Plastics

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===== Veteran's Affairs =====

==== VA Faculty ====

[[resident:david_mathes|Dr. David Mathes]]\\
[[resident:david_mathes|Dr. Seth Tebockhorst]]\\
==== Generic Monthly Schedule ====

Subject to change! Melissa Munkwitz can update you on any changes, particularly with OR time. \\

General Schedule 
^ ^ Tuesday ^ Wednesday ^ Thursday ^
|Dr. Mathes |AM/PM Tebockhorst +/- Mathes Plastics/Hand Clinic in E1 | Tebockhorst MPR | OR - 7:45AM Start|

==== VA Templates ====

Here is the page for the [[Resident:VA_Templates|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 Phone Numbers ====

^ Phone Numbers ^ Role ^ ^
| Vocera | 15239 | 720-857-5239 |
| IT | 14681 | 8556734357 |
| ED | 16298 | 
| DJ | Plastics RN | 303 803 5199 |
| Zeina Omisola | Plastics RN Coordinator | 720-989-5327 |
| Jenn Hutton | SCI Wound Care RN | 720 469 8217 |
| Melissa Munkwitz | Hand/PRS PA | 414 587 8491 |
| IT Help Desk| 855 673 4357 |

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:  720-857-5239 or 1-5239 (in-house), then say the name of the person you want to call (example: Pre-op charge nurse, K3 [room number] nurse/provider/resident, wound care, OR 1 nurse, radiology, outpatient pharmacy, etc.)\\

==== VA APP'S ====
The VA now has APP's that help manage inpatient needs and consults. There are sometimes gaps in coverage. If you admit a patient, please sign out to them so that they know the plan in case they get called (this limits phone calls to you!) 

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==== VA Remote Access ====

Get Card reader either from VA IT (as of June 2024 they don't write down your info and don't care about getting it back) or Amazon. Make sure MAC compatible if user\\
https://www.amazon.com/dp/B002N3MM6W?psc=1&ref=ppx_yo2ov_dt_b_product_details (MAC friendly)\\
https://www.amazon.com/Identiv-SCR3310v2-0-Smart-Card-Reader/dp/B07VVSY96H/ref=sr_1_6?keywords=IDENTIV&qid=1699290763&sr=8-6&th=1 (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\\


==== General Information & Onboarding ====

Welcome to the VA. The senior resident has good autonomy at this location and you are expected to run the service. We no longer have a PA or interns on service (including night coverage). 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 PRS Program Coordinator 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.\\
    *{{ :resident:va_fingerprint_request_form.pdf |}}\\
    *{{ :resident: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\\
    *Program coordinator 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

^ ^ Code ^
|Locker room code | 1-4-5 Enter |
|Men's Locker #59 | 8008 |
|Woman's Locker #90 | ? |

====Expired Badges====
    * OH NO I HAVEN'T SCANNED MY BADGE >90 days SO NOW IT'S EXPIRED\\
    * EMERGENT: Call Police Dispatch 720-723-5800 and request reactivation for emergent purposes. This gets recorded in Facility Access Section for follow-up and verification with the supervisor/service. \\
    * NON-EMERGENT: Email VHAECHfacilityaccessrequest@va.gov to request badge re-activation in advance of your rotation. 
    * If you are already on campus when you realize this, use intercom button at entrance of staff garage marked "POLICE" and you will be granted entrance after answering few questions. You must then visit Facility Access Section in A2-104 during normal business hours for re-activation. REQUIRED: WOC letter with non-digital signature (can get from HR on 1st floor in A building\\

==== Meals ====
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. She will ask you how many days you are "on call" to determine how much money you get - tell her 5 days for each week. 
==== Clinic ====

Hand clinic and Plastics Clinic:
1st floor, building E. Code 251 enter. On Tuesdays it is you, Mathes, Dr. Tebockhorst and Melissa the PA or some combination of those people. Everyone sits in the "Care Team Center" E1-223. You will sit in the main team 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. These clinics are more organized. So you should only have to look at 1 schedule. Melissa will print out list of all patients for clinic and leave in team room. Make sure if scheduling patient for follow-up via RTC in orders, you select the correct follow-up clinic. Ask Melissa\\

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)\\

Note Formats on CPRS:\\
I recommend you creating templates for new patients vs. post-ops etc. Go to templates in lower left corner of CPRS, right click "My templates" and create new template. When filling out notes, you can drag these to empty note page and will copy over. \\
When you click "new note" it will pop up with progress note title:\\
Plastics: PLASTIC SURGERY RESIDENT/FELLOW CLINIC NOTE\\
Hand: Type in Hand --> will pop up options, select HAND RESIDENT CLINIC NOTE\\
Sign notes by right clicking and selecting "sign note now"\\
It will show a prompt saying "are you the primary for this encounter"--select yes.\\
You have to select encounter type, complexity, add Dr. Gordon, and diagnosis for encounter, then sign\\

For pre-ops patients, patients need: an H&P (select "SURGICAL PRE-OP H&P" as progress note title), 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 <55 need HCG (under pre/post procedure orders-pre-labs-urine pregnancy), 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.\\  

If ordering studies/labs that require follow-up or change management - please make sure to add to "tasks to follow up on" spreadsheet in Excel. Melissa and next resident will then be able to follow-up after you change rotation. \\

==== IMAGING ====
PACS is IMAGING PACS (XERO Viewer) here.

Access by opening CPRS:
1. Tools 
2. Imaging Apps
3. IMAGING PACS 
4. Type in patient's last initial and *#### (last 4 of SSN) 


==== Surgery ====
Find surgery schedule by selecting clinic schedule RMR SURG PLASTC MD OPER. All Gordon hand cases are now under this schedule as well\\
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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. Go to office next to resident workroom to ask for one. 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

You can also go into VistA under "tools" "more" and "operating room schedule" from here you can select the date and see the schedule

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. It's good practice to double check the charts beforehand to make sure that was all done. 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.\\

Ordering Tumescent: Go to surgery main menu, order tumescent\\

==== Outpatient Surgery and Inpatient Tasks  ====

All the things you need are in the tabs at the bottom of the screen \\
Right click with the mouse to sign orders/notes/etc. \\
I pre wrote all my instructions and op not in an email to myself to make copy and pasting easier, you’ll see why below. \\


Outpatient Surgery Discharge. \\
1. Go to Notes, click New Note, Brief op note\\
	- Fill in the form \\
	- Sign after it populates as a note\\ 
2. Go to Orders tab \\
	- Click “ Pre/Post Procedure Order Sets”\\
	- Click “POST PROCEDURE ORDERS (click here)”\\
	- Under “outpatient discharge orders” there is a 1,2 and 3 click thru each one and fill in what you need 	\\
	- easiest to have some generic dc instructions in you email or something that you can just copy and paste in there \\
3. Outpatient meds I could never order, so I would ask Melissa or ask for a surgery APP to help me \\
	- Melissa is there tues - thurs and can help you \\
	- Tebock does his own meds or can for you \\
4. Op note \\
	- Go to “Surgery” tab \\
	- Find the surgery date and name you just did in the left hand column \\
	- Open that *date*, OPERATION REPORT\\
	- Right click to edit, and then you can type your op report in there. \\
	- once you SIGN it you cannot edit, it disappears so make sure you are happy. Some people write the notes on their own comp or in word then copy and paste, then sign. \\
	- I never got the phone call dictation to work, this works just as well. \\
\\
Admitting at the VA \\
HIGHLY recommend doing this in the resident bowl so a surgical APP can help you. \\
1. Complete brief op note, can do op note too if you want, or do it later. \\
2. Go to “Orders” tab \\
	- Open “Surgery Main Menu”\\
	- Under surgical speciality menus there is “General Surgery Menu” click that \\
	- <<Click Here>> General Sx Admission Order Set, let that go through all its things. \\
	- Can also just click all the orders you want here in the “general surgery menu”\\
	- don’t forget no ice or heat to breast, surgical bra or binder, drain care can write those as nurse free text orders. \\
3. Restarting Home Meds: In the Meds tab \\
	- under “Outpatient Meds” you can hold Shift and highlight all meds you want to be continued. \\
	- At the top of the CPRS screen there is “Action” click this and in the drop down menu select “transfer to inpatient”\\
4. You must complete a “Life-sustaining Treatment” note, you’ll need their family contact phone number before hand!!!\\
	- Go to Notes tab, select New Note, Search “Life sustaining “\\
	- fill in the form\\
	- sign after it populates as a note\\
\\{{ :resident:va_inpatient_orders.jpg?nolink&400 |}}
\\
I have an APP check this before I leave \\
\\
How to discharge at the VA \\
1. Check meds on the “Meds” tab and make sure outpatient meds are what you want, if needed order whatever post op meds you want (Residents usually can’t order meds so you have to ask a PA to order them for you - like Melissa or one of the surgery APPs) \\
2. Go to Notes and “New Note” and chose the “Provider discharge instructions” \\
	- fill out the form, easy if you have some instructions already written you can copy and paste, if not just free hand it \\
	- sign after it populates in a note \\
3. Home oxygen, if needed \\
	- Click Consults tab \\
	- click “New Consult” from the left hand column \\
	- On the far right column in that pop up window it says “PULMONARY…”, click that\\	- Under “Home Oxygen” there is a “New Home O2 Order” click that to get a home O2 order and get O2 delivered to bed \\
	- In your dc order (under step 4) you can write in the “special instructions”, “do not dc until home O2 delivered.” \\
4. Go to orders \\
	- in the left column click, Discharge pathway, follow the instructions in order\\
	- Pharmacy Discharge Consult, fill the pre filled form, you’ve already checked the outpatient meds, sweet \\
	- you’ve already done the provider dc instructions, yay 	\\
	- “Click here to order Discharge Order”\\
5. Go to D/C summary and click “new summary”\\
	- chose any template that says “dc summary” or some version of that, it doesn’t matter which\\
	- fill out the form\\
	- sign when complete \\
6. Do the PDMP Query \\
	- top right hand corner just clinic and follow steps and sign \\
\\
If your unsure surgical APPs are very nice and helpful I would have them check my work before I left \\
All BLUE orders need to be signed, you can hold shift and select them all and sign at once \\





==== Dictations/Op Reports ====

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\\
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\\

DRAGON SUPPORT:
\\18006541187
\\18008337776


==== SCI ====

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 
  * See Plastic Surgery TEAMS spreadsheet for pending SCI consults. You keep this up to date
  * 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. 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


==== End of rotation Tasks ====
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)\\

Make sure TEAMS spreadsheets for SCI consults & Tasks to follow up are updated.\\


==== Templates for Notes ====

See Aline's guide here: {{ :resident:plastics_va_.docx |}}

Ryan's VA Templates here: {{{{ :resident:va_hand_templates.docx |}} & {{ :resident:va_prs_templates.docx |}}