Job description
DUTIES:
- See all patients at team visits: Review chart for previous surgeries, audiology, speech and genetics reports, outside provider reports, primary care status, previous team recommendations and insurance status. When seeing the patient/family weight and measure the patient and complete the Nursing Evaluation Form.
- Do physical exam to include at least oral exam and ears. Clean ears of cerumen for patients seeing audiologist that day. Make appropriate verbal recommendations based on history and exam and tell parent/patient about possible other team recommendations.
- Assist front staff in ensuring that patients see all providers needed for that visit.
- Open notes in Aprima and complete the Vitals, start the CC, HPI, Hx, Dx and Plan sections. Do the Nursing HPI using completed Nursing Evaluation form. Make sure that Dr. Wilson is listed as the Billing Provider and the Rendering Provider under the right hand slider Visit Information.
- Team conference. Gather the team when all are finished seeing patients. Ensure that providers sign the conference attendance sheet. Take notes of the provider recommendations to be listed as the Plan on the team note in Aprima.
- After the team conference, complete the Social Services, Pediatrics, Audiology and Psychology HPI using the providers’ handwritten notes. Complete the Plan section by listing the team recommendations as obtained from the team conference.
- Create the team report from the View button in the patient note screen—click on Generate Document. Go to “Use Formatting Model” and type cpp cl and press the tab button on the keyboard—this will bring up the Cleft Palate Team Conference Report, partially completed. Click on the Preview Tab.
- Edit the Team Conference report on each patient, deleting unnecessary words and correcting any errors in grammar.
- When the team report on the patient is complete, print 3 copies, one to be sent to the parent, one for the chart and one to be given to the front desk staff for billing team nurse services. Print envelopes and create cover letter for parents; send team report to parents. Fax the team report to patient’s primary care provider. (Find the fax number either on line or by calling PCP office.)
- Make sure the billing sheets are correctly and completely filled in. Add the ICD-10 code to each billing form. Leave billing sheets and one copy of the team report on the front of the chart for front desk staff to process. File the provider reports and team report with team report on top.
- Complete each of the patient recommendations that require action. If action is required in the future, note this on your Outlook calendar as a reminder. Check the recommendations as they get done or at least when there is a reminder in your calendar to do them.
Referrals
- Request CCS authorizations using online SAR request form at https://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/dhcs4509.pdf. Note on your calendar to check the status in 8-14 days.
- Request HMO authorizations for specialists outside the CPP through the primary care provider. Create the document “cpp PCP Authorization Request” in Aprima. Send it with documentation justifying the reason for the referral and with the patient’s insurance or Medi-Cal information. Note on your calendar to check the status of the auth by calling the PCP office in one week.
- No need to get authorization for PPO referrals, may send referral directly to specialty office with insurance info and medical reports.
- Create referral form in Aprima—generate the document titled “cpp Consultation Request”.
- Make specialty appointments for patients after faxing the Consultation Request, authorization, medical reports and demographics, unless the office requires that only the parent call for scheduling. Inform the patient/parent of the date, time and place of the appointment. Write it on the Consultation Request form and also add in the appropriate space when and how the patient or parent was notified. Note on your calendar reminding yourself to remind the patient the day before the appointment. Note on your calendar the day or so after the appointment to obtain the report from the specialty office.
- If unable to reach a family to notify them of an appointment, write on your calendar reminder to keep trying. Send a letter to the family but don’t assume they received it until you have verbally confirmed all appointments.
- For referrals to orthodontist see below.
Obtaining Outside Reports
- Use a current release of information sheet (Authorization for Use or Disclosure of Medical Information) signed by the parent or patient at time of annual team visit. Before completing it, make sure it is correct and complete and make a copy. Complete the form with the name of the office you’re requesting info from, “Attn” (write your own name), dates and what reports are being requested.
- Obtain the fax number of the office you are requesting from, either from the rolodex, online or calling the office. Fax the request to the office. Once you have the confirmation that it went through, use the fax stamp and write the date it was faxed. Mark on your calendar to check status in 1-3 weeks, depending on where you’re sending it. Call the office at that time if you haven’t received the report.
- When the report arrives, review it and the patient’s chart to determine what action, if any, is necessary. Do a written chart review.
- Chart Reviews
- May be done on any given patient any time, but may be BILLED TO CCS up to 12 times per year.
- Should be done 1) on reception of a pertinent outside report, 2) on a patient who for whatever reason (complicated case, history of family non-compliance, etc.) has need to be followed closely or 3) randomly when time permits.
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