CLINIC HELP SECTION 

• The ACGME Requires 36 half-day (4 hour) sessions per year. 

• UNLV-SOM Patient Goals for each ½ day session: 4-6 for interns, 6-8 for 2nd years, and 8-10 for third years.

  • These are patients that are actually SEEN, not just booked. 

• Patient Booking & Timing

  • Please see the patient within 10 minutes of them being roomed.

  • Patients are double booked at 11:20 and 4:20 to compensate for available slots as well as late and no-show patients.  If both patients arrive at the same time and you need help, do not hesitate to ask.

• Patients no longer are required to be logged on New Innovations (but procedures are!!)

• Every effort should be made by schedulers and residents to keep all well child checks with the same resident to establish a “continuity panel of patients”. Residents should document required follow-ups on the AFTER VISIT SUMMARY. Sick patients will not always be guaranteed to the continuity resident. 

• You should assume ownership over your patients as you are their doctor.

  • If labs, radiology tests, or referrals ordered, YOU should be following up these results and communicate them with families via phone calls with telephone notes documented in EMR. Usually found on the TASKS tab on the far right

  • Third years should verbally sign out complex or chronic continuity patients to interns prior to graduation to assure adequate transition of care.

• The Continuity Clinic Curriculum session will be protected time for the first 30 minutes and will be every day, unless otherwise notified

  • Even though the patient is booked for 10 minutes prior to the end of the session, you must try to stay and participate until the session is complete.

• TIP: Sign on BEFORE clinic to “pre-round” on your clinic schedule so you are more prepared, e.g. WebIZ, discharge notes, labs, etc. This will help significantly with efficiency and patient care. 

• In order to improve continuity, ALL continuity clinic sessions will be in the afternoons (as of July 1, 2020), and any changes (temporary or permanent) will be made on a case by case basis and must be approved by program and clinic leadership.

There may be a time where a patient or parent requires critical care in our clinic which we can provided some limited care and stabilization before emergency medical services arrive.

• In clinic we have:

  • An Automated External Defibrillator (AED) - at the corner by the outdoor deck

  • Oxygen Tanks

  • Suction

  • Nebulizer

  • Emergency Medications: Epinephrine, Diastat, Albuterol, Atrovent

  • PALS algorithm card

• We will try to do quarterly code training as part of the Continuity Clinic Curriculum to prepare you.

• Should there be a critically ill patient or caregiver:

  • Provide any direct care that is needed

  • Inform clinic supervisors and administrators

  • Call 9-1-1 if necessary

• AAP Oral Health Flip Chart - for teaching/explaining oral health to patients

• Dental appointments should be made 6 months after the 1st tooth eruption OR by 12 months of age. 

• Topical Fluoride Varnish should be applied to dried teeth (use gauze) every 6 months after first tooth eruption until dental appointments have ensued. Be sure pt has no allergies to pine nuts, and always discuss or hand out post treatment care. Don't forget to bill (CPT) as well!

  • Healthy Children Fluoride Information

  • Smiles For Life (online module): Course 6: Caries Risk Assessment, Fluoride Varnish and Counseling

  • Flouride Varnish Application CPT code: 99188 

• The list of dental providers can be printed directly are available on the handout wall, or on the AAPD Website

• Dental Clearance Billing:

  • • Primary Diagnosis: Pre-Operative medical clearance Z01.818

    • Secondary Diagnosis: Dental Caries, Etc

    • CPT CODE (consult code):  99241-99245 (based on complexity)

A CONSULT code should NOT be used in general pediatrics clinic (only subspeciality) - however scenarios for a consult code in a general peds clinic include dental and surgical clearances in this instance you must include the THREE R'S:

• • 1. 1. R - Request for Consult (must be in the HPI with which Physician or Dentist is requesting)

       2. R - Reason for Consult (must be in the HPI/AP why the consultation is needed)

       3. R - Report of Consult (the note must be printed and faxed/sent with who requested it)

• PCO-Preoperative Assessment Chapter

• Pediatric Dental Residents may rotate with us for a half day session.  Their goal is to learn more about what we do in primary care, and their focus is on anticipatory guidance (both oral health and general pediatrics care).  Feel free to have them observe you, especially during well visits, and observe them when they give oral health anticipatory guidance, and fluoride treatments.  Also, bring to their attention any interesting oral findings.  Lastly, use this time to ask them any questions about oral health.

• See the Resources Page for Links to Screening Tools 

• ASQ (Ages and Stages Questionnaire) to all 9, 18, and 30-36 Month Olds (AAP Recommendation although our clinic does a 14-month ASQ at 15 month WCC to spread out paperwork). 

• MCHAT (Modified Checklist for Autism in Toddlers) to all 18 and 24 Month Olds

  • All answers should be yes except 2, 5 and 12

  • M-CHAT Total Score 0-2: No Follow-Up necessary. If child is younger than 24 mos, screen again at 24 mos (or after 3 mos has elapsed). Continue developmental surveillance.

  • M-CHAT Total Score 3-6: M-CHAT/F is important to evaluate risk. If child continues to score 3 or higher, refer immediately for clinical evaluation and to determine eligibility for early intervention services. Please note, if Follow-Up score is 2 monitor carefully, since child may need referral.

  • M-CHAT Total Score 7-23: Child is at risk for ASD or other developmental delays. It is acceptable to refer immediately without completing the M-CHAT Follow-Up.

• EPSD (Edinburgh Postnatal Depression Scale) at all well visits until 6 months

  • Maternal Child Health Coalition Referral Form

• PHQ-9 (patient Health Questionnaire 9) for all adolescents 11 years old and above. 

  • If the first two question answers are not concerning (PHQ-2), you can omit the other 7.

• All other screening forms such as Vanderbilt, SNAP, etc. are printed in the Red Room or available in the Resources Section. More Screening Tools Here

• All screening tests must be CPT billed with the 59 modifier. Make sure to document results in the ROOMING or SCREENING section. 

• ADHD screens should only be billed when you review them; i.e. after the teachers have completed them NOT when you hand them out.

Autism Diagnosis

• Dr. Lafredo (Tuesday Mornings) or Dr. Savarese (all day Wednesdays) on their behavior days

• PALS - Pediatric Access Line (w/ UNLV Child & Adolescent Psychiatry)

• Capability Health

• DSM-5 Criteria

Applied Behavioral Analysis Referrals

• What is ABA or Applied Behavioral Analysis? 

• AAP Bright Futures Autism Toolkit

• For Nevada, there are a few relatively new requirements for ABA Therapy reimbursement that affects Carmen's ability to process a referral for ABA Therapy.

• When you are ordering a referral for ABA Therapy it must include an FA 11 Form which is a certification of the diagnosis of Autism.

  • Trini is unable to process the referral without a completed FA - 11.

  • This form requires a test and a score to be included FA-11 Form.  (Child Autism Spectrum Test, DSM-5, not the MCHAT), but it doesn't need to be attached (document it in the note however)

  • Order a referral to "Behavior/Development" and type in ABA Therapy needed in the comments section.

  • Place this form and the screening test you used in the PURPLE folder at Shona's (MA) desk.

• Dr. Savarese Tip: "When I see a patient I Check Other and fill in either a CAST or DSM-5 (If the patient is younger than 3 years).  These are simple enough to do in the office."

• Don't for get to use the CPT Code 96110 for behavioral screening and document the results in the Screening tab for Autism.

• Useful Forms:

  • Form FA-11F 

  • CAST (multilingual), CAST Scoring key

  • MCHAT (multilingual), MCHAT Scoring Key

If for whatever reason we lose power or lose a WIFI connection please consider the following:

• Ask the M.A.s or Kathy for

  • printed templates for Well Visits and Acute Visits, then add them to electronic note when the power/wifi comes back up

  • printed After Visit Summaries 

  • printed urgent referral forms if needed

• Lab Slips are available in the slots ouside the doors

• Use the RX pads for urgent meds (or call it in)

• Red Outlets have power if needed

• Use manual vital signs collection

Fax Machines:

• • Front Desk (behind Check Out Area): 702-944-2852

  • Nurse’s Station: 702-944-2851

Phones:

• • 702-944-2828 = main line (mommy call after hours/weekends for patients)

  • 702-750-1171 & 702-750-1104= larger physician work room

  • 702-791-1339, 702-791-1222 = mommy call answering service

  • 702-992-6841 = nurse’s office 

  • Nurse’s Station: Ext 30664, 30714, 30728 

Printers: 

• • Great Silver Room - PRN0033, PRN0020 (by attendings)

  • Red Room - PRN0027, PRN0282 (far side of the room)

  • MA Station - PRN0028

  • Checkout Desk - PRN0022 (can print in color)

Computers:

• • Each laptop/desktop is configured for a specific printer which can be changed for everything BUT the EPIC After Visit Summary

  • If you are in the afternoon session, shut down the computer completely

  • Please plug-in your computer after you are done for the day (and do not stack them, they will overheat!)

  • Wired mice are scattered around clinic for your use (mostly in the Red Room)

  • Desktops are reserved for attendings

  • you are welcome to use your own laptop but you may have issues with printing from Epic, also you will connect to UNLV BYOD

  • TIP:  press [fn] f3 to turn off the back lighting for the keyboard and safe some battery life!

  • Please submit a laptop ticket for any laptop issues, please be specific, thanks!

Can't Login to a clinic laptop/windows?

• • check that you are using your firstname.lastname as the log in user

  • you may need to add unlvmed\firstname.lastname as the user (to ensure the server)

  • type your password in slowly and check for any CAPS error

  • make sure you are connected to wifi

  • plug in an ethernet cable (wifi could not be picking up)

  • still can't login? call IT at 702-895-0777

WIFI Networks

• UNLVMED

  • Accessible by UNLV Medicine issued devices using your UNLV Medicine credentials.

• UNLVMED BYOD (guide here)

  • Accessible by personal device using your UNLV Medicine credentials. (windows login)

  • For Android devices use the PEAP certificate, and for the CA Certificate select "don't validate"

    • if you change your windows password you will have to go to your wifi settings to change the password here as well.

IT SUPPORT - CONTACT INFO

• • email: help@medicine.nevada.edu

  • UNLV Issues (contact the UNLV Central IT Office)

    • 702-895-0777 (7am - 7pm)

• • Interpreter Phones

    • A set is available at the MA station and by Nubia's Desk

    • Follow instructions on the phone for Language Link - 1-877-650-8021, Account 25135#, Location 1#

    • Calls are $0.62/minute, please ONLY use in clinic or for mommy call, and avoid long holds

    • *for any other clinic or hospital, please use the respective facilities' translation services*

  • Spanish: try the front desk (preferred Carmen) or MA’s. 

    • Dr. Jones-Betancourt is fluent in Spanish.

    • We have volunteer Spanish interpreters throughout the week. 

  • Other Languages: 

    • Medicaid Amerigroup has a phone line: 1-800-600-4441. You must provide insurance ID number.

  • Sign Language: 

    • Insurance should provide the interpreter but it needs to be scheduled in advance.

  • Be sure to note on AVS when extra time or if extra services are needed (e.g. sign language interpreter). 

  • TIP: Use “Google Translate” on the AVS/CVS to communicate important concepts to parents. 

  • Check the "Multi-Lingual" section in the Parent Handouts for more language handouts

• Click here for the Mommy Call Resource Page

• This is a an after hours line we provide our patients for medical advice 

• Labs & Imaging may also call any critical results.

• Scheduled Residents are on call to field these questions and if they need support, a scheduled attending is available for assistance

• Language interpretation is also available for a 3-way call:

  • 1-877-650-8021, Account #25135, Location #001

• Newborn Screens (NBS) are usually  sent at 2-3 days of life (prior to newborn nursery discharge) and ideally at 10-14 days of life (although can be sent as late as 6 months of age). NICU babies should have 3 (one sent upon admission to NICU, one at 2-4 days of life, and one upon NICU discharge or 10-14 days (whichever is later).  Third NBS Algorithm 

  • Can be ordered and sent from our clinic. Be sure to choose “NBS” (sometimes listed as PKU) CPT code from common list and link with either well-child check or separate ICD-10 code “screen for metabolic condition.”

    • You CANNOT order a screen on Fridays (or days before holidays) as the sample needs to be received by the state lab within 24 hours (thus on a business work day). 

    • Patients can always be sent to the UMC outpatient lab (across from the cafeteria) at any time regardless of birth hospital.

    • Be sure to fill a glove with hot water and have the patient's parents hold it against heel for warming.

  • Do not forget to add the CPT code in WRAP UP -> Charge capture

  • Nevada NBS Guide for Practitioners 

Obtaining Results:

• • 1. Check if there are any scanned documents or mentioning of results in previous notes (PMH) . You ALWAYS must retrieve the first NBS for all newborns as the results are always returned to the birth hospital.

    2. Check alphabetized accordion folder in small physician work room for previously received but not yet scanned/documented results. Newborn screens are no longer stored in nurse’s office.

    3. Options: 

       • In EPIC (and if the baby was born at UMC),

         • click CHART REVIEW TAB-> MEDIA  and scroll down to find Newborn Screening (hearing screens are labeled this as well)

         • if born at UMC, look at the newborn encounter and scroll down to the bottom for the links

       • Online Database (if < 12 months of age): http://nbsereports.med.unr.edu/ , alternate log in

         • you need to input at least THREE search items (its better to use less than 4 letters to expand the search)

         • facility collection codes are: 6830 (UMC NICU), 6002 (UMC Nursery), 1835 (UNLV PEDS)

       • If urgent, have attending look up online results or call Newborn Screening Office at 775-688-1335 (Option 1) and remember to have mother’s last name on-hand.

• *If the patient was born prior to 7/1/14 (before the Nevada NBS program started), you must call Oregon NBS Office at 503-693-4174.

• Documenting Results in EMR:

  • • Please document in the SCREENING or ROOMING TAB -> MCHAT/ASQ/NBS

    • You can also document in the Well Child Visit HPI/Interval history template

Details the level of supervision that is required for each resident. Each resident’s status will be reviewed and updated every 6 months and communicated via evaluations in New Innovations.

• • All residents < 6 months through their training are required to precept every patient to a supervising attending who then must examine the patient themselves.

  • Residents > 6 months through training must still precept every patient before discharge but can earn the independence of not having a supervisory attending required to examine their patient if the encounter is of low complexity. 

  • Residents > 18 months through training may earn the independence of staffing of uncomplicated patients with only a one-liner given prior to patient’s clinic discharge.

  • Residents > 24 months through training may be granted the ability to independently precept and teach medical students and interns.

*Refer to the resident handbook for more details*

Always check both New Innovations and EPIC for your clinic schedule before a block starts since clinics can move around frequently!

Sick & Late Policy (See the Resident Handbook for any Updated Procedures):

• 1. Contact the chiefs by calling their office (702-671-6444) or cell phones at a reasonable hour. If they are not able to answer leave a message.

     1. • Contact Cynthia Chase (702-671-2038), Pediatric Coordinator. If she is not able to answer leave a message.

        • Contact Shelly Williams (702-992-6834 or 702-671-6402), Lied Clinic Manager. If he is not able to answer leave a message.

  2. Contact a supervising attending by calling a physician work room (702-671-2378 or 702-671-2209) or cell phone before the start of your shift at an appropriate time. (For example- if clinic starts at 8:30 AM contact them around 7:30 AM). Personally call your attending. Do not just text or email the attending.

     1. • Please also contact an attending if you are running late. 

Requesting Time Off:

• • Must be completed 30-days in advance for ALL non-urgent requests with no exception. 

  • Must be completed through the chief residents.

  • It is a good idea to send an email to the Chiefs, Nubia Guerrero, and/or Shelly Williams to be sure your clinic schedule is blocked. 

Switching Patients Between Residents/Providers

• • Switching patients between schedules only occurs at the discretion of supervising attendings and should be rare instances.

  •  Only an attending can speak with schedulers to make a switch. Residents CANNOT directly request switches from schedulers. 

    • Will be done to preserve continuity, facilitate flow, or compensate for numerous no-shows on a resident schedule. 

    • Will not be completed to honor resident inefficiency but may be warranted under circumstances of complex time-consuming visits. 

    • Will NOT compromise continuity.

    • Residents are NOT permitted to have front desk “punt” patients to the same-day list. 

Please keep up to date with your "Tasks" in EPIC which can be found on the schedule page and to the right bar "Show Tasks".  This section will show tasks such as Lab Results, Imaging Results, Patient Calls, Medication Refills, Clinic Results, etc. that must be taken care of promptly, and regardless of training level or rotation.  If you will be calling the family, please click the Encounter button and start a phone note and fill out as much information as possible, and also CC/Forward (or speak with in person) the attending you staffed with for that patient.   TIP: only use a clinic phone or the Doximity Dialer App on your phone; do not use your personal line.

• VACCINES MUST BE ORDERED UNDER THE ATTENDING'S NAME WHO YOU PRECEPT (for billing & documentation purposes)

• Immunization Resources Section

• All residents should fax the request to allow for WebIZ website access. Always inspect documentation and ask the parents if you see or suspect any inconsistencies as sometimes children have multiple WebIZ forms under different names.

  • WebIZ’s do not update for a visit until you and an attending sign your note for your encounter.

  • For parents wanting proof of vaccines fill in the appropriate areas, stamp it with a clinic stamp and your stamp, and sign it; then tell parents the official WebIZ database will be updated in 2-3 business days.

    • Parents can also access the database themselves if they have internet access.

  • TIP: when searching, you only need the first 2 letters of the name, (the less letters the broader the search)

• Can be administered by residents, students, MA’s, or nurses. 

• If parents refuse vaccines and you’ve tried all you can, they must fill out documentation that must be scanned in and you must document and put it as an ICD 10 diagnosis (refusal to vaccinate). AAP Guidance, Pediatrics Article

• Please remain in clinic at the end of your clinic session until all vaccines have been administered to your patient (some patients do have allergic reactions to vaccines!).

• HPV Vaccines starting under 15 yo can be dosed twice, 6 months apart. If starting after 15yo, the dose schedule is 0m, 1-2m, 6m CDC Handout, CDC & ACIP Recommendation. Also, all patients must be monitored for syncopal symptoms 10-15 minutes post administration

• For families without insurance, make sure to offer them the option to go to the Southern Nevada Health District Immunization Clinic, vaccines there cost $20 for the first vaccine (administration fee), and $8 for each shot after. (we charge more in our clinic)

  • For uninsured patients, it is $20 per vaccine in our clinic

• There are no more NURSE VISITS (aka shot visits or NBS visit) where no physician sees the patient.

• Vaccines during June to July 2018 did NOT transfer over to WEBIZ, please see an attending to check CPS for verification

• We have Meningitis-B (Trumenba, >16yo) for VFC only and PPSV-23.

• We do not carry Typhoid or Yellow Fever vaccines. We must refer families to the Southern Nevada Health District. CDC Yellow Book, CDC Traveler's Health Website

• We do not carry the RSV (Synagis) vaccine, patients can obtain this at Cards or Pulm offices

• Quick Combo Tips: Pediarix (6w-7y), Pentacel (6w-4y), Vaxelis (6w-4y), MMRV (1y-12y), Kinrix (4y-6y)

• TIP: If the vaccine record looks way off, and before you go shot happy and duplicate shots, ask these questions first:

  • Ask the parents if they recall getting the vaccines on time. Parents don't forget these experiences. If they do recall vaccines then do some investigating!

  • Do the parents have a copy of outside vaccine records? make a copy and put it in the nurse inbox

  • Does the patient have a double last name, or a last name that could be easily misspelled? - the patient could have multiple EMRs or WebIZ records, do some research, or ask an MA to help you; if you find two copies, print them both out and put them in the nurse inbox and write "please merge"

  • Was the patient at the Lied clinic in June 2018? (some vaccines didnt migrate over from the prior EMR) - check the UNR EMR Archive if so)

  • CCSD view on vaccine timing: "**Live vaccines (MMR, Varicella and live,attenuated Influenza) must be separated by 28 days if not given on the same day. Four-day rule does not apply to live vaccines. "

    • For non-live vaccines Example: If first dose of Hepatitis A administered 10/24/06, second dose given 04/20/07. This can be counted as a valid dose. 

coming soon