hooper, RN – Infection Control – ext. 3265 For technical issues in resolving reminders, contact: Lindy Stem – York Campus – ext. 3207 Jerry Parish – Nashville Campus – ext. 5047