In preparation for working with our healthcare team, we strongly encourage all to VIEW THIS VIDEO developed by the North Coast Aboriginal Health Improvement Committee with financial support from Northern Health.

Outpatient Care

Haida gwaii Health centre cLINIC
Regular clinics are booked with 15-30 min appointments (in person and virtual). Clinic starts at 10am, with lunch from 12-1:30 pm (1pm on Fridays), with last appt booked at 4:30pm. 
​Locums and Residents are required to enter DIAGNOSTIC CODES for each billable clinic encounter. These are entered in MOIS, on the encounter line, in the appropriate column. You can search for diagnostic codes in MOIS (hit the "..." associated with the relevant column). You can also refer to the cheat sheet below.
Outreach clinics
​The Sandspit clinic happens on a Tuesday (once a month) - you need to catch the 09:30 ferry between Skidegate and Alliford Bay and then drive 10km into Sandspit; the clinic is inside the school building. The clinic ends around 3:00pm, and usually allows you to catch the 3:30pm ferry back.
​The Skidegate clinic happens on a Thursday afternoon, once a month. It starts at 10:00 at the Skidegate Health Centre (ask PCA for directions). It runs from 10:00 to 5pm, with the last 2-3 appointments often dedicated to home visits, when needed. The Skidegate Home Care RNs can help you with the logistics (call 250-559-4610 and ask to speak with one of them a few days before your clinic). You will need to be able to log into your desktop remotely to access MOIS in Skidegate - find out how to do so before you go! 
pregnancy and birth services
Please consider offering midwifery support to all patients who present to the clinic or ER with pregnancy, including:
- those who are considering or planning to terminate
- those who are experiencing a pregnancy loss
- those who hope to carry an ongoing pregnancy
You can reach the on-call midwife at 250.637.1115 and you are welcome to share this number with patients.
For more info, check out Haida Gwaii Maternity Program
Cancer CAre
​Tracy Morton and Caroline Shooner (sharing Practice A) are GPOs covering Cancer Care for all of Haida Gwaii; if you are working for Practice A, you will not be expected to deal with patients in the Cancer Care program. You will be given a list of these patients - any results for these patients will be dealt with separately, by either Tracy or Caroline.
Community Services

Inpatient Care

the ward
ACUTE CARE:
  • ​MDs are expected to round on their Practice's Acute In-Patients (and any LTC Patients requiring attention) every weekday morning, and remain accessible to troubleshoot any issues that arise until 5pm at which point the MD on call takes over until 8am the next day.
  • On Weekends and STATs, the MD on call will see all Acute In-Patients. If the MD on call admits a patient from another practice, they are expected to hand them over at 8am to the MD covering this practice. On post call days, the MD post-call can handover their own acute patients to the MD on call after they have completed their morning rounds.
  • ​Please note: there is an inbox at the RN station for each Practice - it should be checked every morning. RNs often leave notes to MDs about their patients on pink paper.

LONG-TERM CARE:
  • Long-term Care patients are seen on an as needed basis (and at least once a month by their MRP). 
admissions
  • ​The on-call MD admits patients during their shift. They will continue to follow them during their admission if the patient belongs to their practice, or handover the patient at 8am (end of ER shift) to the MD who is the patient's MRP. Patients who are not from our community (Eg.: Masset patients or visitors) will be followed by the MD on call ("Doctor of the Day"), unless the admitting physician decides to follow them throughout their admission (this may be most appropriate for complex cases such as patients admitted under the MHA).
  • There are pre-assembled admission packages in a file cabinet at the RN station (General, MHA, Detox Admission etc.) - please request the appropriate package from the ER nurse, along with a print-out of their medication list on Medinet for reconciliation. For patients admitted under the Mental Health Act, please refer to our MHA binder for guidance. 
  • Please copy your admission note into Power Chart where it can be viewed by nursing and other care providers. You may also print it for the paper chart.
discharges
  • Discharge summaries should be copied into Power Chart where they can be accessed by all providers - this will also ensure that a copy is forwarded to their MOIS record.
  • Discharge summaries must also be faxed to Skidegate Home Care for Skidegate residents at 250-637-0743 for continuity of care (the care team in Skidegate does not have access to our EMR). Please fax the summary asap, at the time of discharge, or task Medical Records to do so.
  • If possible, update the patient's Long Term Medications list in MOIS at the time of discharge. Discharge prescriptions can be faxed to our pharmacy at 250-559-4915. 
transfers
  • We use PTN for all ER/In-Patient transfers (1-866-233-2337); when you call PTN, you will be walked through the transfer process and connected with the required higher level of care service. Our main referral centers are Prince Rupert, Terrace, Kitimat (ortho only), Vancouver and Prince George (her is a list of our preferred Specialists.). The monthly call schedule for specialists can be found on a clipboard at the RN station (PTN will also assist you to find the appropriate referral person/centre). Feel free to ask one of the local MD for help when trying to figure out where to best send your patient, and keep in mind that weather delays are common, so initiate transfers early!
  • ​Your Transfer Note serves as a Discharge Summary (no need to do both). Please copy your Transfer Notes into Power Chart, where it can be easily accessed by off-island providers.
intercom (vocera)
We use VOCERA intercom devices to communicate with each other when in facility (cell phones are also an option, but VOCERA use is encouraged). 
​

CODE WHITE

If at any point you do not feel safe in a situation and you need support, please initiate a CODE WHITE and our team will be there! To do so, press the red button on the bottom left side of the black VOCERA or double tap the round button on the small white VOCERA. 

Emergency Shifts

ER SHIFTS
  • Call shifts are 24 hours long, from 8am to 8am. The number of ER visits is quite variable, averaging 12 or so per shift (summer is busier with visitors). Patients who register to be seen in ER will be triaged by an RN who will assign them a CTAS score between 1 and 5, with 1 being the most acute and need of immediate attention. ​
  • The on-call MD admits patients during their shift. Please see "ADMISSIONS" tab above for details of our admission process.
  • The on-call MD will also field calls from PTN requesting a patient be repatriated - in general, as long as we have a bed available and the patient is deemed stable enough for repatriation, they are accepted. The repatriation time frame is unpredictable (can take days), so that the MD who accepted the patient may not be the one who admits them later on. The accepting MD should document the repatriation conversation in the patient's chart (in MOIS). 
ER ASSISTANCE & SPECIALIST SUPPORT
  • On occasion, the MD covering the ER may require the assistance of additional providers to manage an unstable/complex patient or polytrauma.
  • The physicians use a group on Signal (All DG Docs) to quickly connect with each other for advice or to request hands-on assistance. Locums and Learners will be added to this Signal group on their first day of work.
  • RCCbc also provide virtual support via their RTVS initiative. On Mondays and Wednesdays, RCCbc's VERRa physician covers the ER virtually form 8pm to 8am - the local MD on call remains available for any cases that require hands-on care. We have an iPAD in the ER for that purpose, which can also be used for Psychiatric consults for patients admitted under the MHA. 
HANDOVERS
  • MDs use the Signal App to handover to the group at 8am via a Signal Group called "All DG Docs". The Signal handover should be very brief - just let the MD group know if there are any new admissions (name, diagnosis, assigned practice), any ER patients held overnight for re-assessment by MD on call and/or any patients expected to return to ER for a recheck or an out-patient procedure (such as IV antibiotics). All the details should be found in your notes, so no need to repeat these in the Signal message. For unstable/complex patients, it is best if the post-call MD also takes the time to huddle with the incoming on-call MD/RN team to ensure no balls get dropped!
  • Handover any out-patients patients that require follow-up by messaging their respective MRP using MOIS. Simply right-click on your last encounter and send a message titled "needs follow-up"; no need to write anything else - your notes should suffice.

Specialist Care and Off-Island Investigations

Specialist Referrals
  • We are fortunate to have a number of regular visiting specialists. Whenever possible, we try to refer patients to them as access is often faster and also less expensive and onerous. Referrals should be tasked to the Visiting Specialist PCA (PCIPT 1 PCA 5 DGS) indicating priority of referral with a number between 1 and 3 (1 is highest, 3 is lowest). Please refer to our preferred Specialists list for the current list of visiting specialists.
  • ​If there is no appropriate or timely referral possible to a visiting specialist, referrals should be tasked to the practice's PCA. Our usual referral centres are Prince Rupert, Terrace, Prince George and Vancouver (see referred Specialists). You can also find specialist using the Pathways website, which provides helpful information regarding available specialists, their focus and wait times.
Off-Island Imaging
Ultrasound and CT imaging requests can be sent to Prince Rupert Regional Hospital or K'Syen Hospital (Terrace).
MRI imaging requests are usually sent to K'Syen Hospital (Terrace).
Please task the completed forms to your PCA, indicating the urgency of your request. 

EMR (MOIS) DEEP DIVE

Accessing Your Schedule & Documenting Clinical Encounters

​To view your schedule for the day, open the "Scheduler" module (bottom left of MOIS interface) - this will take you to your same day schedule; you can select different days by clicking the arrows in the top left of the screen; you can also view another provider's schedule using the drop down menu, top middle of the screen (or by selecting another Day View from the Provider Schedules, top left, which allows you to view the day sheet of multiple providers at once),
documenting clinic visits
  • Please document ALL your encounters into the patient's MOIS chart (clinic, ER, inpatient rounds, home visits, telephone calls) - this ensures the best continuity of care.​
  • To create a new encounter line, go to Patient Chart -> Encounter -> New Record; select the type of encounter under "Code"  (R - regular visit, T - telephone call, ER - ER visit, I - inpatient visit, H - home visit, etc.), and write the time of visit (for ER visits, this time must match the time of ER registration which you will find on the paper ER record)
  • If the patient is a visitor and not in our system, right click on the encounter line and select "Quick Registration" - this will allow you to create a new patient file (just put in their name, PHN and DOB, no need to fill in all the fields!).
NB: Your PCA will usually room your patient and change their code in MOIS from "A" (arrived)  to "I" (in room); if, on occasion, you bring a patient into the room yourself, please mark them "I" so the PCA is aware and does not go looking for them; most importantly, mark them "D" when discharged so PCA or Clinic RN know that room is free for next pt. PCAs will not room patients for residents and students.
Documenting procedures
Document every procedure you perform (biopsy, joint injection) by creating a new encounter in the Procedures folder.
documenting emergency visits
  • Patients seen via the ER will also have a paper ER record; you do not have to double chart - just type your note in MOIS , print it and attach it to the ER record. Please sign the ER paper record and write on it "See attached MOIS encounter". 
  • When you create an encounter, use the exact time of ER registration, noted on the ER paper record (top left); you need to sign the paper ER record and mark the time of discharge, and then put it into the Med record box, at the nurse's station.
documenting facility admissions and discharges
Admissions - when you admit someone, there is an Acute Admission package (three options: General Acute, Detox and Mental Health) to complete (ask RN to pull it out for you & also print out the Medication Reconciliation form to review/order admission meds); create a new encounter in MOIS in which you can type your Admission (remember to print it for the hospital chart as hospital staff cannot access MOIS, or copy it into the patient's Power Chart). You can also dictate your admission by calling 1-833-613-1697 and following the prompts; facility ID is 27; Admission Hx is 01 and Discharge is 03. 
Discharge Summaries - when you discharge someone, please create an entry in the patient's "Facility Admissions" MOIS folder, and type/copy your discharge summary into it. This step is not necessary if you copy the note into Power Chart or dictate your discharge summary as Cerner will then deliver it electronically into MOIS. Please always copy your discharge summary to Skidegate Home Care for Skidegate residents (as our Med Records person to fax to Skidegate Health Home Care), as they do not have access to our MOIS or Power Chart. It is important that the discharge summary be faxed the same day as the Skidegate patient is discharged, to ensure continuity of care.
diagnostic codes
​Locums and Residents are required to enter DIAGNOSTIC CODES for each billable clinic encounter. These are entered in MOIS, on the encounter line, in the appropriate column. You can search for diagnostic codes in MOIS (hit the "..." associated with the relevant column) or refer to the cheat sheet below.

Creating Orders

***Please remember to copy your host/preceptor on ALL orders***
Ordering Labs
  • To order labs, go to "Orders" in the patient's chart, select "New Record"; under "Order Type", select "LAB"; under "Order for", write something that will give an idea of what you are requesting (Eg.: Urine culture, or Diabetic Screen) and then attach the general lab req (STANDARD OUTPATIENT LABORATORY REQUISITION) which you then populate and save;  
  • At the top of the requisition, please indicate the diagnosis relevant to your requested investigations  - the lab will not process requisitions without a diagnosis!
  • Please also ensure that your host/preceptor's complete info is entered in the top right corner of the form, including their phone number. 
  • if the results need to be copied to a specialist, please include their name and MSP # on the form (you can search for their info by clicking the relevant search button at the top left of the form).
  • Do not create standing orders - these should be delegated to the patient's MRP. 
  • Fax all Lab Requisitions for Northern Health Labs individually to ScanLab at 250-645-8061. You can do so directly from MOIS (ask us how to use the eFax option!).  If the test is due before 24hrs, print req and give it to the patient to take to the lab (as Scanlab takes up to 24hrs to process). 
Ordering IMAGING
  • To order imaging, from inside a patient's chart, go to "Orders" and select "New Record";  then under "Order Type", select "Imaging"; under "Order for" type the kind of imaging requested (for example, "CXR" or "CT Abdomen & Pelvis" - NB: when you save it, if MOIS tells you that they cannot find this reason, just hit "Cancel" and save to override MOIS) and then attach the relevant form which you then populate and save; next to your signature, be sure to note the name of your physician host or preceptor. 
  • Plain Xrays can be done locally - Fax the requisition via the EMR (ask us how!) or regular fax machine (FAX = 250-559-4924) and instruct patient to go to Xray Dept when it is open. No appt needed. Xray hours are on the requisition.
  • CT, MRI, Bone Scan, NM Scan require patients to travel off island - once you have complete the order, right click on it and TASK it to your preceptor/host's PCA (see Tasking Cheat Sheet below) with any relevant instructions (desired location, timing, etc) - don't forget to TASK it, as otherwise it will not get done! CT scans are usually done in Prince Rupert; MRIs and NM scans in Terrace. Wait times vary (days to weeks), but if you need urgent imaging done, contact the regional Radiologist on call.
CREATING A CONSUlt
To create a consult, from inside a patient's chart, go to "Orders" and select "New Record"; then under "Order Type" select "CONSULTATION"; under "Order to", search for the specific consultant you have chosen (if there is one); under "Order for", write the reason for consultation (NB: when you save it, if MOIS tells you that they cannot find this reason, just hit "Cancel" and save to override MOIS); attach letter template (use your host's/preceptor's template - ask us how, if you cannot find it) and then select the documents you wish to attach 
Once your referral letter is complete, you must TASK it otherwise it will not get processed - this is super important; TASK it to the PCA if it is for an OFF-island appointment, and to the Visiting Specialists group for ON-island appointments. Ask the PCA for the latest update of our Visiting Specialist schedule.  
For a directory of our most commonly referred to specialists (OFF-ISLAND and VISITING), consult our Preferred Specialists spreadsheet.
Ordering Out-Patient InfusionS
For patients requiring outpatient IV antibiotics or other IV infusions (iron, zoledronic acid), MD must write out-patient orders and give them to the ER Nurse who will then make the necessary arrangements.

Managing Medications

Creating prescriptions
​To create a new prescription, open the folder "Prescriptions" (ALT+S) and select "New Record", then click on F4 to open the Drug List; search for the drug you want, double click on it, then fill in Dose/Frequency and Amount columns; to print, highlight your entry and click on "Print Rx" (top right) - sign printed Rx and place in your outbox (you can also fax Rx directly from MOIS - ask one of us how!); please document all one-time Rx and all med refills in Prescriptions.
Long term medications - list maintenance
  • ​Open the "Long Term Meds" folder to add or edit LTM meds as needed
  • Click "Review" in the top menu if you completed a comprehensive review of LTM list (such as when a patient is discharged from hospital)
  • Please enter even short trials of medications if they were started with the intention of continuing them long term (such as anti-depressants)
  • If you make a change or discontinue a long term medication, please make a note in the Comments section to explain your rationale
accessing PHARMANET
​When accessing a patient's Pharmacare record on Medinet (www.medinet.ca), please ensure that you select the correct patient location from the drop down menu (HOSPITAL vs Emergency vs Primary Care Clinic). 

Accessing Results

Archived results
You can access archived results by clicking on the folders located along the left side of the screen, when you are inside a patient's electronic record.
  • Measures = Labs, path, ECGs (these appear only once they have been signed off on HeartStation), Holters, etc.
  • Imaging = Xrays, CT Scans, MRIs, etc.; click on attachment to view report
  • Consults = Scanned and electronically delivered consult reports; click on attachment to view report
  • Procedures = Surgery reports, c-scopes, etc.; click on attachment to view report
  • MAR = Imms
  • Facility Admissions = Discharge summaries
New results to be reviewed and signed-off
To ensure that you get all results for our practice, you must blend your workspace with that of your host(s). To do so, go into "Workspace", click on "Workspace Summary" and then "Change W/S". Then make sure to select not only your workspace, but also that of your host (MDs you are covering for ). Then click "save as default" box at the bottom. Then click "Refresh" in the Workspace Summary and you should be good to go. If you have any trouble, please connect with your host or our clinic manager.
Within the Workspace Folder, inside your Basket, you will find a number of folders: Measures, Imaging, Consults, Procedures, etc. This is where new results and reports come in. Open each folder to view results and then CHECK them off as you review/act on them. They will disappear from your basket and will be archived in a given patient's chart. Be careful not to check off a result before you have had a chance to review/act on it - this is very easy to do and leads to potentially significant misses. 
This is also where you will also receive all digitally delivered consults. Please note that some consults may arrive in paper form into your clinic INBOX - these will get scanned AFTER you process them (i.e.: add relevant content into "Health Issues" summary +/- take any actions recommended by consultant, then initial the top right corner of the first page of the consult report). Once reviewed and signed off, paper reports will be scanned and archived into the patient's electronic chart.
accessing Results outside of MOIS
  • ECGs are read by the Internal Medicine Group in Terrace and will appear in your MOIS inbox once they have been signed off. You can also access them in Power Chart at any time.
  • XRAYS (images and reports) can be viewed within Power Chart; when in a patient's chart (Power Chart), go into Imaging folder, click on the study of interest, and then on the image icon in the top left corner. Imaging reports also usually have a link at the top of the report which you can paste into a browser - it will take you directly to the image study.
  • OFF-ISLAND Consults, Admissions, etc. = When patients are seen/admitted off-island, the documentation of their encounters can be found on Care Connect; you can log into this via the patient's Power Chart records (via the eHealth Viewer, at the bottom of the menu on the left, when inside a patient's Power Chart). If need be, ask us how!

Communications

MESSAGING IN MOIS
  • ​The "Message Board" is where you will receive most (if not all) of your messages from the PCA or other staff/MDs asking you to do something for them or for FYIs. Think of it as your "to do" list. When a message is coded "V", it is urgent and should be opened ASAP. 
  • Please use the Message function to handover patients (those from other practices you admitted overnight, or at the end of your locum/rotation). Simply right click from any encounter/result you wish to flag and message the MRP who needs to follow-up. Remember to code "V" if you want them to see your message asap (in which case, best to text or call them as well).
  • We discourage people from tasking MDs (we prefer messages), but on occasion someone will send you a Task - so check that folder periodically. 
CREATING TASKS in MOIS
  • We use Tasks to flag orders for our PCA and other members of the interprofessional team.  Right click on the order,  select "Task", and then select appropriate Org Role from the LEFT upper corner drop down menu (see table below for who to task for what) ; it will open the task window which you can complete: title of task, content, and priority (V = same day, H = within 48hrs, M = within 1 week, L = when possible).
  • Remember to Task all orders that you do not process completely yourself, which is most of them. If you do not Task your order to someone, it will not get noticed or done! (sorry for the repetition but this is a critical step, and we all drop the ball here every now and then).
HANDOVERS
  • MD on call handover - MDs use the Signal App to handover to the group at 8am via a Signal Group called "All DG Docs". Please download the Signal App and request an invite to this group when you join us. The Signal handover should be very brief - just let the MD group know if there are any new admissions, any ER patients held overnight for re-assessment and/or any patients expected to return to ER for a recheck or an out-patient procedure (such as IV antibiotics). All the details should be found in your notes, so no need to repeat these in the Signal message. For unstable/complex patients, it is best if the post-call MD also takes the time to huddle with the on-call MD/RN team to ensure no balls get dropped.
  • At the end of your locum/rotation, please handover any patients that require follow-up by messaging their respective MRP using MOIS. Simply right-click on your last encounter and send a message titled "needs follow-up"; no need to write anything else - your notes should suffice!
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