The TSWF Nursing Services AIM form is intended to be used by nurses and clinical support staff in adult PCMH clinics. The form is not designed for use in pediatric and non-PCMH immunization clinics.

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Nursing Services Recent Changes

  • 15 changes for Jan-Apr 2018 update
  • Updated blue cue to Outcome of Patient section on Immunizations, Meds 1, Meds 2, Procedures 1, and Procedures 2 tab
  • Added new check box to Outcome of Patient section on Immunizations, Meds 1, Meds 2, Procedures 1, and Procedures 2 tab
  • Added a clinical cue to the Family History text box (“Including, but not limited to, diabetes, heart disease, HTN, colon cancer, breast cancer, and/other cancers, and conditions that run in the family.”)
  • Added a clinical cue to the PHQ-9 ribbon (“If clinical judgement suggests, and/or patient is on anti-depressants and has a history of depression, skip PHQ-2, open ribbon, and go directly to PHQ-9.”)
  • Changed ribbon wording to: Depression Screening (PHQ-2 and PHQ-9)
  • Renamed the “Sexual Assault Toolkit” ribbon as “Sexual Assault Resources”
  • Removed the Overall Health question
  • Removed Secure Messaging question from Annual Questions field
  • Added REALM SF details and words to the forms (listed individually)
  • Placed the REALM SF scoring chart to the right of the text box with instruction:
    “The score is based on the number of words correctly read aloud.”
  • Consolidated MSK upper and lower into one tab
  • Reformatted Red Flags field
  • Moved Lifestyle/Exercise questions to Exit CCP tab
  • AUDIT-C revision:
    -Deleted previous AUDIT-C score field
    -Added AUDIT-C score to the existing date field
    -Reformatted clinical information
  • Deleted the Allergies field and added blue cue text explaining the change

History

  • Created June 2014
  • Standardize documentation
  • Intended use in adult PCMH clinics

The TSWF Nursing Services form was created in early 2014 and went live on the AHLTA Enterprise in June 2014. It was created to standardize the nursing services documentation of administered immunizations, medications, nursing procedures, and patient education & counseling performed at the point-of-service. The form’s intended use is acute, routine, or other scheduled patient visits in adult PCMH clinics.

Form Lead

TSWF-Nursing Services Form Lead
Timothy Hill

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