Neurology outpatient clinic
Revised May 2009
NEUROLOGY OUTPATIENT CLINIC
I.Purposes and Objective
The purpose and objective of the Neurology Outpatient Clinic is to provide excellent care for patients with neurological disorders in a clinical setting conducive to learning and teaching.
II.Policy
A.Clinic Attendings
Two to three faculty members are generally assigned as attendings to the clinic per half-day depending upon the number of residents assigned to clinic. These physicians staff all residents in clinic and are responsible for clinic operations that half-day, including assigning emergency work-ins and add-on patients, handling phone calls from physicians, and staffing the clinic nurse for management of patient telephone calls.
B.Continuity of Care
In general neurology clinics and in the residents' continuity of care clinics, continuity of care is provided by the residents, i.e., the same resident sees the patient at all clinic visits whenever possible.
The resident physician's responsibility for the care of these patients extends beyond seeing the patient in clinic. Such responsibility includes diligent follow-up of lab tests and diagnostic studies, handling phone calls to and from the patient, and sometimes handling phone calls to and from referring physicians. At times it may be appropriate for the resident to see the patient in clinic at a time when that resident is not normally assigned to clinic, for example, if an urgent problem develops which cannot be deferred to that resident's next available clinic opening. In such cases, arrangements must be made through the clinic staff to ensure that an examination room is available. Residents who are on a rotation other than a clinic rotation should also make sure there is no scheduling conflict with the responsibilities of their current rotation. If the patient must be seen by another physician (for example, during a vacation period), it is desirable for the resident to contact the physician who will see the patient to brief him or her on the case.
In specialty clinics (Ataxia, Cerebrovascular Disease, Cognitive Disorders, Epilepsy, Movement Disorders, Multiple Sclerosis, Neurogenetics, Neuromuscular, Neuro-oncology, and Sleep Disorders) patients are also seen by both a resident and an attending physician. Follow-up visits may be scheduled to the specialty clinic or, at times, to the resident's continuity of care clinic. When the follow-up visit is to the specialty clinic, the patient is often not seen by the same resident. Residents are encouraged to discuss with the attending which patients are appropriate for the resident to follow in their continuity of care clinic.
III.Procedures for Clinic Visits
A.Prior to Clinic Visit
1. Prior medical records can be reviewed in CareWeb prior to a patient visit. Last minute cancellations or add-ons will be posted on the master schedule in the staff room and on the CareWeb schedule section. Patients can be added to the schedule anytime there is an opening. Be sure to check the master schedule and CareWeb for any changes.
2. New patients must register at the information desk in the TaubmanCenter lobby prior to the visit if a registrar has not contacted the patient by phone in advance.
3.The patient reports to the receptionist at the main desk in the Neurology Clinic.
4.The receptionist compiles a folder for each patient with a charge form, , Neurology Checklist and Neurology Outpatient Note When the patient arrives, the receptionist sends a text page to the appropriate physician. Because the paging system is not 100% reliable, it is your responsibility to check w/the receptionist regarding your patients' arrival. The folder with the patient's forms is placed in a slot at the reception desk according to the exam room number assigned to the physician. If you are running late (more than 15 minutes), please let your waiting patients know so they won't think they've been forgotten. If you are running more than 30 minutes late, inform the clinic attending who may rearrange your schedule.
5.The physician picks up the folder from the reception desk and announces the patient's name, introduces him/herself to the patient, and escorts the patient from the waiting room to the assigned exam room. Exam room assignments are indicated on the monthly exam room schedule. An updated daily exam room schedule is posted on the staff room door. The neurology clinic does not have medical assistants.
B.During Clinic Visit
1.The physician will take the history and conduct a general physical and neurological examination. All new patients should disrobe and put on a gown for the examination. The physician may use the curtain for patient privacy or leave the exam room and return later. Remember to respect a patient's privacy by pulling the curtains when leaving the room if the patient is disrobed. When abnormal findings are present which cannot be readily observed with the patient clothed, the patient should remain gowned for examination by the attending.
For return visits, the resident should determine the need for the patient to disrobe and gown. The resident does not need to perform a complete exam at each return visit, but should perform those parts of the exam that pertain to the patient's problem.
2.Each patient seen by a resident must be presented to a clinic attending physician. The resident should note the attending's name on the handwritten outpatient note and Neurology Checklist.
3.Notes in the CareWeb system by the resident should be reviewed and signed by the attending physician noting their involvement in the history, examination and medical decision making.
4.The patient and/or family should be instructed concerning diagnostic tests, medications, and follow-up appointments with the referring physician or return visits to the Neurology Outpatient Clinic.
5.The clinic nurses are available for assistance with patient management, temperature checks, injections, lumbar puncture, and the delivery of spinal fluid specimens to the lab. They also help educate patients, particularly MS patients who are beginning disease modifying therapy. They are also a useful resource regarding education materials (kept in the cabinet in the staff room) and support groups.
6.An outpatient social worker is available by consult, phone or page for financial, interpersonal, or placement issues.
C.At End of Clinic Visit
1. The physician will:
a.Complete the MSP charge form by entering a diagnosis and indicating the attending physician and the type of service performed.
b.Complete the Neurology Checklist.
(i)Check all studies being ordered and indicate whether the studies should be done the same day or at the return visit. The blood lab is located on Level 3 and closes at 6:00 p.m.
(ii)Specifically indicate when and to which clinic or physician the patient is to return for a follow-up visit.
(iii)Include the resident's and attending's name, doctor number and the patient's diagnosis on the Neurology Checklist and be sure to sign at the bottom. This form is also used by the blood labs as a requisition, so it is important that the information is complete.
c.Complete a Diagnostic Service Requisition for the radiological studies, nuclear medicine scans, EEG, evoked potentials, EMG, vascular studies, pulmonary function and cardiology studies. Include the resident's name and four-digit doctor number and the attending physician's four-digit doctor number, but not the attending's name, on each requisition and referral. Complete an outpatient consultation form to refer the patient to another clinic. Forms are available in the forms rack in each examination room and in the staff room. Please write your name clearly and include your page number when required. Enter the location code NEU on all requisitions. This will enable the diagnostic service to send the report to the correct location. (Patients through the age of 19 obtain X-rays in Mott Children's Hospital and require a Mott X-ray requisition.)
When an MRI scan is ordered for a patient who may be claustrophobic, a sedative is often prescribed. The MRI staff recommends Valium 10 mg; any other sedative requires a special arrangement with the MRI nurse. It is recommended that the patient be instructed to bring the medication to the MRI rather than take it before arrival because the appointment may be delayed. If the patient requires sedation for an MRI, he/she will need someone else to drive from the appointment.
d.When ordering any lab tests or radiological procedure, the physician should inform the patient of the plans for follow-up of the test result and document the plan in the test results section of the Neurology Checklist. Doing so not only constitutes a good practice for any physician, but also helps to relieve the clinic nurse and clerical staff of phone calls from patients wanting their results Please check one of the following boxes on the checklist to indicate plans for test result follow-up:
1."MD will call in ______days."
2."MD will call only if abnormal."
3."Next appointment." This implies the physician will discuss the test results at the next appointment.
4."Patient call MD _____/______AM PM." This means you have asked the patient to call you. It is best to fill in the date test results will be available and which day/time you are easiest to reach.
e.We receive many calls for prescription refills that could be avoided. Remember to check whether the patient has enough refills on their prescriptions to last until their next appointment. In fact, unless there is a good reason not to do so, please write for one or two extra refills on each prescription. For example, if you expect to see the patient in 6 months, write the prescription to last one extra month, with 6 (not 5) refills. Write the patient's name on all prescriptions to prevent issuance to the wrong patient. Document in dictation the number of PRN medications given, especially for narcotics.
Prescriptions for Schedule 2 controlled substances must be issued on State of Michigan Schedule II prescription forms that are pre-printed with the physician's name. Ritalin is a Schedule II drug which is an exception to this. It can be written on a standard prescription form.
Prescriptions for Medicaid patients should be printed on tamper-proof paper—in accordance with state laws. The receptionist provides this paper with the patient’s folder.
f.If the patient requires admission, follow the Admission Procedures described later in this manual.
g.Insert all papers into the folder and escort the patient to the waiting room. Insert the paperwork in the cashier's chart rack. Instruct the patient to wait in the waiting room until the clerk calls their name.
2.The billing representative (cashier) obtains appropriate insurance information and accepts payment or discusses payment plans for services rendered. An MSP form must be submitted for every patient seen. Please do not tear or throw away any form.
3.The appointment clerk schedules diagnostic tests, appointments in other clinics and with Social Work, and return visits to the Neurology Clinic. All clinic phone lines close at 5:00 p.m., but a clerk is on site until 6:00 p.m. to handle patients checking out of clinic between 5:00 and 6:00 p.m.
IV.Admission Procedures
A.To schedule an admission, fill out a Neurology Admission Information form and submit to Debbie Walter, Admissions Coordinator. In Debbie's absence, the cashier will coordinate admissions. The information to be included is:
1.Tentative admission date
2.Justification for admission
3.Specific treatment plan
B.Some procedures to be performed during hospitalization may need to be scheduled in advance by the Admissions Coordinator. For those procedures that require the patient to be away from the inpatient service, try to schedule appointments the afternoon after admission so that the patient can be presented to the attending at morning rounds.
Procedures requiring advance scheduling include:
1.CCTV-EEG Monitoring
2.Polysomnography
3.Plasmapheresis
C.Observation stay admission may be appropriate whenever a patient's care is expected to take less than 23 hours. Observation stay admission should be used when a patient's condition is expected to improve, but when close monitoring for several hours is needed to decide whether to admit or release the patient.
On the neurology service, observation stay admission may be appropriate for migraine; seizure in known epileptic; dizziness; syncope, or weakness of undetermined etiology; migraine of unknown etiology; or head trauma without focal neurological findings. Other medical diagnoses for which observation-stay admission is commonly used include allergic reactions, asthma, dehydration, epistaxis, and renal colic. Observation stay should not be used for procedures routinely requiring hospitalization, such as arteriography, myelography, or chemotherapy. It may be appropriate to monitor a patient with a minor complication from a procedure where the procedure itself would not normally require admission.
Patients admitted under observation-stay admission may be converted to regular admission status. In contrast, patients who undergo regular admission may not be converted to observation stay admission.
D.For emergency (same day) admissions, the physician will:
1.Inform the clinic nurse, who will:
a.Assess and monitor the patient prior to transport. Non-medical staff (e.g. admission coordinator or clinic clerks) should not be asked to monitor or transport a patient.
b.Help determine disposition of the patient and whether the patient needs to go to the Emergency Department or may wait in the admitting lounge. No nursing care is available to patients in the admitting lounge.
c.Call nursing report to the inpatient unit.
2.Inform the Admissions Coordinator (Debbie Walter) or in her absence, the billing representative, and complete an Admitting Physician’s Order Form.
3.Speak to Emergency Department attending if the patient needs to be sent to the Emergency Department.
4.Contact the senior inpatient resident to advise him/her of the admission, describe the patient’s problem, and inform him/her of the plan established with the clinic attending.
E.For same-day and future admissions, the physician must still complete the MSP charge form and deliver it to the cashier. For same day admissions, the patient needs to be directed to the cashier only if a procedure (e.g., LP) was performed.
F.The physician should submit the dictated note with inpatient plans and scheduled procedures to the senior inpatient resident who will be responsible during the inpatient period. If the patient will be admitted before transcription has been completed (approximately one week) the resident should notify the senior inpatient resident of the patient and the proposed inpatient plans.
G.Any overbook admission to the neurology inpatient service should be discussed with the senior inpatient resident by the admitting physician before scheduling is finalized. This allows for better planning by the inpatient team.
V.Appointment Scheduling
A.All appointments and diagnostic tests are scheduled by the neurology clinic appointment clerks.
B.An appointment slip for a future return visit is given to the patient at the end of the visit. When this is not possible, the appointment notice will be mailed to the patient.
C.All patients are mailed a reminder notice approximately 2 weeks prior to their scheduled appointment. In addition, a clerk telephones patients one to three days prior to the scheduled appointment to remind them of the appointment.
D.The appointment clerk will not overbook patients to a specific physician's schedule without authorization from the physician or a clinic attending. Authorization will be noted on the appointment schedule for that day.
E.Each half day, one attending physician has a same-day-service clinic for urgent referrals of new patients. If residents receive phone calls requesting an urgent evaluation, they should refer the call to the clinic appointments clerk. If the patient is too acutely ill or cannot be accommodated as a same-day clinic referral, the patient should be directed to go to the Emergency Department.
F.The clinic attending may reassign scheduled patients to other residents as needed to ensure a smooth flow in clinic.
G.EMG results are available immediately, and patients may be scheduled for return visits the same day. Results of CT scans, MRI scans, EEG, evoked potentials, and neuropsychological testing will not be available the same day, and Neurology Clinic return visits should generally be arranged at an appropriate interval following these tests.
H.Elective arteriograms and myelograms are generally performed as outpatient procedures. Patients are monitored by the radiologists for several hours after these procedures. These procedures can be arranged by the appointment clerks. If the patient is felt to be a high risk for complication, it may be appropriate to admit the patient for the procedure.
VI.No-show and Cancellation Policy
A.Patients are charged $20 if they miss a scheduled appointment and fail to notify us of the cancellation 24 hours prior to the appointment. This charge is intended to serve as a deterrent, and patients are informed of this policy when they are sent their appointment reminders. Patients who miss three consecutive appointments receive a letter reminding them to give advance notice if they do not plan to come and that we may not be willing to schedule them in the future if they miss additional appointments.