The Monday Clinic
Operations Manual
October 2006
Public
Version
Contents
I. Introduction..................................................................................................................... 3
History.............................................................................................................................. 3
North Dallas Shared Ministries.......................................................................................... 3
Patient Population.............................................................................................................. 3
II. The Monday Clinic........................................................................................................ 4
Mission Statement............................................................................................................. 4
Expectations...................................................................................................................... 4
Scope of Services............................................................................................................. 4
Triage............................................................................................................................... 5
Clinic Flow........................................................................................................................ 6
Roles and Responsibilities.................................................................................................. 7
III. Drugs and Diagnostics................................................................................................. 8
Tests................................................................................................................................. 8
OTC Drugs....................................................................................................................... 9
Prescription drugs.............................................................................................................. 9
IV. Referrals and Follow-up............................................................................................ 10
Outside referrals.............................................................................................................. 10
Follow-up....................................................................................................................... 13
V. Appendix...................................................................................................................... 14
Contact Information......................................................................................................... 14
Contact Numbers............................................................................................................ 14
Map................................................................................................................................ 14
Zip Codes served by NDSM:.......................................................................................... 15
Fire Alarm Procedure for North Dallas Shared Ministries................................................. 18
Procedure for Security System......................................................................................... 18
Check List for Monday Clinic.......................................................................................... 19
Incident Report............................................................................................................... 25
Procedure for Intake using Paper Forms.......................................................................... 26
Bloodborne Pathogen Exposure....................................................................................... 27
Exposure Incident Report................................................................................................ 29
Follow Up Contact.......................................................................................................... 34
The Monday Clinic is a student-run free clinic that began as a project headed by a group of first year medical students at UT Southwestern. At the beginning of the spring semester in 2006, they united with the ideas of creating a clinic where medical students could help care for the community and improve their ability to provide medical care during the preclinical and clinical years.
NDSM was formed in 1983 by five
The clinic serves low income patients from
The Monday Clinic will:
1) Provide
high quality, free medical care to the underserved population of
2) Provide an interactive learning environment for medical students thereby allowing them to develop clinical, organizational, and leadership skills;
3) Instill in students a lifelong commitment of service to the community and others in need; and
4) Introduce medical students to the needs of the uninsured.
Students will uphold the highest standards of professionalism. This includes, but is not limited to:
- Speaking to and treating patients with respect
- Maintaining patient confidentiality
- Dressing in appropriate attire
- Conducting interviews and physical exams to the best of your ability
- Knowing one’s limitations: Seeking expertise in cases where you lack experience
- Following all established NDSM policies and procedures
Patients are only seen at The Monday Clinic on a space-available, walk-in basis and clinical advice is not provided by telephone. No appointments are given, and service is on a first come, first served basis. Only adults are seen at The Monday Clinic, and no immunizations can be given at this time. Acute minor illnesses are treated. No chronic care is provided. In the event that a patient needs continuity of care for a chronic condition, please see the Los Barrios referral policy.
The following adults will be considered eligible for services. Those who are:
- Stable and whose vital signs fall within the following:
- Heart rate <110
- Respiratory rate <30
- Systolic blood pressure >100 / Diastolic blood pressure<110
- Temperature <104°F
- Oxygen saturation >93%
- Alert and fully oriented
- Present with common conditions such as URIs, sore throats, cough, earaches, conjunctivitis, and common, treatable symptoms such as wheezing and dysuria.
- Present with minor injuries, minor contusions and abrasions
- Present with simple incision and drainage of cutaneous abscesses and no fever
- Vital signs as stated above with vomiting, diarrhea, constipation, or abdominal pain
- Present with rashes and no fever
- Present with first or second degree burns <5% BSA and not involving hands, feet or face.
- Under age 35 with vital signs as stated above with chest pain
In the unlikely event that patients with serious medical conditions present to the clinic, nurses and physicians together determine how to move the patient to a higher level of care. Most patients will be triaged or referred for higher levels of care after being
screened for that condition by nurses, physicians, or mid-level providers. However, if anyone on the premises of NDSM experiences a life-threatening emergency, 9-1-1
will be called.
A. Clinical triage during registration:
Consultation with a Monday clinic physician will be obtained immediately whenever any patient is found to have vital signs that are outside of the ranges defined above. If the attending is not yet present, please page him or her.
B. Clinical triage for higher-level services:
- Non-emergency Referrals. For patients who are stable and have already been evaluated by Monday clinic physicians, please see the Los Barrios referral process below.
- Emergency Referrals: For patients who have been evaluated by Monday clinic physicians and are found to be in need of referral to the nearest emergency room, the following steps will occur:
- The patient or patient’s caretaker is informed of the urgency of his condition by the attending physician. This discussion is documented on the patient’s progress note along with the date and time of the discussion, and a copy is made for the patient to take to the ER.
- The
clinic supervisor confirms with the patient that transportation is immediately
available and provides written directions to Parkland or Children’s
- If immediate transportation is not available, the clinic supervisor will call for a taxi to take the patient to the nearest emergency room. The cost of this transportation will be reimbursed by NDSM.
- 9-1-1 will be called whenever anyone on the premises of NDSM experiences a life-threatening emergency. Life-threatening emergencies include, but are not limited to, the following: immediate need for supplemental oxygen, requirement of cardiopulmonary resuscitation, seizures, tachypnea associated with the inability to complete 5-word sentences, inability to bear weight in association with pain or following an injury, unresponsiveness, active bleeding.
Patient Intake:
The Intake/ Discharge coordinator will begin the night by letting patients into the waiting area and handing out tickets to indicate their order of arrival. The number of patients treated in a given night is determined by the number of rooms in operation. The patients will then be called to the window in order of their ticket number. The intake staff will obtain the patient’s full name, zip code, complaint, and whether or not they have been a patient at NDSM before. They will then be asked to fill out the Patient Information Form as well as a Patient History Form. At this point the staff will conduct basic triage to evaluate whether or not the patient’s complaint is in compliance with the clinic’s scope of care and whether the patient might be better served by attending a specialty clinic (podiatry, dermatology, etc.) Refer to the triage procedure as described above. Once the forms are completed by the patient and returned to the window, database volunteers will admit the patient. The database should be searched for ALL patients, even if they say they have never been to the clinic; often it is helpful to search by birthday, first and last names. If they are a first time patient, they will be entered as such into the computer system and a new chart will be assembled. If the patient is returning, after confirming the information provided by the patient is the same as the database, the chart will be pulled from the NDSM chart room. Check the chart for notes on the front of the file, and make sure there is nothing which would preclude the patient from being seen. In either case consent forms will be printed for the patient to sign, and the intake number should be placed on the left hand corner of the consent form. Once the file is assembled it will be placed in ‘Ready to be seen’ file in the order it was received (according to the intake number on the file).
Medical Exam:
When the medical students assigned to a room are ready for a patient they will go to the front and get the next chart in the ‘Ready to be seen’ file. The medical students will be responsible for finding the patient in the waiting room, taking them back to the exam room, and then conducting standard vital signs in the exam room. Once vital signs are completed, the students will conduct the history and physical. Ideally, the first-year medical student will practice history taking with assistance from the more experienced second year. The second year will practice physical exam skills with assistance from the senior medical student (either a third- or fourth-year student) on their team.
Once the medical students feel they have an adequate history and physical, along with a basic differential diagnosis, they will present their findings to the senior student. The senior student can then follow-up with any additional physical exam or history information that they deem necessary, and take the opportunity to explain and discuss the case with the pre-clinical students. Once this has been completed and the diagnosis has been further defined, all students will present to the attending physician with a recommendation on diagnosis and treatment options. The attending physician will assess the patient and the differential diagnosis, and discuss the treatment plan for the patient. If necessary, a variety of on-site and send-off labs can be ordered in accordance with NDSM’s lab policies. Prescription drugs can be prescribed to the patient by using the Walgreen’s pharmacy voucher, which will allow the patient to have the prescription filled, free of charge, at a nearby Walgreen’s. A limited formulary of over-the-counter medications are also available at the clinic, and can be given directly to the patient by the attending physician. If the outcome of the visit is that a more in-depth follow-up visit is required, a variety of referrals can be made, and details conveyed to the patient through the Intake/Discharge Coordinator.
Discharge:
When the visit is concluded, the patient will leave the exam room and meet with the Intake/Discharge Coordinator before leaving the clinic. This will be a chance to review the visit and confirm the patient’s understanding of the treatment plan, any referrals or follow-ups, and any information about pharmaceutical access. When the patient leaves, their chart should be returned to the front desk for data entry and re-filing by the intake/discharge staff. All medications, labs, and diagnosis should be entered in the database. Any direct referrals should be attached to the front of the chart and all lab requisitions. Vouchers should be loose in the file. Once the pertinent information from the visit has been entered in the computer-based record system their chart can be placed in the Clinical Director’s office to await lab results, follow-up, etc.
Note: It is highly recommended that all Monday Clinic volunteers have a completed Hepatitis B series and an up to date TB test.
One first year and one second year student will be assigned to each exam room. Each senior medical student (either a third- or fourth-year) will oversee two exam rooms. The attending physician(s) will oversee the clinical operations of the entire clinic.
1st year students - First-year students will work as part of the health care team to learn the basics of patient interaction and medical care. They will work alongside the second-year students to obtain the vital signs, history, and physical, and will practice patient interviews and history taking along with vital signs as they feel comfortable. They will also assist in presenting the case to the attending physician, and in making decisions on the treatment plan. They will assist the second year student in writing the clinic note.
2nd year students - Second-year students will guide the vitals, history, and physical exam process during the initial part of the patient visit. They will assist and teach the first-years through the patient history, and refine their own skills in physical exam. They will then consult with the senior medical student and follow-up in obtaining any additional information necessary to complete the history and physical before presenting to the attending physician. They will be responsible along with the first year for writing the clinical note in the chart.
3rd and 4th year students - Senior medical students will be responsible for guiding the overall care of patients who come to The Monday Clinic. First- and second-year students will present their history and physical exam findings to the senior medical student, who will then work with them to refine the differential diagnosis and solidify a treatment plan. The senior medical student will listen when the other students present the case to the attending physician and will provide additional information relevant to the case, as needed.
Intake/Discharge Coordinator - The intake/discharge coordinator will oversee the intake and triage process and will be available to answer any questions and address problems that may arise during patient registration. They will also receive each patient’s chart before the patient is discharged and review the chart to assure that everything has been done according to the standards of the clinic, that the patient clearly understands his or her treatment plan, and that the proper protocol is followed for any referral given for follow-up care.
Clinic Manager - The clinic manager is ultimately responsible for all operations of the clinic for the evening. The manager will begin by overseeing the student orientation at the beginning of the evening and then move to managing the medical operations of the clinic once patients are seen. The clinic manager will be responsible for running or overseeing all in-house labs and will be responsible for the protocol for send-off lab work. In addition, the manager and intake/discharge coordinator will assure that all administrative and data collection responsibilities have been completed before the clinic closes.
Intake/Discharge Staff - The intake/discharge staff will be responsible for proper registration and triage of all patients who come to the clinic. They will ensure that the patients fully fill out the pertinent paperwork, and the staff will subsequently enter their information into the electronic medical records system. The staff will also assist in patient discharge and ensure that proper record of the visit is made in the records system.
Translators - Roles of the interpreters include assisting with patient registration, facilitating communication between patients and physicians during the medical visit, making phone calls as needed to report lab tests, and explaining services available outside the NDSM clinic. While interpreters should only accept assignments consistent with their language fluency, the use of dictionaries—especially for medical terminology—is encouraged.
Attending Physician – Attending physicians will be the
authorities and role models providing their experience and knowledge to the
clinic in the form of providing finalized treatment plans for patients and
teaching all medical student volunteers.
The attending physician will be ultimately responsible for the care of
patients, and he will ensure that the highest possible level of care is given
to the patients who come to NDSM. These physicians must read (if not write) the
patient note and sign/cosign it.
The clinic manager will have been trained in advance to perform all of the basic labs that can be run at the NDSM clinic, and can assist all other students in the proper use of these labs. Interested medical students will learn the correct way to run labs and how to submit them as determined by patient need. The following tests can be done in house:
· Capillary blood glucose
· Urine dipstick
· Pregnancy test
· Rapid strep test
· Stool guaiac test
If necessary, additional tests are available on a send-out basis through Quest Diagnostics. Specimens can be obtained and left in the drop box for pickup, or patients can be sent to Quest for testing (such as a fasting blood glucose test). Testing should be done only when medically appropriate. Please refer to the appendix for procedures concerning all in-house labs and sending labs/patients to Quest.
The NDSM clinic stocks a variety of non-prescription drugs that can be given to patients at no cost. Formularies can be found at each physician station.
The clinic stocks a basic formulary of prescription drugs, ranging
from antibiotics to albuterol to steroid creams. These can only be given to a
patient if a pharmacist is present. For non-formulary prescription drugs, or if
a pharmacist is not present, patients can be given a voucher to receive the
prescribed medicine from a nearby Walgreen’s pharmacy at no cost to the patient.
Physicians are encouraged to prescribe generic drugs and to consider cost
whenever possible and medically appropriate. (For example, Levaquin is commonly
prescribed for urinary tract infections, but studies show that Ciprofloxacin
has a very similar coverage profile, and is significantly less expensive;
indeed,
Walgreen’s
Vouchers - Vouchers can be given to the patient for either over-the-counter
or prescription medications. The Walgreen’s at
IV.
Referrals and Follow-up
Patients should be referred to other NDSM clinics before outside referrals if these clinics can appropriately treat the patient’s condition.
Other clinics at
NDSM:
|
Clinic Services and Hours |
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Minor Illness and Immunization Clinic |
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Tuesday & Thursday (adults & children) |
5:00 PM |
|
Tuesday (children only) |
10:30 AM |
|
Specialty Clinics |
|
|
Foot Clinic |
|
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Tuesday |
5:00 PM |
|
Dermatology Clinic |
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1st & 3rd Thursday |
5:00 PM |
|
2nd Tuesday |
5:00PM |
|
Woman's Clinic |
|
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1st & 3rd Wednesday |
5:00 PM |
|
Adult Dental
Clinic |
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1st and 3rd Friday |
8:00 AM |
Other Referrals: NDSM also keeps information on referrals to other places including:
a.
b.
c. MLK Clinic
d. Emergency rooms
e. Los Barrios
Recognizing that continuity of care is extremely important to successful outcomes, great care should be taken with each chart at the end of each evening to ensure that complete and accurate information is left in order for NDSM to follow up appropriately. If it is determined that a patient needs follow-up of any sort (referrals, labs, etc.), the follow-up form should be completed and clipped to the front of the chart. Instructions for follow-up should be made as explicit as possible. See attached.
V. Appendix
NORTH
972-620-8696
Fax: 214-234-8747
Email: admin@ndsm.org
NDSM Free Medical Clinic for the Working Poor
Incident Report
Nature of Incident::
Date of Action Taken:
Action Taken:
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Follow up date:
Follow up information:
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Signed below when fully resolved by:
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Date: |
Date: |
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Rationale: Avoiding blood exposures is the primary way to prevent transmission of Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Thus, all volunteers at NDSM Free Medical Clinic are required to follow universal precautions at all times (see attachment A), and safety needles are to be used for all injections, except when the sole purpose of the injection is to provide local anesthesia or administer a PPD. To further decrease the risk of acquiring infection from accidental bloodborne pathogen exposure, all medical personnel and translators should complete a 3-dose series of Hepatitis B vaccine before working in the clinic.
Definition: An exposure that might place volunteers or patients at risk for HBV, HCV, or HIV infection is defined as a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g. exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.
In the event of
bloodborne pathogen exposure occurring at NDSM Free Medical Clinic, the
following procedure must be followed immediately and rigorously.
- Immediate
care of the exposure site.
Wash wounds and skin sites that have been in contact with blood or body fluids with soap and water; mucous membranes should be flushed with water.
- Report
the exposure immediately.
The clinic director and medical director or her designee should be informed directly or by phone within 4 hours of the event. A written report (see Attachment B) should be completed by the medical volunteer(s) involved, in cooperation with the clinic supervisor responsible at the time, before any of them leave the clinic.
If the source of the blood is known, that person should be told of the incident (through a translator, if necessary), before he/she leaves the clinic. The accuracy of contact information, including street address and at least 2 phone numbers, should be verified by the clinic supervisor.
- The
following blood tests should be obtained as soon as possible from the source:
- Hepatitis B surface antigen (HbsAg) using a serum separator* tube (tiger top)
- antibody to Hepatitis C virus (anti-HCV) using a serum separator* tube
- antibody to human immunodeficiency virus (HIV antibody) using a serum separator* tube
- RPR if source is an adult using a serum separator* tube
- If
the source is unknown, the following should be obtained as soon as
possible from the exposed person:
- anti-Hepatitis B surface antibodies using a serum separator* tube
- AND the exposed person should be administered one dose of any Hepatitis B vaccine on-hand before the exposed person leaves the clinic.
(No blood needs to be drawn initially from the exposed person when the source is known and his blood has been drawn.)
- The need for further testing or treatment of the exposed person will be determined within 48 hours by the medical director of her designee. (see Attachment C.) This decision will be based upon U.S. Public Health Service Guidelines for the Management of Occupational Exposure, after consultation with the National Clinician’s Postexposure Prophylaxis Hotline (888) 448-4911 when needed.
ATTACHMENT A - Universal Protocol
Universal
Precautions
- Barrier protection should be used at all times to prevent skin and mucous membrane contamination with blood, body fluids containing visible blood, or other body fluids (cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids, semen and vaginal secretions).
i.
Barrier
protection should be used with ALL tissues.
ii.
The
type of barrier protection used should be appropriate for the type of
procedures being performed and the type of exposure anticipated. Examples of
barrier protection include disposable lab coats, gloves, and eye and face
protection.
- Gloves are to be worn when there is potential for hand or skin contact with blood, other potentially infectious material, or items and surfaces contaminated with these materials.
- Wear face protection (face shield) during procedures that are likely to generate droplets of blood or body fluid to prevent exposure to mucous membranes of the mouth, nose and eyes.
- Wear protective body clothing (disposable laboratory coats (Tyvek)) when there is a potential for splashing of blood or body fluids.
- Wash hands or other skin surfaces thoroughly and immediately if contaminated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply.
- Avoid accidental injuries that can be caused by needles, scalpel blades, laboratory instruments, etc. when performing procedures, cleaning instruments, handling sharp instruments, and disposing of used needles, pipettes, etc.
- Used needles, disposable syringes, scalpel blades, pipettes, and other sharp items are to be places in puncture resistant containers marked with a biohazard symbol for disposal.
ATTACHMENT B - Exposure Incident Report Form
NDSM Free Medical Clinic for
the Working Poor
Exposure Incident Report
Please refer to Bloodborne Pathogen Exposure
policy before completing this report.
Patient’s Name:
Patient’s File #:
Date and time of Exposure:
Name of Person EXPOSED:
If patient, File #:
Nature of Procedure Being Performed:
(Include how and when the exposure occurred. If the exposure was
related to a sharp device, include the type and brand of the device)
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Details of the Exposure:
(Include type and amount of fluid or
material and severity of exposure)
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Details of Exposure SOURCE:
(The source is the person whose blood would
have been found on the needle or
other sharp object when that needle
penetrated another person’s skin OR whose
blood or bodily fluids came into
contact with another person’s nonintact skin or
mucous membranes. Please include age, general health status, as
well as history
of Hepatitis B vaccine, and place
of birth, if known.)
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Details of Person EXPOSED:
(Please include age, general health
status, history of Hepatitis B vaccine, and place of
birth if known.)
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Action taken:
(Attach copy of requisitions for any lab tests ordered; include TIME DRAWN.)
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Follow-up information:
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Signed below when fully resolved by:
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Name |
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Name |
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NDSM Medical Director |
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NDSM Clinic Director |
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Date: |
Date: |
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ATTACHMENT C
Dr. Susan Briner - Medical Director
Cell # = 214-683-5093
If
no answer, please leave a message and phone numbers where you can be
reached during the next 4
hours.
Nancy Volk – Clinic Director
Cell # = 214-616-7959
Home # = 972-934-9402
E-mail addresses for further communication after verbal report:
sbriner@jcaho.org and randelh1r@aol.com = Dr. Briner
cldirndsm@excite.com = Nancy Volk
SIGN-OUT SHEET:
Request for Follow-up
Please attach a completed copy of this
form to the chart of every patient seen in
clinic today who
needs follow-up.
Patient’s Name:________________________________ Today’s date_____________
File #:_________________ Patient speaks English Spanish
Please indicate the reason for follow-up and check all boxes that apply.
1. REFERRAL. Patient was referred elsewhere for care beyond the scope of NDSM.
Sent to ER Given 7AM referral to Los Barrios.
Needs direct referral to __________________________________________
(name of clinic or agency)
2. LAB TESTS. Outsourced labs were ordered at NDSM and results are pending.
Labs were drawn at NDSM and sent from here.
Patient was given lab slip and instructed to have testing done at laboratory.
Please list all the outsourced labs that were ordered:_________________________
___________________________________________________________________
3. PHONE CALL. Please contact patient by phone.
To confirm he is stable or improving.
To convey the following information:________________________________
___________________________________________________________________
Follow-up information will be communicated to the physician whose name,
pager or
cell #, and e-mail are listed below:
Name: ___________________________________pager or cell#___________________
e-mail_______________________