Outpatient Handoff

EPIC Context: DURHAM COUNTY HEALTH DEPARTMENT WOMENS HEALTH

• •Drag providers from the master list to your name.

Dot phrases (copy from Jasmine Arrington):

• •.PWNOBDCHD — new OB
• •.PWROBDCHD — return OB
• •.RXNOTE — put in comment box for all prescriptions

Workflow:

• •No computers in patient rooms — review everything before you go in.
• •Don’t worry about orders, labs, follow-up — nurses do it all. If you want to order labs (urine culture, etc.), ask the nurse. No In Basket responsibilities.
• •If you find a new problem, talk with supervisor and go over the plan. Important to ask about asthma.
• •Review all new patients with supervisor (may or may not happen depending on how busy the day is).
• •You can send med student in 1st for new OB (also returns) — have them get subjective + history.

Prescribing:

• •.Rxnote — put in comment box every time on prescription (includes language, allergies, MRN).
• •Select “Durham County Health Department Pharmacy” at the bottom of the order as pharmacy selection — will be ready for pt to pick up on 1st floor upon leaving.
• •Need to click on prescription and “print” to send to the pharmacy so it can actually be dispensed (someone will show you).

Documentation — Prenatal Vitals:

• •Chart every visit.
• •Answer the 4 cardinal questions.
• •Fundal Height — not until 20 wks. Should equal weeks gestational age; ±2 still normal. If GA greater or less than expected for two consecutive visits, order anatomy ultrasound.
• •Fetal Heart Tones — 110s–150s normal; if early in pregnancy, 160–170s may be normal. Use Doppler most of the time; use US M-mode for early pregnancies (8–12 wks).

New OB visit — concise but thorough:

• •Is this a desired pregnancy? Was it expected?
• •Do you feel safe at home? Supported?
• •PMH — medical problems they see doctor for.
• •Gynecologic history — most recent Pap smear; STIs (when, treated, test of cure if in pregnancy).
• •Surgical history — ask about uterine procedures specifically (fibroid removal, C/S — pay attention to scars).
• •How do you feel? N/V? Constipation? Back pain? Counsel on what to expect in pregnancy.
• •Diet + exercise: expected weight gain, 30 min moderate physical activity, no kickboxing.

Preeclampsia / ASA risk assessment:

• •Need 1 major or 2 moderate criteria to qualify for ASA.
• •Major:
• ◦History of preeclampsia, especially with adverse outcome
• ◦Multifetal gestation
• ◦Chronic hypertension
• ◦Pregestational type 1 or 2 diabetes
• ◦Kidney disease
• ◦Autoimmune disease (e.g. SLE, APS)
• •Moderate:
• ◦Nulliparity
• ◦Obesity (BMI > 30)
• ◦Family history of preeclampsia (mother or sister)
• ◦Black race (as a proxy for underlying racism)
• ◦Low income
• ◦Age 35+
• ◦Personal history (low birth weight or SGA, prior adverse outcome, >10-year pregnancy interval)
• ◦IVF

Everyone gets 1 point for low SES. Anyone with major criteria other than history of preE goes to HROB.

• •If positive screen: low-dose ASA until delivery. Receive BP cuff + sheet to document. >140/90 — write down + call DCHD. Severe ≥160/110 — go to triage immediately.
• •Visit frequency: <28 wks → q4 wks · 28–35+6 → q2 wks · 36+ → q1 wk.
• •FHTs >8 wks (if takes >30 sec, get US M-mode — apply lots of pressure if T1).
• •>20 wk fundal height (tape measures in room drawer, single use).
• •Leave the room to get chaperone for Pap smear / STI screening / breast exam.

Return OB visit:

• •How are you feeling? N/V, blurry vision, headache, etc.
• •4 cardinal questions: vaginal bleeding, loss of fluid, contractions, fetal movement.
• •Late 3rd trimester: breastfeeding, birth planning (C/S, VD), postpartum contraception.
• •If patient wants tubal: paperwork signed ≥ 30 days in advance for Medicaid (gov website to print). Begin discussion ~30 wks. Include interpreter ID on form.
• •36 wk visit: position ultrasound (head down?). Curvilinear probe vertical orientation, Mom completely flat, place directly on pubic symphysis. Looking for a line up and down with patient (or arrow) — white circular outline (hyper-attenuated). If round but not white, may be the belly → transverse.
• •“I’m going to talk with the team and then we’ll come back and talk about the plan.”

• •Stay at health department to finish notes. Feasible to catch up at lunch. Notes should be totally done before leaving.
• •Done 30 min before intern school starts so you can get there — just remind the provider you’re with.

• •Get to HROB by 12:10 PM on first day — get oriented to clinic + MAs.
• •You’ll have your own patients assigned to you, ~10 max.

EPIC Context: Duke Perinatal Durham Clinic

Dot phrases: .mfmmasterlist and choose postpartum clinic.

Workflow:

• •Stop at front desk to be let into the back workroom.
• •You’ll be with the U/S resident and 1 attending preceptor; 1 MA assigned to each of you for the afternoon.
• •Let MA know if contraception is known in advance, fetal death (ask to room far away from seeing lots of babies).
• •MA will give you vitals, name of pt, and any concerns before seeing patient.
• •Pay extra special attention to BP, especially if HTN disease.
• •Write down GsPs, when delivered, modality, comorbidities needing follow-up (gDM with medication or pre-gDM, HTN disorder of pregnancy, did they go to 3-day PP appt?), sub-specialist follow-up, PP bleeding or depression, contraception.
• •They have someone on site for mental health for patients to talk to (Julia with social work — see Key People).
• •Mostly work with MAs and nursing assistants here — you need to communicate everything you need from them (meds, orders, tests, labs, contraception).
• •The attending doesn’t have patients — you have your own panel and see all of them. Will be present for all procedures. Route all notes to the attending. Stay until you finish all notes ideally, but can finish from home.
• •Most visits are routine PP, lots of IUD / Nexplanon placements.

Documentation / Appointment Talking Points:

• •Summarize labor course, IOL, complications, PP hemorrhage, vaginal laceration, STAT C/S, baby that died (highlight red/bold), baby in NCU (highlight in yellow). Get it from the discharge summary for intrapartum course.
• •Follow up with patients on traumatic, difficult events.
• •Note medications continued/discontinued + impact on breastfeeding (Lactmed.com).
• •Wound vac, etc. that needs changing or evaluation.
• •PP contraception: given before discharge or not? Counsel that not using contraception = increased risk of uterine rupture in first 18 mo following pregnancy and increased risk of preterm birth (not something they have to do, but a known risk).
• •Confirm if patients want bridge contraception until ultimate management (e.g., vasectomy). May need UPT (urine pregnancy test) if getting BC.
• •Still on anticoagulation? Stopped prematurely? Explain why anticoag is important.
• •Follow up with PCP / sub-specialists.

Exams:

• •C/S: no vaginal exam, examine scar.
• •SVD: offer vaginal exam if laceration → ask attending to join to evaluate.
• ◦Up to 2nd degree: don’t need to look at it.
• ◦2nd degree bothering them: look at it.
• ◦Greater than 2nd: should evaluate.
• •Post-placental IUD: string check, bedside U/S if don’t see strings.

Responsible for In Basket — call/message patients back with results, answer questions.

Pearls:

• •Look up breastfeeding interactions with meds and any unfamiliar morbidities.
• •In-person interpreter for all Spanish-speaking patients (Ana — see Key People).
• •For fetal death, still review milestones — sex, period resumed, expelling clots.
• •Depression screen → if above 10 or SI positive, dig into mood. If blue ribbon, no EDPS. Julia Tarr is social worker (see Key People).
• •When people get tearful → stabilize: let them know we’d like to continue the conversation and have resources to help after the visit.
• •No contraception for self-pay → give them info to Health Department for LARC at sliding scale. Warn them even Pap smear is $200.

EPIC Context: Duke Clinic Gynecology

• •Cervix clinic patients are not assigned to you.
• •Responsible for In Basket — follow up with Pap / STI results each week.

Precharting is attending-dependent:

• •Dr. Kerner → prep clinic note only.
• •Dr. Huchko → prep clinic AND procedure note.
• •Dr. Muascher → no prep, she does all the notes! (You still follow up on results.)

Dot phrases (get from Jasmine Arrington):

• •.CXNEW2023
• •.CXRETURN2023
• •.CXLEEP2023
• •.CXCOLPO2023

Use the ASCCP app a lot — get familiar.

• •Use yellow sticky notes in EPIC with plan discussed with attending based on results.
• •Can then follow up in basket based on what was discussed as next step.
• •Click Result Mgmt to send message to providers and patient at the same time.

A newer clinic — great for managing pregnancy of unknown location in the office setting (not in the ED), and great for transvaginal ultrasounds with Irene (1J ultrasonographer). She loves to teach and is great at it.

Attendings: Dr. Hagey, Dr. Swartz, Dr. Gray, and FP fellow Dr. Gleeson.

Dot phrases: .1jepacnew · .1jepacereturn

• •Work 1-on-1 with attending / fellow — see patients and staff with attending/fellow.
• •Prechart!

Helpful practice bulletins to familiarize yourself with:

• •Early pregnancy loss
• •Tubal ectopic pregnancy

New for your class — part of the effort to introduce you to ultrasounds earlier, before your formal OB ultrasound rotation. You’ll be with the 1J ultrasonographer Irene on those days. Watch for more information from the chiefs at orientation.