Intro to the BWH Pain Rotation

Welcome Letter

Hi everyone,

Welcome to your chronic pain rotation/fellowship! If you are reading this guide, chances are that you are new to our chronic pain clinic at BWH. We are happy to have you and look forward to working with you! Our hope is that by providing this guide, it will make your transition to our pain clinic easier. The best way to use this guide is to read the relevant sections according to your assignment for the following day, so as not to be inundated by the amount of information in here. Unfortunately, if you are a new pain fellow, you should probably read all of this.

If you are a resident or rotator with any questions, please reach out to the assigned “outpatient chief” for your rotation month. If you have not yet received an email and directions on when/where to meet with your outpatient chief for your first day, please feel free to reach out to them. Please also let them know all the days you will be unavailable during your rotation (i.e. post-call, vacation, didactics, etc.) so that they can plan accordingly.

Again, welcome to the chronic pain service, we are looking forward to working with all of you!

Google Doc for Attending Med Order/Procedure Preferences: https://docs.google.com/document/d/1scNdG88Q5-I5NOWLAtDCWY-t9QMNCvi4rGeIX15a2wo/edit

Setting up Epic

Logging in/Contexts:

When logging in Epic, select your job as a “resident/fellow” and under Department, the possible departments you will use are “BWH Pain MGMT 850” for your work at 850, “BWH Chronic Pain” for inpatient pain, “BWH Pain Spine Hale” if seeing patients at Hale, and “BWF Pain Clinic” when working at Faulkner

Getting to attending schedules

Once you have logged in, click on the little schedule icon in the top left corner of Epic (just below the Red Epic dropdown tab)

Creating Attending Schedules in Epic

Then under the calendar with list of all the dates, you will create a schedule by pressing the green “+ create” button

• You will have to do this for every attending you work with
• For the “Name,” you can simply enter the attending’s name. Then under the “available columns” search tab, type in “department” and add the available column that says “Provider/Department”
  • This additional column will allow you to see where each provider is working for each given day (850, Hale, Faulkner, etc.)
• Then click on “Configuration” and enter the name of the provider you are working with (i.e. Robert Yong if you are with Dr. Yong) and add their name.
• In the “Department” column, it will now say either BWACCPMCPAIN (which is 850), BWFCLIPC (which is Faulkner), or BWHPAINSPINE (which is at Hale). This will tell you where the provider is working for your assigned day.

Choosing each provider

Helpful DotPhrases (Smart Phrases)

• Red epic dropdown in the top left corner of the screen > tools > SmartTool Editors > SmartPhrase Manager
• Find the user “Ang, Samuel” and add all the smartphrases beginning with .SPA, smartphrases beginning with .BAD, and any smartphrases beginning with .AL.
• Please also add the smartphrases .aaainitial and .akinitial.
• These will be incredibly useful in saving you time when writing or prepping your notes for clinic/procedures
• If it makes it easier, please feel free to add all the smartphrases owned by Ang, Samuel

Helpful SmartSets (for med orders)

• Please go back to the red epic dropdown in the top left corner of the screen > Tools > Decision support > User SmartSets > Enter “Ang, Samuel” into user versions > copy all the smartsets beginning with “BWHAMB” so that you have all those smartsets on your account as well

General Flow for Pain Clinic

• Patients will typically be roomed in assigned exam rooms by the medical assistants (MA’s) in each respective location. As soon as they are roomed, the MA’s will enter the assigned room into the “huddle note” area of the schedule board so that it is visible to you (with the exception of Faulkner). You can also see if/when a patient arrives, as it will say “arrived” next to their name or “checked in” typically when a patient is brought back to be roomed
• Before seeing the patients, you should enter your initials next to their assigned room (I.e. SA ll E1) so that your attending/other providers you are working with know that you are seeing the patient and there is no confusion about whether someone has gone to evaluate the patient
• Grab the plastic folder for the respective patient from the plastic bins near the MA’s (can ask them if you are not sure where) and bring it with you while you go to see the patient.
• After you are done gathering the history and performing a physical exam, you will then find the attending you are working with and discuss the patient with them. You will then return to see the patient together and come up with a final treatment plan.
• When you are done seeing the patient with the attending, please fill out the follow-up sheet (will be the last sheet in the plastic folder, hopefully you remembered to pick this up) and give this to the patient to make their next appointment at the front desk

General Flow for Pain Procedures

• The flow of procedures is more specific to the locations, but procedures are typically done at 850 and Faulkner
• At 850, patients are brought either into the procedural rooms (P1 to P4), the bay areas outside the procedural rooms, or into one of the fluoro rooms directly if they are going to have a fluoro procedure and there is space in the room (F1 or F2)
• Patients should be consented for their procedures as soon as they arrive and are checked in at 850 to save time between procedures. At Faulkner, wait to be notified when it is appropriate for you to consent.
  • For most procedures, this will involve verifying that they are not on any anti-coagulants (more important for neuraxial procedures), no recent infections or antibiotic use, and no allergies to any of the medications being used/cleaning solutions/latex.
  • At this time, you should also explain the common risks of each procedure: typically bleeding, infection, though sometimes headaches as well (particularly with epidurals) It is also helpful to verify the site of pain as well as the patient’s score prior and after the procedure/s
  • If the patient is having their procedure at Faulkner, please also remember to mark the respective area in which the patient will be having their procedure performed (i.e. place initials on lower back for lumbar epidural steroid injection)
    • Also, at Faulkner specifically, please clarify right before prepping the patient in the fluoro room whether or not a patient may be allergic to chlorhexidine or any other alcoholic based preparation solution, so as not to trigger an allergic reaction
• The nurses and fluoro techs will assist in obtaining the medications and positioning the patients in the fluoro suite, but please feel free to help them
• Before the attending arrives, you can ensure you have sterile gloves, proper supplies including needles and syringes for procedure, lead on so you are protected from XR, hair bouffant, and start drawing up medications necessary for the procedure. You can also begin to prep the patient’s respective procedure site with chloraprep/betadine as necessary
• Complete the procedure and the patient will be brought out by the nurses to be monitored for a short while, at which point you can check another pain score if necessary. Please also fill out the follow-up sheet (will be the last sheet in the plastic folder, hopefully you remembered to pick this up) and give this to the patient to make their next appointment at the front desk

Writing/Preparing Notes for Clinic and Procedures:

If you are assigned to any outpatient procedures the following day, you should place medication orders for each of the patients the day prior to the procedures. In addition, while it is certainly not required that you prep notes for clinic/procedures the day before, we recommend strongly considering it, as it may make your days run much smoother (you will also see that the pace of clinic/procedures can be very fast-paced, so it is easy to fall behind if you do not prepare in advance.

Of note, attendings order medications at Faulkner, so you do not need to place medication orders at Faulkner

You can speak with any other trainees/rotators that you may be working with to divvy up the notes/order prep equitably

Writing Clinic Notes

The most common clinic notes that you will write notes for are: “New Patients,” “Established Patients,” “Telephone/Telehealth Visits,” and “Virtual Visits”

General Info

• For any notes aside from new notes, you will carry-forward the last pain provider note from note.
• The new interval history will above all the previous interval histories (keep as many of these previous interval histories as relevant) and HPI section. You can copy forward old notes by clicking “Create Note” under the “Notes” tab > clicking “Copy Previous Note” on the toolbar for “My Note” just above the area for your blank text > select the most recent pain provider note to carry-forward
• When using any DotPhrase template for your notes, please ensure that if there is a smartphrase date entered in the note, you first refresh the note so the date is updated to the date of the visit. Then you can right click the date and click “Make Selected Text Editable” on the day of the visit so that the date will remain the same when carried forward for future updated notes
• Place any necessary orders for meds/procedures using the bottom left “Add Order” section that may be necessar
• For any virtual visits, please add the phrase .VVATTESTATION at the bottom (Wrap-Up SmartForm Navigator)
• DO NOT sign encounters, the attendings will sign the encounters when they are done filling out their attestations etc.
• Reminder: When you are done seeing the patient, please fill out the follow-up sheet (will be the last sheet in the plastic folder, hopefully you remembered to pick this up) and give this to the patient to make their next appointment at the front desk

New Patients

• For new evaluations, please use the dot phrase .aaainitial (or if you are working with Dr. Kim specifically, .akinitial for the appropriate new patient template and fill it out accordingly.
• When preparing these notes, it is often helpful to chart review notes to see what pain symptoms they are presenting for (i.e. lower back pain), what service they are being referred from (i.e. ortho would like a transforaminal steroid injection to see if patient’s pain is coming from a specific nerve room being compressed) or if they are self-referred, as well as any comorbidities (i.e. history of AFib on Apixaban)
• When you first enter a new patient’s chart, there is often an ambulatory referral hyperlink on the right side of the screen. Clicking this and reading through will often give you information about the chief pain complaint as well as the referring provider and their respective service. Additionally, it may provide information regarding what that specific provider would like you to evaluate
  • If you do not see a referral hyperlink when opening the patient’s chart, you can click on chart review > use the dropdown next to “notes” and click “Referrals” and look to see if there is a pain referral there. In a small number of cases, there is not and you can browse previous notes to see if you can gain some information
• Typically, it is helpful to fill in some basic information in the note template prior to the visit such as chief pain complaint, adding relevant history (i.e. 40 yo male with history of migraines, depression, AFib on Xarelto, laminectomy L3-5 in 2010 and fusion T2-10 in 2012 presenting with chronic low back pain). Referred by Dr. X from orthopedics for evaluation and management. Then it may be helpful to include some details from imaging, if available.
• The rest of the note you can fill out while seeing the patient and asking them about their pain symptoms

Established Patients:

• The most common reasons they will present for follow-up:
  • To follow-up after a procedure to determine efficacy
    • Use the phrase .spafuprocedure and fill in the relevant pain relief changes for the interval history
    • Update the “Interventions” section of the note just below the HPI with this information so it is carried forward in the future for historical purposes
  • Follow-up for continued med titration (i.e. increasing gabapentin)
    • Use the phrase .spafumedtitration and fill out relevant changes in dosing and pain relief for the interval history 2. Place orders for meds/refills as necessary
  • Post-op visit
    • Use the phrase .spapostop and fill out the relevant sections for the interval history 2. At 1-week post-op, dressings are taken down from surgical procedures. For the standard post-op patient after SCS placement or intrathecal pump placement, they can start to shower, but still should not submerge the wound (bath)/go swimming until approximately 1 month out from their procedure 3. They should continue to wear the abdominal binder (if they have one/have it on) for approximately 1 month 4. Ask questions about any pain at the surgical site out of proportion, redness, drainage, fevers, infectious symptoms, etc.
  • Reprogramming of SCS
    • Use the phrase .SPAREPROGRAMSCS for the interval history
    • Note that the respective biotech company’s rep will be the one to do the reprogramming, but you should still see the patient and quickly follow-up with them to determine which areas of their pain are uncovered by their SCS device or what other issues are going on with their SCS device
  • Medication refill (opioid scripts typically require monthly visits for continued refills).
    • Use the phrase .spamedrefill and fill out the relevant sections for the interval history.
    • Ask patients about any side effects from their medications.
    • Then you can use the phrase .spaopioidplan to generate a plan that will show you many of the necessary details for your plan
    • An easy to see way to see which meds they are on is to start the visit and go under the “Plan” tab and scroll down to their med list
    • All patients on opioid medications and their related medications (i.e. belbucua, butrans) should have an opioid agreement on file as well as a urine screen within the last 12 months. If they do not have ALL of these things, these items should be updated prior to refilling opioid scripts. PDMP (state service to monitor opioid prescribing) must also be reviewed at every visit to ensure no aberrancies when filling controlled substance scripts. You can use the dropdown by “Chart Review” to find PDMP.
    • Again, using the phrase .spaopioidplan, you can easily see when the last urine screen and opioid agreement was. If you need a new opioid agreement, it can be obtained from the MA’s or from plastic bins next to patient exam rooms at the 850 clinic. Furthermore, if a urine screen needs to be updated, please order a “Pain management profile (urine)” and ask the MA’s to obtain a urine specimen cup for the patient. If the most recent urine screen was completed at the patient’s prior visit, you should review the urine screen results for any aberrancies since you will be the first provider (since the urine screen was obtained) to have these results.
    • If you have your DEA, please feel free to sign the medications through to the patient’s desired pharmacy. If not, please pend the order for the attending.
    • The easiest way to refill the script is again under Plan > Medication Management > Reorder button next to the medication. When checking PDMP, you should look at when the controlled substance was last prescribed and have your start date of the refill coincide with the end date of the last script provided.
• Reminder, for all established patients, please copy forward the most recent note by a pain provider (see how to do this above), and insert your interval history above any other interval histories AND the HPI.
• For any scheduled telehealth/virtual visits, please check with your attending whether they would like you to speak with the patients or if they will be completing the visit themselves (some attendings prefer to just call the telehealth patients themselves).

Writing Procedure Notes

A few attendings will write their own procedure notes – most notably Dr. Yong and Dr. Kim. Otherwise, you should write the procedure note. The majority of attendings prefer that you copy forward the most recent pain provider note and update it, then embed your procedure note within the updated note. See the picture below. The exception is Dr. Michna, who is okay with you just creating an individual procedure note (see below).

Embedded Procedure Note

• Copy forward most recent pain provider note and update this note.
• Use the phrase .spaprocedure for your interval history and fill in what procedure the patient is presenting for that day
• Update the “Interventions” section just below the HPI to include the procedure that the patient will be having
• Embed (write) your procedure note just above the “Assessment and Plan” section of the note (see below). You will find a SmartPhrase for most procedures by typing .spa*** or .bad*** (fill in whatever procedure you are looking for)

Dr. Michna’s Procedure Notes

• Click on the Notes Tab > click “Create Note in NoteWriter” > select “Pain Procedure – Provider” > put in your own name as performing provider and Dr. Michna’s name as authorizing provider > click or search for the procedure you are looking for (I.e. L ESI Fluoro for lumbar ESI with fluoro).
• Click the following boxes for each procedure note: “yes” to verbal and written consent, tick the box next to Time-Out performed, tick the box next to patient was prepped and draped in a usual sterile fashion, select less than 10 cc EBL, then scroll to the bottom and select whether or not you used local anesthesia, “no” to sedation (in 99% of cases), and tick the box next to patient tolerated the procedure well with no immediate complications
• In the note box, you will then enter the free text for your procedure below all the auto-populated information. You will find a phrase for most procedures by typing .spa*** or .bad*** (whatever procedure you are looking for)

Placing Medication Orders for Procedures

• Enter the patient's chart > Under the pre-charting tab (which epic should default to), press “Start the Visit.” Do not worry, when you exit the chart, it will go back to the way it was, and it is okay to press this to order the medications
• Next, click on the “Plan – Diagnosis and meds & Orders” subtab
• Scroll down until you see SmartSets. If you copied the SmartSets (see Setting Up Epic portion of this guide), then all the SmartSets should now be available here. Attendings will have different preferences for medications for each procedure, so please see their preferences here as well as basic technique for how to do each procedure: https://docs.google.com/document/d/1scNdG88Q5-I5NOWLAtDCWY-t9QMNCvi4rGeIX15a2wo/edit
• Click on the corresponding SmartSet related to the procedure you are planning to do, open the SmartSet, and sign those medication orders through (for context of orders, just type a brief name of the procedure)
• Of note, if you are unsure what medications to order for a specific procedure, a pretty safe bet is choosing the “Samuel – MBB” SmartSet that contains bupivacaine 0.25%, lidocaine 0.5% and Depomedrol. Please feel free to tweak the orders as necessary
• You can also just search for the “BWH Pain Clinic” SmartSet to see all the options for orders
• Each outpatient chief can also give you guidance on their own preferred SmartSet orders