Plastics

Dr. Michael Gordon
Dr. David Mathes

Subject to change! Krysta and Melissa can update you on any changes, particularly with OR time.
Hand fellow usually covers Weds hands cases–check weekly with fellow or Melissa.

Here is the page for the VA Templates. Currently only the generic operative report template is here. In the future, it would be nice to have the common plastic surgery discharge instructions here as well. The VA templates for notes need to be updates.

VA Prefixes: 720-857-xxxx or 720-723-xxxx. Use this last number to call back pages. ie. 1-2345, call 720 723 2345 skipping the 1.
Vocera: 720-723-7997 or 1-7997 (in-house), then say the name of the person you want to call (example: Pre-op charge nurse, K3 [room number] nurse, OR 1 nurse, radiology, outpatient pharmacy, etc.)

Get Card reader either from VA (will loan, but may lock you up if you lose it) or Amazon. Make sure MAC compatible if user
https://www.amazon.com/dp/B0177O5XNA?psc=1&ref=ppx_yo2ov_dt_b_product_details (MAC friendly)
https://www.amazon.com/Reader-Saicoo-Military-Compatible-Windows/dp/B071NT53M7 (for USB-C users)

Make sure you have received Welcome Letter in email giving remote access. IF you have not, email Ashley.Herrera@va.gov

Download Citrix (must download this VA specific one) Steps below:
https://raportal.vpn.va.gov/.
Click First Time downloads –takes awhile
Restart Computer
Same website, log-in with Smart Card option

Make sure card reader driver is downloaded at this point

Login to Remote VA (Bookmark this site)
https://citrixaccess.va.gov/vpn/index_citrix_splash.html.
Open Desktop West, general or ECH-CPRS (again 1st time takes forever)
Make sure PIV reader plugged in, should pop up screen that asks you to select Smart Card for PIV Login, click picture of PIV
If next screen doesn't show your name at top and says some generic VA thing, click More choices in lower left and select your name
Enter Pin # and you're in

Welcome to the VA. The senior resident has good autonomy at this location and you are expected to run the service. Krysta Bearish is the PA who helps coordinate for Breast Surgery as well. She works Tuesday through Friday and is present at clinic and available if needed for the operating room. There are no longer interns covering plastic surgery at the VA day or night. Mary is the plastics scheduler but easy to go through Krysta for most things. For cases at the VA, it is VERY important to make sure you have everything ordered beforehand. They won't have anything like Integra or implants on consignment.

Signing up for the VA can be a huge hassle. Please start the process as early as possible. You will need the following processes to get started with onboarding

*TMS Training (open the VA User Job Aid Form and review instructions before starting the training) – keep a copy of your TMS Certificates

• Complete VHA Mandatory Training for Trainees-Refresher (if done before), VHA Mandatory Training for Trainees (if not done)
  
• If you need help with your TMS Account when you log in please contact 1(855) 673-4357 or email VHAECHTMSHelpDesk@va.gov
  
• Please email Selena both of your TMS certificates to add to your file.
  
• Review VA Policies and then sign the VA Local Policies Acknowledgement Form and return it to Selena.
  
• va_fingerprint_request_form.pdf
  
• va_local_policies_acknowledgement.pdf
  

*VA Fingerprints

• Fingerprints must be completed at a VAMC facility. Don't bother doing them at an outside facility, there are always issues
  
• Recommended: Email VHAECHAcademicAffiliations@va.gov or Kayla.Lewis3@va.gov to schedule an appointment at the Aurora VA for fingerprints. the resident will need to bring 2 forms of ID - see PIV Acceptable Forms of ID. See RMR map for office location and directions for where to park for this visit.
  

*VA WOC Letter

• Selena must send you Without Compensation (WOC) Packet and you must sign it via DocuSign
  
• If completed and held up at this stage Please reach out to VHAECHSurgeryPSA@va.gov .Michael T. Kilmer is the director who signs the letters
  

*VA Badging (after completion of fingerprints)

• You need to be sponsored for a badge, email Ashley.Herrera@va.gov this takes few days -a week. I’d check back in with her after a week and email her again to get scheduled to obtain a badge.
  
• When you present for your badge, I recommend earlier in day, not lunch hour in order to get both building and computer access as these are 2 separate people and the computer people leave at 3.
  

*Trial & error

• Prior to starting VA rotation or taking call, recommend trying badge both for computer & door access during business hours
  
• Set up Remove access as below
  
• Must sign into remote access every 30 days to prevent expiring
  

When signing up make sure you have the following things:

• Access Code
• Verify Code
• PIN
• Signature Code
• Dictation Code (45 followed by the last 4 of your social. ie. 45XXXX)
• Microsoft Teams access (add Plastic Surgery team and inpatient list): From VA home page, click Sharepoint, then Apps in upper left hand corner

We get weekly meal vouchers here redeemable at the canteen, coffee shop, or canteen store. Every Mon/Tues, get them from Ashley Herrera at the front desk next to the resident office.

Plastics Clinic - Tuesday AM 8-11:30. We are in Maroon Peak clinic. 3rd floor specialties clinic in Building E, in rooms 224 - 228. 3-2-4 “enter” is the code to the door to get back into the clinic from the waiting room. They're using VSE now to show when patients arrive. Once the vital signs are taken, you call for the patient yourself and bring them to your room. You can edit the memo to say you are seeing the patient by adding your name/initials or adding “done” in the memo if the patient has been seen so everyone else is on the same page. The attendings have been using the 3rd room (room 228) from the main door as his office. You and Krysta select your own rooms and camp out there throughout clinic. I also encourage you to at least peek in on your post-ops, as you are afforded quite a bit of independence in the OR and it’s a good way to learn from your mistakes. Because of COVID, we are disinfecting the rooms ourselves between patients.

Hand clinic: 1st floor, building E. Code 154 enter. On Tuesdays it is you, Dr. Gordon and Melissa the PA. You will each have a room and will call patients similar to plastics clinic. On Wednesdays, you will sit in the main room and the nurse will room patients and write on the schedule when people arrive and when she roomed them; you will write initials next to one you see. Wednesday mornings are you, Melissa, and the attending. In the afternoon, the ortho residents should be joining after their didactics.

Clinic names on CPRS:
Plastics: Rmr Surg Plastc (MD MPR, MD Oper, MD/PA, MD/PA postop, Md/PA preop, MD/Res Eval) (VVC is video)
Hand: Rmr Surg Hand (MD, MPR, OPer, Md/PA urgent, Pa post, pa screen)
Make sure if scheduling patient for follow-up via RTC in orders, you select the correct follow-up clinic

If you have a case to schedule, the patient should be provided a business card with the contact information for the office (Krysta has those available). Sometimes we can offer them an OR date same day, but most of the time she will call them later in the week to get them onto the schedule.

For pre-ops, patients need: an H&P (“Surgical Preop-Op H&P”), pre-op labs (under pre-procedure labs), signed consents (consents are electronic: under “Tools” → iMed Consents → Plastic Reconstructive Surgery → Consents Basics → then select appropriate consent and follow prompts).

For pre-op labs: Women <50 need HCG (under pre/post procedure orders-pre-labs-urine pregnancy), BINAX (under labs- POC), pre-procedure (NPO/IV/Iodine/CHG/Hair), and CBC/coags if indicated. I recommend placing/confirming these orders in clinic or the night before cases or you will be woken up to a page at 6am.

PACS is IMPAX here. Click the icon on the desktop and search by using the last #4 of patient's SSN (“*1234”)

Make sure you always set up an encounter by right clicking note, select edit encounter and select yourself as a primary provider. Also select billing level of complexity, whether condition is service related, and a diagnosis for the encounter. Then write the note - there are specific plastic surgery headings to select. You can create your own template or use a pre-populated one. When you sign the notes - you are the “Primary” signer. Once you sign, right click and add co-signers. Add relevant attending and Krysta Bearish.

If you are seeing a NEW patient consult: “Plastic Resident/Fellow Consult Note”
If you are seeing a patient for follow-up, post-op: “Plastic Resident/Fellow Clinic Note”
If you are seeing a pre-op: “Surgical pre-op H&P” then follow the prompts and check all the boxes

The plastic surgery operating room day is Thursday. The first case is supposed to roll into the room before 08:00 AM to not be deemed “late.” Start time is supposed to be 07:45 AM. The operating room is on the 3rd floor of the D building. There are locker rooms in the back of the resident call room.

Residents wear blue scrubs at the VA. There is a scrub card that can be obtained from the administrator's office and Krysta can help you obtain that. In a bind, you can sign out a pair of scrubs from the office as well.

To check the OR status, go to Sharepoint and search for “VA ECHCS Perioperative Services”. Link is https://dvagov.sharepoint.com/sites/ECHOR/IP%20DAILY%20CALENDAR/Forms/AllItems.aspx?viewpath=%2Fsites%2FECHOR%2FIP%20DAILY%20CALENDAR%2FForms%2FAllItems%2Easpx

Prior to procedure, patients need orders, a pre-op H&P (by attending) and a consent. You do not need to write note on day of surgery. Krysta typically handles all of this when she sees the patient pre-operatively. I recommend letting Krysta do the pre-ops while you see new patients and post-ops. You should mark every patient. Dr. Mathes likes you to text him all patient names/last 4 of SSN at the beginning of each OR day so that he can write all his notes in the AM.

Under orders, “Write Delayed Orders” “Admit to Plastic Surgery”, relay orders immediately Surgery Main Menu - can use general surgery Go through each tab

Admitted patients will go to the Building K - 3rd floor.

Prior to discharge INPATIENTS, the patients will need:

1. Discharge order
   
2. Discharge Instructions (under Notes-discharge instructions)
   
3. Pharmacy Consult
   
4. Pain medication
   
5. Operative Note must be dictated the same day
   
6. Discharge summary (under D/C Summ tab)
   

(Clicking discharge menu under orders will walk you through this)

Prior to discharge OUTPATIENTS, select:

1. Pre/post procedure order sets
   
2. Post
   
3. Outpatient discharge orders 1,2,3
   

For narcotic prescribing, email vhaechepcshelp@va.gov to get your pharmacy ID

You can either dictate (see below) or type your operative notes. However if you type, make sure it goes into the right encounter (it is often easier to simply dictate). If typing, select surgery tab in CPRS. Select surgical date, and then select operative report for associated attending. If it was an intra-op consult, this may not exist and you will be forced to dictate. Next right click blank document to edit report. And copy and paste op note here from word document(you only get once chance with 0 edits). Right click again and hit sign. You will get a warning memo that you can't view report. This means it has gone to attending for their attestation.

The attendings expect us to dictate all of the operative reports. Attached below are the dictation instructions. Your dictation code is 45 followed by your last 4 of your SSN. To get dictation number, go to academic office next door or email richard.wagner6@va.gov. I recommend doing this sooner even if you plan on writing your op notes just in case.

DENVER VAMC Dictation Instructions

1. To access dictation system:

      From within the facility, dial x15075\\
      From outside the facility, dial 800-394-3845\\

When the call is answered, you will be greeted with a voice prompt which gives you instructions.
2. Enter your USER ID, followed by the # key.
3. When prompted, key in the patient’s full 9-digit SS number, followed by the # key.
4. When prompted, key in Work Type, followed by # key.

WORK TYPE REPORT TYPE
1 DISCHARGE SUMMARY 2 OPERATIVE REPORT 3 CONSULT & PROCEDURE 8 PROGRESS NOTE

At the sound of the tone, please begin your dictation.

* THE FOLLOWING MUST BE DICTATED DURING THE BEGINNING OF DICTATION*
• IDENTIFY PATIENT NAME (SPELL THE LAST NAME AND FIRST NAME).
• ENTER FULL SOCIAL SECURITY NUMBER
• CLINIC SPECIALTY TITLE (i.e., ORTHOPEDIC, NEUROLOGY, PRIMARY CARE, ETC.)
• DATE OF SCHEDULED APPOINTMENT
• NAME OF CO-SIGNATURE (ATTENDING) IF APPROPRIATE.

3. If you wish to dictate multiple reports, press ‘8’ to end one and begin another.
4. To obtain a job number for the report you just dictated, press ## before hanging up. KEEP THIS NUMBER UNTIL THE DICTATION IS AVAILABLE FOR ELECTRONIC SIGNATURE.
5. To disconnect, simply hang up.

DICTATION KEYPAD FUNCTIONS
1 To pause dictation.
2 To resume dictating after pausing.
3 Rewind – rewinds approximately 3 seconds. Press ‘2’ to resume dictating.
8 To end current report & begin another
## To get job number of report just dictated before hanging up
To disconnect, simply hang up.

‘LISTEN’ ACCESS
1. DIAL 800-394-3845
2. Press 333, followed by the # key.
3. Enter the patient’s full 9-digit SSN or Report number, followed by the # key.
4. The latest dictation or selected report will begin to play.

‘LISTEN’ KEY FUNCTIONS
1. PLAY
4. WILL GO TO END OF REPORT
2. PAUSE
6. NEW SEARCH
3. REWIND AND PLAY

SCI - This is the inpatient spinal cord unit (first floor of H). This unit is run by PMNR doctors and wound care.

• There are no longer MDC meetings
• Krysta typically gets first call. Whoever you are in clinic or OR that day is who I tend to staff the patient with.
• Our criteria is that their co-morbidities are relatively well-controlled, osteo has been addressed, and their albumin is 3 or above.
• Intraoperatively, Dr. Mathes typically does V-Y advancements, and Dr. Gordon does rotational flaps.
• Postoperatively, Dr. Mathes typically likes to keep the patients on antibiotics until the bone biopsies result. Dr. Gordon likes to keep dressings on for as long as possible (2 weeks) and sutures in for 4 weeks. Drains stay in until nothing consistently draining. Once sutures are out, can start on movement protocol (led by PMNR).
• Patients are typically seen every Tuesday after clinic. Will see with Krysta. Have her or the charge nurse call for wound care nurse (Jen) to help you turn and go over what they have been doing for wound care. Unless ongoing concern for a wound, we typically stop following a week or two into their motion protocol.
• Criteria:
  • Co-morbidities are relatively well-controlled, osteo has been addressed
  • Albumin is 3 or above

Set up a Surrogate: In CPRS - under “Tools” —> select “Options” —> select Surrogates —> select “Add Surrogate” put in name of next resident coming onto rotation and select start date as your last Friday on rotation (just make sure you clear your inbox your last day of rotation)

See Aline's guide here: plastics_va_.docx

Ryan's VA Templates here: va_hand_templates.docx & va_prs_templates.docx