Module 3: Patient Care and Population Health Study Guide

Lesson 1: Customer Service Conflict Resolution

• Purpose of Surveys: Surveys collect feedback to evaluate if standards, needs, and expectations of customers are being met. Feedback is a critical tool for improving the healthcare system.
• Regulatory Foundation: The survey program was established in response to the National Defense Authorization Act Public Law. No. 102-484, § 724, 106 Stat. 2315, 2440 (1992). This law mandates the administering secretaries to conduct an annual formal survey to determine:
  • Availability of services and types of services received.
  • Facilities where services are provided.
  • Familiarity with availability and facilities.
  • Health status of recipients.
  • Satisfaction with the system and quality provided.
• Data Collection Entities: The Defense Health Agency (DHA) and the Decision Support Division (DSD) collect information to measure beneficiary and staff satisfaction. This supports strategic planning, marketing, improving access/quality, and responding to Military Health System (MHS) and Department of Defense (DoD) requests.
• Joint Outpatient Experience Survey (JOES): Standardizes outpatient surveys to focus on the beneficiary experience at Military Treatment Facilities (MTFs).
  • JOES-C: Includes a separate monthly survey known as the Consumer Assessment of Health Providers and Systems (CAHPS-clinician and group survey). It focuses on direct and purchase care provider offices and allows benchmarking against civilian results.
• Interactive Customer Evaluation (ICE): A website managed by DISA that enables customers to research services or rate their experiences at DoD facilities.
• Conflict Resolution Core Principles:
  1. Never Argue: Arguing Only worsens the situation; the patient may not always be right, but professional decorum is required.
  2. Remain Calm and Professional: This protects the medic against corrective action. Control body language and facial expressions.
  3. Private Setting: Escort the patient to a private office to remove viewers and prevent the perception of an unprofessional encounter.
  4. Seek Help: Notify a supervisor or a Patient Advocate for conflicts that cannot be resolved at the medic level.
• The 5-Step Problem Solving Process:
  • Step 1: Define the Problem: Listen and address it immediately; gather information using open-ended questions.
  • Step 2: Identify Solutions: Be impartial and weigh the pros and cons of each side.
  • Step 3: Choose the Best Solution: Keep emotions out of the process and work together.
  • Step 4: Implement the Solution: Take action.
  • Step 5: Evaluate the Results: Assess the outcome to ensure the right solution was reached.

Lesson 2: Professional Standards and Ethics

• Ethics and Moral Character: Ethics involves judgment and choices. Moral character consists of virtues such as temperance, wisdom, courage, fortitude, faith, hope, and charity, alongside confidentiality, honesty, and compassion.
• Obligation: A pull to act based on character traits; if moral character is sound, resultant behavior will be sound.
• Standard Professional Codes:
  • Registered Nurses follow the American Nurses Association (ANA) code of ethics.
  • Licensed Practical Nurses follow the National Federation of Licensed Practical Nurses (NFLPN) code.
• Core Ethical Terms:
  • Autonomy: Respect for others and the right of individuals to make their own decisions.
  • Justice: Fairness.
  • Non-maleficence: The duty to do no harm; the basic ingredient for a code of ethics.
  • Beneficence: Doing good.
  • Fidelity: Being faithful to do good and acting responsibly.
  • Veracity: Truthfulness, which breeds trust.
• 12 Standards of Conduct for Patient Care:
  1. Respect each person as an individual and listen to their needs.
  2. Know the limits of your role and knowledge; speak up if untrained.
  3. Perform only tasks within the legal limits of your role.
  4. Perform only tasks you have been trained for and that are documented/signed off by a trainer.
  5. Perform no act that will harm the person.
  6. Follow the nurse’s directions to the best possible ability; clarify unclear orders.
  7. Follow unit policies and procedures; do not create your own methods.
  8. Complete each task safely.
  9. Keep person's information confidential (need-to-know basis).
  10. Protect privacy and property.
  11. Report errors and incidents honestly and immediately (e.g., via the Joint Patient Safety Reporting (JPSR) system).
  12. Be accountable for your actions.
• Patient Rights Examples:
  • Receive quality medical care.
  • Refuse treatment and be informed of consequences.
  • Privacy and confidentiality.
  • Be informed of the professional credentials of the healthcare team.
  • Full information on health status in a language they understand.
  • Be advised of research and have the right to refuse participation.
• Patient Responsibilities Examples:
  • Provide accurate medical history.
  • Inform providers if they do not understand explanations.
  • Comply with medical/nursing treatment plans.
  • Follow facility rules (noise, smoking, visitors).
• Death and Dying Concepts by Age Group:
  • Infant: No real concept; senses changes in routine.
  • 2–6 Years: Viewed as temporary/reversible; children may blame themselves (punishment for being bad).
  • 6–11 Years: Viewed as final but only happens to others; believe it can be avoided.
  • Young Adult: Most difficult reactions; fear of pain/suffering and worry about those left behind.
  • Middle-Aged Adult: Regret for mistakes; thoughts of things left undone.
  • Elderly: Acceptance; viewed as freedom from pain and a chance to reunite with loved ones.
• Stages of Emotional Reaction (Grieving):
  • Denial: Refuses to believe the worst. Medic should provide support/comfort without sharing in the denial.
  • Anger: Directed at family or the health care team. Medics must practice self-control and avoid reacting defensively.
  • Bargaining: Wishes for life extension or relief. Medics should listen and arrange support from clergy.
  • Depression: Feelings of powerlessness/mourning loss. Medics should allow the patient to do most of the talking.
  • Acceptance: Peace and logical plans. Medics should involve family in the care process.

Lesson 3: Legal Aspects of Patient Care

• National Practitioner Data Bank (NPDB): Operated by the Department of Health and Human Services (DHHS).
  • It is a workforce tool established by Congress in 1986 to prevent practitioners from moving state to state without disclosing previous damaging performance (malpractice, adverse licensure actions, etc.).
  • Reports are confidential and not available to the public.
  • Malpractice payments must be reported within 180 days of the Surgeon General (SG) receiving notice, unless the SG determines the standard of care was met.
  • All reports must be documented in the Centralized Credentials Quality Assurance System (CCQAS).
• Consent for Treatment:
  • Informed Consent: Patient provides consent after details are explained (reason, method, risks, options, outcomes, and effects of refusal). Adults must be mentally competent.
  • Implied Consent: The law assumes a person would consent to life-saving treatment if they were able (unconscious or incapacitated). This also applies to minors/incompetent patients when guardians are unavailable.
• Standards of Care: Defined as guidelines specifying predicted care for specific situations, derived from healthcare laws and practice guidelines. Often reflected in a Protocol.

Lesson 4: Information Systems

• Defense Enrollment Eligibility Reporting System (DEERS): The database for uniformed service members (Active, Retired, Reserve), DoD civilians, and families. Registration is mandatory for TRICARE eligibility.
• MHS GENESIS: The DoD's modernized Electronic Health Record (EHR) system. Provides a single unified record for inpatient, outpatient, and dental care. individual DHA components are responsible for training users.
• Tri-Service Workflow Forms (TSWF): Standardized documentation entry into MHS GENESIS.
  • Forms include Ambulatory Comprehensive Intake and Ambulatory Quick Intake.
  • Includes tabs for vital signs, pain scale (DVPS scale), vision screening, and military-specific data (Special duty, PHA, profile).
• Outpatient Coding:
  • International Classification of Diseases (ICD): Used by technicians to code diagnoses based on numerical classifications.
  • Current Procedural Coding (CPT): Used to code procedures.
  • 99211 Code: A "non-count" code used by technicians and nurses. It indicates third-party billing is not applicable. "Count" visits are for credentialed providers only.
• CarePoint Portal: A DHA delivery portal for business intelligence and healthcare transparency. Peer Review Tracking applications in CarePoint usually handle non-Genesis encounters.

Lesson 5: Documentation

• The Golden Rule: "If it wasn't documented, then it wasn't done!"
• Standards: Documentation must use black or blue ink. Errors are corrected by a single line-through, the correct info, initials, and date. Scribbling out errors is prohibited.
• AFMAN 41–210 (Tricare Operations and Patient Administration): Governs administration of medical records.
• Inpatient Record:
  • DD Form 792: Twenty-Four Hour Patient Intake and Output Worksheet (IV fluids, urine, drainage).
  • AF Form 3066: Doctor's Orders. Physicians write and sign all orders. Verbal orders can be accepted by an RN in emergencies but must be countersigned by the physician within 24 hours.
• Outpatient Record:
  • SOAPP Note:
    1. S (Subjective): Info stated by the patient/family (e.g., "Patient states he has body aches").
    2. O (Objective): Observable data (Vitals, behavior, exam findings). Example: Vitals such as BP: 110/75, Temperature: 102.8.
    3. A (Assessment): Preliminary conclusion reached by the Provider.
    4. P (Plan): Activities used to resolve the problem (Diagnostic, Therapeutic, Educational).
    5. P (Prevention): Counseling on health/wellness based on identified risks.
• Standard Form (SF) 600: Chronological Record of Medical Care. A permanent record used when MHS GENESIS is unavailable (e.g., during EHR downtime or in برخی ER settings). Entries must include complaint, duration, physical findings, and treatment.
• Patient Education: Standards set by The Joint Commission (TJC). Medics must find the patient's learning style to tailor delivery.

Lesson 6: Advanced Directives

• Advanced Directives: Prohibit certain care if there is no hope for recovery.
• Living Will: States treatments a patient does or does not want (e.g., ventilator use, DNR orders) if they become terminally ill and unable to communicate.
• Durable Power of Attorney: Designates an agent to make healthcare decisions once the patient is incapacitated; it ends upon the patient's death.
• Do Not Resuscitate (DNR) Order: Prohibits the initiation of CPR during respiratory or cardiorespiratory arrest.

Lesson 7: Considerations for Patients with Access and Functional Needs

• Causes of Immobility: Pain, Neurological damage (Stroke, spinal cord injury), Structural defects (Scoliosis, contractures), Weakness (Cancer), Psychological problems (Depression), and Rehabilitation (Bed rest).
• Integumentary Effects: Decubitus ulcers (pressure sores). Caused by compression of skin/tissues between bone and the bed surface. Factors include shearing force (tissue layers slide over each other) and friction.
  • Stages: 1, 2, 3, and 4 based on damage depth.
  • Prevention: Turn at least every 2 hours, keep skin clean/dry, use waterproof pads, and avoid abrasive soaps.
• Musculoskeletal Effects: Muscle atrophy (wasting), contractures (muscle shortening/joint stiffening), disuse osteoporosis (calcium imbalance making bones brittle), and backaches from poor alignment.
  • Footdrop (Plantar Flexion): A contracture where toes point downward permanently.
• Cardiovascular Effects: Increased heart workload, orthostatic hypotension (sudden BP drop upon standing caused by inadequate vasoconstriction), cardiac straining (e.g., straining to defecate), and thrombus formation (blood clots).
  • Embolism: A clot that travels to the lungs, blocking pulmonary blood vessels.
• Respiratory Effects: Loss of muscle tone, inadequate gas exchange, hypostatic pneumonia (infection from pooled secretions), and atelectasis (collapse of alveolar tissue).
  • Imbalance: Carbon dioxide build-up creates an acid-base imbalance leading to cardiac failure.
• Diabetes Mellitus: Pancreas fails to release enough insulin.
  • Type I: Insulin dependent; sudden onset in children/young adults.
  • Type II: Non-insulin dependent; often heredity/overweight-related, after age 40.
  • Gestational: Develops during pregnancy.
  • Emergencies: Hypoglycemia (low sugar, most common) and Hyperglycemia (high sugar). Field treatment "Glucose for everyone" is the rule.
  • Foot Care: Medics should never perform nail trimming for diabetics due to infection/amputation risks; this requires a doctor's order and is performed by a nurse/physician.
• Paralysis:
  • Quadriplegia: Legs, trunk, and arms.
  • Hemiplegia: One side of the body.
  • Paraplegia: Lower trunk and legs.
• Traumatic Brain Injury (TBI): Classified by the Glasgow Coma Scale (GCS):
  • Mild: GCS 13–15, LOC <30 min, PTA <24 hours.
  • Moderate: GCS 9–12, LOC >30 min to
  • Severe: GCS 3–8, LOC >24 hours, PTA >7 days.
• Burns Evaluation:
  • Rule of Nines (Adult): Head/Neck ($9\%$), Upper Extremity ($9\%$ each), Anterior Trunk ($18\%$), Posterior Trunk ($18\%$), Lower Extremity ($18\%$ each), Genitalia ($1\%$).
  • Rule of Nines (Infant): Head/Neck ($18\%$), Upper Extremity ($9\%$ each), Anterior Trunk ($18\%$), Posterior Trunk ($18\%$), Lower Extremity ($14\%$ each), Genitalia ($1\%$).
  • Degrees: Superficial (First), Partial-thickness (Second - blisters), Full-thickness (Third - charring).

Lesson 8: Ambulance/Emergency Response Operations

• Flight Line Operations: Requires local Airfield Driving Training Program (ADTP), color vision exam, and written test.
• Speeds: Max 15 mph on taxiways; max 5 mph when approaching or passing aircraft.
• Markings:
  • Restricted Area Boundary: Solid red line; never "Break RED" without permission.
  • VFR Hold Line: Two solid yellow lines and two double dashed lines. You must "Hold Short" (STOP) and receive tower permission to cross solid lines.
• In-flight Emergency (IFE): Calls handled via the "crash phone." Info needed: type of aircraft, souls on board, fuel remaining.
• 9 Line MEDEVAC Call:
  1. Location (Grid coordinates).
  2. Radio frequency.
  3. Number of patients by precedence (Urgent, Urgent Surgical, Priority, Routine, Convenience).
  4. Special equipment (None, Hoist, extraction equip).
  5. Number of patients (Litter vs Ambulatory).
  6. Security at pick-up site (No enemy, Potential enemy, Escort required).
  7. Method of marking pick-up (Panels, Pyrotechnics, Smoke).
  8. Patient nationality/status.
  9. NBC Contamination (Nuclear, Biological, Chemical).

Lesson 9: Population Health Principles

• Case Management: Collaborative process assessing and coordinating services to promote cost-effective outcomes.
• Disease Management: Focuses on optimizing health for specific populations with chronic conditions (e.g., metabolic syndrome).
• Utilization Management (UM): Identifies issues in healthcare delivery and manages the use of resources. This is distinct from Utilization Review, which examines past history while UM focuses on current/future processes.
• Referral Management:
  • Clinical Component: Reviews referrals for medical necessity and appropriateness.
  • Administrative Component: Manages electronic transmission of requests and ensures they meet access/continuity standards.
• Health Care Integrator (HCI): Leads teams in population health initiatives and mentors Patient Centered Medical Home (PCMH) teams on managing at-risk populations.

Questions & Discussion

• Question (Page 7): The purpose of a survey is to collect feedback from the customers in order to serve them better? Answer: True.
• Question (Page 13): A patient is yelling at the front desk about a non-working appointment line and unreturned messages while others watch with concern. What initial steps would you take? Process Answer: Escort them to a private office, remain calm, define the problem by listening, and identify solutions without arguing.
• Question (Page 33): ______________ is making a moral decision on what should be done in a given situation. Answer: Ethics.
• Question (Page 36): What is an example of a patient right? Answer: Refusing treatment, being informed of research projects, and expecting compliance by others.
• Question (Page 55): Which emotion reaction to death is where the member feels powerless to change the situation? Answer: Depression.
• Question (Page 76): Where do retail network pharmacies check TRICARE eligibility? Answer: DEERS.
• Question (Page 77): Who is solely responsible for coding patient encounters? Answer: Providers.
• Question (Page 84): Name the acronym representing a widely used method of documentation for health care providers. Answer: SOAPP.
• Question (Page 89): Verbal orders must be countersigned by the physician within how many hours? Answer: 24.
• Question (Page 91): True or False: SF 600 can be typed and must be in blue or black ink if handwritten. Answer: True.
• Question (Page 106): Which common cause of immobility includes scoliosis and contractures? Answer: Structural defects.
• Question (Page 144): What is the loss of sensation and/or the ability to move a part of the body? Answer: Paralysis.
• Question (Page 161): A child is crying, screaming, and refusing attention from anyone. What phase of separation anxiety? Answer: Protest.
• Question (Page 172): Symptoms of heat stroke? Answer: High fever, headache, dizziness.
• Question (Page 276): Can you drive on the runway without permission during an IFE? Answer: False.