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Appendix C
PLANNING PREPARATION WORKSHEETS
(Low Back Pain Example)
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Measure
# primary care visits low
back pain per year
• active duty personnel
• other beneficiaries
# specialty visits for low
back pain per year
• active duty personnel
• other beneficiaries
# imaging studies for low
back pain per year
• active duty personnel
• other beneficiaries
# physical therapy sessions
for low back pain per year
• active duty personnel
• other beneficiaries
Other:
Clinic 1
Clinic 2
Clinic 3
Clinic 4
Clinic 5
Clinic 6
ER
Other
_________________________________________________________________________________________________________
SAMPLE BASELINE DATA FORM FOR LOW BACK PAIN GUIDELINE
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RANDMR1267-C.1
Patient phones in and schedules
appointment with appropriate
medication
Patient walks into clinic without
an appointment
“Check In” desk in clinic.
Receptionist processes chart.
• ADS form processed
• Chart and note for clinic placed
Vital signs taken by nursing staff
Patient escorted to exam room
Exam room with provider
(physician, physician’s assistant,
nurse practitioner
Possible routes
Immunization clinic
Check out at clerical
desk
Ancillary testing
(radiology, labs, etc.)
Shots given
Follow-up scheduled
Follow-up
Pharmacy
(if needed)
Courtesy of :
Ron Moody, MD
Major, U.S. Army
Figure C.1—Sample of Family Practice Clinic Flow Diagram
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SAMPLE FORM FOR COMPARING CURRENT PRACTICES TO
LOW BACK PAIN GUIDELINE KEY ELEMENTS
Identify serious problems
What are we currently doing?
Conservative treatment of acute low back pain patients
What are we currently doing?
Evaluate patients who get worse
What are we currently doing?
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Evaluate patients who do not get better
What are we currently doing?
Manage chronic low back pain or sciatica
What are we currently doing?