Pearls from MA/LPN/RN Staff

Things that would be useful for the MAs/LPNs/RNs:

Epic chart:

• please fill out the social history documentation tab in Epic as this helps the nurses and staff who room our patients know what is going on in their lives in a way that enhances the care they can provide

• RNs would appreciate a little more of a step-by-step plan in your notes.  “patient will try home exercises which are handed out today.  If pain persists beyond x weeks, will refer to physical therapy …”

• Please reconcile medications.  When your rooming staff room patients, they will mark if a patient is taking a medication or not but it is our responsibility to remove the medications they are not taking and make sure the chart reflects correct doses for what they are taking.

• Check your in-basket at least once per 24 hours on non-holiday weekdays (not weekends or holidays) and respond to messages your MAs/LPNs/RNs have sent you.  They will continue to get calls from patients, often repeatedly, and it is hard for them to not yet have an answer from you.

• Do not use unapproved abbreviations because it makes it very difficult for our staff to know what your message is saying at times (see UCONNECT for approved abbreviation policy).

• Always chart what medication changes or recommendations you make to patients.  RNs mentioned that sometimes folks will reach a patient after-hours and make recommendations which are not charted. This is really confusing when the RN then calls the patient the next day not knowing that we have already dealt with the issue.

• Update the problem lists

Labs:

• If you want them to come for future labs, please order the lab and also tell them to schedule the lab appointment

• For Northeast: Put time of collection and your initials on wet prep specimen label and thin prep pap specimen label

• Place lab orders on all labs ideally before you leave the exam room or directly afterward.  Lab needs orders to be in place before they receive the specimens

• Please let your MA/LPN know if you have left a lab specimen in the exam room.  They want to get that specimen out of the room before the next patient is sent to that room.

• Be aware of what time your lab closes

• Don’t use “results notes” to send info to MAs/LPNs/RNs that you would like relayed to the patient.  Instead, please create a telephone encounter.

• Be aware of what you put in routing comments as these will now be part of the medical record.

Clinic flow:

• Huddles: Let your MA/LPN know when you arrive to clinic ASAP.  Please give your MA/LPN a brief history of what has been going on with the patient.  Make sure you have reviewed the patients prior to huddling.

• Residents should have awareness of their own schedules and not ask a patient to follow up with them in 2 weeks if they know they don’t have any availability then.  They should explain and use their team APPs more for these types of follow up needs.

• Residents should be willing to take on others’ patients if they have a no-show and should communicate with triage RNs if this is the case.  They should also please ask for help and discuss how things are going with their MA/LPN if they are getting further and further behind.

• If the resident needs the MA/LPN to do something (like immunizations, EKG, etc.) they should place the order and use their flags and also ideally tell the MA/LPN face to face.  If that is not possible, they should secure chat them rather than just only use the flag.  (MAs and LPNs from several clinics reiterated the importance of using flags consistently.)

• If the resident orders DME or home health, they should tell the MA/LPN this as they will need to fax the order.  The visit note also needs to be completed immediately and faxed along with the Home Health order*

• Try to have patients out of the exam rooms by no later than 5pm

• Be open to learning from your MAs and LPNs things like how to enter PHQs and other work-flow things that would benefit you to know.

• Be conscious about the noise level in the staffing room (this came up at Wingra).

Things to be sure to communicate to patients:

• That DME may not be covered under their insurance

• Expected timelines for hearing about specific things – imaging appointments, specialty appointments, etc.

• realistic recommendations to patients taking into consideration any limitations they may have (cost, transportation, lifestyle preferences)

Inbasket things:

• Please respond to pools rather than just to the person who sent you something

• Send a Mychart directly to the patient instead of asking the MA/LPN/RN to be the intermediary as much on results – normal results and abnormals. 

• Make phone encounter rather than cc chart or orders only encounter.

• Avoid sending very long messages to the RNs to relay to patients as patients will likely have questions they don’t know the answers to.  Instead, please call the patients if it is a long explanation.  This is especially important if the patient prefers Spanish and you speak Spanish but the RN does not.

HIPAA:

• Don’t leave labels in the room – HIPAA violation – patients get sent back before room can be cleaned, patient goes to wrong room, etc.

And some words of wisdom regarding MA/LPN/RN roles from Stacy Leidel (Wingra)

I recently updated the Wingra Resident Orientation Manual with role information. My goal was to help the residents route results/phone encounters to the appropriate staff member and to know who to ask for help with certain clinical tasks. It’s also important for our culture to know what other members of the team have to offer and respect professional expertise.

I didn’t include LPNs in the Wingra document because we only have MAs. LPNs are licensed and regulated by the Board of Nursing. However UW Health uses them as MAs, so for example, they would not assess a wound, start an IV, teach patients how to do insulin injections, or triage a symptom call. Northeast folks might have more detail on how this works in practice.

Clinic roles - Medical assistants and LPNs

Medical assistants are cross-trained in the clinical and administrative tasks required to assist providers in ambulatory settings. MAs are required to have a high school diploma. Their training typically consists of a 10-12 month didactic and hands-on training program that includes digital literacy, anatomy and physiology, pharmacology, medical law and ethics, medical terminology, basic health care administration, and first aid. For example, UW Health has a 10 month paid MA apprenticeship program. MAs are unlicensed and not regulated by the Board of Nursing or Board of Medicine, and work under direct supervision by medical providers. Since MAs are not nurses they do not have the skills required for triaging symptoms, physical assessment, wound care, initiating IV fluids, administering IV medications, or patient education. Some MAs are also certified nursing assistants and therefore have experience with patient transfers, toileting, use of the hoyer lift, etc. At Wingra, the MA team reports to the clinic manager, with the RN supervisor providing clinical and educational support.

Duties include

• “Rooming” patients during office visits as per the Standard Rooming Criteria--Ambulatory

• Obtaining chief complaint (not a full HPI)

• Obtaining vital signs including height, weight, temperature, pulse, respirations and BP. You may need to remind the MA to obtain oxygen saturations for certain patients during your huddle. 

• Reviewing tobacco history

• Reviewing medication list and allergies. MAs are not able to discontinue medications, but will mark “not taking” if a patient reports they are no longer taking the medication. This should alert you to consider the need for the medication. 

  • It is the prescriber’s responsibility to review all medications before prescribing and discontinue medications that are no longer needed. This keeps the med list up to date for other encounters in the health system and MyChart.

• Completing diagnostic procedures ordered by the provider – ECGs, orthostatic blood pressures, walking desat tests, vision testing, audiometry

• Completing therapeutic procedures as ordered by provider  – ear lavage, fluoride varnish, vaccinations, oral medications (e.g., ondansetron ODT), other injections (e.g., Toradol), suture removal per delegation protocol.

  • If there are any issues with MA procedures please inform Mary, Kris, and/or Stacy.

  • We are not doing any aerosol generating procedures (spirometry, nebulizer treatments).

• Taking measurements for compression stockings

• Applying splints, crutches, basic first aid for wounds (not major wound assessment or dressing selection, which should be done by an RN).

• Assisting providers with procedures and chaperoning for sensitive exams

• Scheduling OB and Maternal-Fetal Medicine referrals and ultrasounds

• Calling transportation for patients at the end of a visit

• Helping a patient get to lab or x-ray if needed

• Calling a clinic or pharmacy to get information needed for patients during a visit

• Faxing paperwork for patients as needed during a visit (such as forms for work) 

• Responding to medical emergencies

• Sterilizing equipment

• Ordering and stocking supplies

• MA visits - blood pressure checks, immunization only visits, Depo-Provera follow-up injections, PPD placement and reading

• Managing the MA pools in epic - On the computer , on the phone, on the fax machine  - handling all asynchronous clinical needs that don’t require an RN or a provider.  

Clinic roles - Team RNs

Registered nurses have an associate’s degree in nursing (ADN) or bachelor of science in nursing (BSN) which leads to eligibility for the NCLEX exam and RN licensure, which is regulated by state boards of nursing. RNs use the nursing process: assessment, diagnosis, planning, implementation and evaluation. Nursing assessment is focused on the manifestations of a symptom and the patient’s response to it. Diagnosis in a nursing sense refers to the RN’s clinical judgment of the situation which forms the basis of the care plan. Planning, implementation and evaluation involve critical thinking and taking the patient’s perspective, context, and meaning into account. We encourage RNs to use their critical thinking skills and the nursing process, and strive for them to work at the top of their license. A simple way to help foster this is to say things like “I am going to consult the RN team about your wound” that recognize valuable nursing knowledge.

Duties include:

• Triage of all symptom-based calls. When a patient calls reporting a symptom, the call center routes the encounter to the team RN pool for triage. There are some exceptions that can be directly scheduled with a provider without RN triage.

  • The triage process is guided by UW Health triage protocols and other resources, and triage RNs receive phone triage education and support.

  • The call center can route some calls (e.g., for chest pain) directly to an RN.

  • The objective of RN triage is to select the appropriate disposition after a focused assessment of the symptom (e.g., same day appointment, appointment within 3 days, refer to ED, etc). Note: The RN team are required to use the SBAR framework (Situation-Background-Assessment-Recommendation) in triage, and often use it in communication with providers.

  • If an RN has questions about a patient situation s/he may send you a phone encounter; if urgent s/he will consult the preceptor of the session and/or route the encounter to the provider pool.

• Providing basic home care advice/patient education per protocol and RN discretion.

• Management of patients on warfarin using the UW Health Anticoagulation protocol

• Management of common conditions (such as UTI, suture removal) via  clinical delegation protocols. 

• Making follow-up calls to complex patients to check on interim progress – make sure to provide specific instructions like “Please contact pt to check on CHF symptoms following furosemide dose increase”

• Responding to clinic emergencies.

• The RNs rotate as “Nurse of the Day”, indicated by a sign near the teaching area. This RN is available for the face to face patient care needs during the clinic session. 

• Basic wound assessment and wound care on a case-by-case basis. (Note: call the RN in during your office visit for the RN to assess the wound and determine if RN follow-up is appropriate). OR take photos and place E-consult to Wound/Burn.

• Administration of IV fluids (e.g., gastroenteritis, hyperemesis gravidarum).

• Glucometer and insulin injection teaching (but not other aspects of diabetes education--place a consult to diabetes education for full diabetic and nutrition teaching)

• Injection teaching (e.g., home testosterone or depo injections)

•  Managing the team RN pool in epic - On the computer , on the phone, on the fax machine  - handling all asynchronous clinical needs that require an RN scope of practice.