Clinic Assistant Updates - Table of Contents Feb. 17th, 2015 – Clinical Updates and Reminders: ................................................................................................................ 3 Acutely Ill Adults ................................................................................................................................................................. 3 Any Clinic Assistant that fails to appropriately flag these patients for staff may be dismissed from the Clinic Assistant program................................................................................................................................................................................... 3 Feb. 9th, 2015 – Clinical Updates and Reminders: .................................................................................................................. 3 Depression Screening.......................................................................................................................................................... 3 Huddling and Chart Prep ..................................................................................................................................................... 4 NextGen Trainings ............................................................................................................................................................... 4 Clinic Assistant Shifts........................................................................................................................................................... 4 Volunteer Resources Webpage .......................................................................................................................................... 4 Jan. 9th, 2015 – Clinical Updates and Reminders: ................................................................................................................... 5 Next Gen Updates ............................................................................................................................................................... 5 PCMH – What is it and what can Clinic Assistants do to help? ........................................................................................... 5 Staying Healthy Assessments .............................................................................................................................................. 6 Clinic Assistant Skills Update............................................................................................................................................... 7 Oct. 17th, 2014 – Clinical Updates & Reminders: .................................................................................................................... 8 1. SUMMIT ...................................................................................................................................................................... 8 2. Flu Shot Reminder ....................................................................................................................................................... 8 3. Ebola Screening ........................................................................................................................................................... 8 nd Oct. 2 , 2014 – Clinical Updates & Reminders:...................................................................................................................... 9 1. Tobacco Usage ............................................................................................................................................................ 9 2. Flu Shots .................................................................................................................................................................... 10 Sep. 23rd, 2014 – Clinical Updates & Reminders: .................................................................................................................. 10 1. 2. Next Gen Updates: .................................................................................................................................................... 10 a. Tracking ................................................................................................................................................................. 10 b. Height and BMI ..................................................................................................................................................... 10 c. Tobacco and Allergies ........................................................................................................................................... 11 Clinic Assistant Skills Update (LEADS): ...................................................................................................................... 14 Sep. 16th, 2014 – Clinical Reminder: ..................................................................................................................................... 14 Sep. 2nd, 2014 – Clinical Reminder: ....................................................................................................................................... 14 Aug. 11th, 2014 – Next-Gen Reminder: ................................................................................................................................. 14 Jul. 28th, 2014 – Next-Gen Reminder: ................................................................................................................................... 14 Jul. 23rd, 2014 – Clinical Reminder: ....................................................................................................................................... 15 1|Page Jul. 17th, 2014 – Clinical Reminders: ..................................................................................................................................... 15 1. Patient Labels: ............................................................................................................................................................... 15 2. Well Child Checks (WCC): .............................................................................................................................................. 15 Apr. 25th, 2014 – Clinical Reminder:...................................................................................................................................... 15 Apr. 22nd, 2014 – Clinical Reminder: ..................................................................................................................................... 15 Apr. 22nd, 2014 – Clinical Reminder: ..................................................................................................................................... 15 Apr. 18th, 2014 – Volunteer Dress Code Reminder: .............................................................................................................. 16 Mar. 11, 2014 – Clinical Reminder: ....................................................................................................................................... 16 Mar. 5, 2014 – Clinical Reminders: ....................................................................................................................................... 16 1. Homeless Patient Screening – Next-Gen Procedure.................................................................................................. 16 2. Follow Up on ER Visit or Hospitalization ................................................................................................................... 16 3. NO BMI Plans ............................................................................................................................................................ 17 Feb. 12, 2014 – Clinical Reminder:........................................................................................................................................ 17 2|Page Feb. 17th, 2015 – Clinical Updates and Reminders: Acutely Ill Adults IMPORTANT CA REMINDER: Please be sure to stay in good communication with your buddy MA. During just this past Friday afternoon shift, we had TWO patients complain about chest pains and were not immediately flagged for staff. All the following circumstances (Designated as Acutely Ill Adults) should be flagged for staff immediately: 1. 2. 3. 4. 5. 6. 7. Complains of shortness of breath, wheezing or choking Pulse Oximetry less than 92% on room air Chest pain or pressure Recent drug overdose, ingested poison or recent skin exposure with dangerous chemicals Complains of severe headache starting in last 24 hours or new paralysis of any part of the body Actively bleeding, vomiting blood, or recently passing bright red blood in stool Has an abnormal blood pressure and or pulse: o Systolic BP greater than 200mm Hg or less than 80 mm Hg o Diastolic BP greater than 110mm Hg 8. Pulse greater than 120/min or less than 50/min 9. Blood glucose: Less than 70 or above 350 10. Hemoglobin is less than 8 11. Temperature is over 102˚F Any Clinic Assistant that fails to appropriately flag these patients for staff may be dismissed from the Clinic Assistant program. Feb. 9th, 2015 – Clinical Updates and Reminders: Depression Screening We are excited to announce that VFC will start implementing annual depression screenings for all patients ages 12 years old and up. We will also screen post-partum mothers of pediatric patients 0-3 months. We ask that all Clinic Assistants review the attached workflow and sample screener BEFORE your next shift in order to correctly screen and enter patient’s PHQ2 (and PHQ9 as needed) information into NextGen. Please check in with your MA buddies for more information. This process is live or is going live at all sites this month: Site Depression Screening Start Date Levine Wed. Feb 4th 3|Page Colen Fri. Feb 6th Simms Wed. Feb 11th *Rose Wed. Feb 18th *Training on Fri. Feb. 13th at 4:45pm Huddling and Chart Prep Please note that all Clinic Assistant volunteers are expected to proactively engage with a MA/Provider team during each shift. Clinic Assistants are encouraged to participate in the huddles at the beginning of each shift. If for some reason you miss the huddle, you still much check in with an MA and plan for your patients. It is helpful to review the Chart Prep Checklist for your team each day. If you find yourself with some downtime, please check in with other members of the Nursing Staff to see if anyone helps needs your help. NextGen Trainings We have two trainings scheduled for this month: Friday, Feb. 20th (12pm-1pm) at Simms/Mann Monday, Feb. 23rd (12pm-1pm) at 604 Rose This is a great opportunity for all CAs, old and new, to brush up on the NG skills. Please sign up for an upcoming training through Volgistics. If you are a Lead Volunteer (or an experienced Level 2 / aspiring Lead Volunteer) please contact me regarding co-hosting this training. I would love to have your help! Clinic Assistant Shifts Room for a shift or two? We have a handful of shifts available at Simms, Rose, and Levine, with a high need for female CAs at Levine on Tuesdays (afternoons) and Wednesdays (morning and afternoon). Please contact me for more information regarding these available shifts if interested. Volunteer Resources Webpage 4|Page Do you use the VFC Volunteer Resources Webpage?!? This is a great way for you to access all the past and present Clinic Assistant updates, review the current CA training materials, and even practice your Spanish language skills with free medical terminology AND audio! You can access the Volunteer Resources webpage at any time by logging into Volgistics or by simply saving this link to your favorites: http://www.venicefamilyclinic.org/volunteers/volunteer-resources Jan. 9th, 2015 – Clinical Updates and Reminders: Next Gen Updates Homeless Patient Screening: Please be aware that the recent NextGen upgrade eliminated the Homeless Patient Template. In order to complete the required Homeless Patient Screening, please notate “Lack of Housing” as one of the Reasons for Visit. The Front Desk will indicate “HP” in details whenever a patient identifies themselves as homeless. Under HPI Detail for “Lack of Housing”, please enter where the patient is staying. o Ex: Street, Beach, Car, etc. o This information is important for our Homeless Grant. Women’s Progress Notes: The Next-Gen upgrade has also affected the way in which we enter “Women’s Progress Notes”. In order to complete Women’s Progress Notes, please select “Preventative Exam” as one of the Reasons for Visit. You will recognize that the Women’s Progress Note is now mapped to the preventative exam option. PCMH – What is it and what can Clinic Assistants do to help? 5|Page * Click here to watch a short video about PCMH. * Huddles: Thank you for huddling! Your effort has helped your teams improve work flow and even patient care. Please review the following reminders at the attached Huddle Expectation Sheet (which has been shared with all nursing staff and providers) as we continue the Huddles. * Expectations for Clinic Assistants: Clinic Assistants are expected to and will be required to: 1. Assign yourself to a team at the beginning of your shift 2. Join the MA and provider huddle (preferable). Or debrief with the MA. 3. ALWAYS consult with your MA and Provider to ensure all necessary steps are completed. If you pick up a chart that is meant for a different team, consult with the MA that is assigned to that patient 4. Check in with your MA throughout the session * Chart Prep! Our MAs have done an amazing job prepping charts in the midst of our clinics’ busy flow. Please continue to prep even if you are not able to prep for your entire patient list. * Meet! Chart prepping is only part of the huddle. Be sure to meet with each other and discuss face to face. Attached are more guidelines for huddling. Like huddles on the football field, it is important to take a “time out” for the team to discuss their game plan. * Communicate throughout the session! Do you have tips on how PCPs, MAs, and CAs can communicate about patients during the session? If so, please let me know so that we can share your best practices. * Give feedback! Don’t forget to tell your teammates when s/he does something great! And don’t be afraid to share your ideas on how your team can work better. Communication is vital for any team! Staying Healthy Assessments You will notice a pink piece of paper that reads “STAYING HEALTHY SCREENING” in the red sleeves. This is alerting us that Front Desk gave the patient a Staying Healthy Screening tool that is required by the patient’s insurance. The patient is to fill out screener and give to provider. Provider needs to review and sign. Unfortunately, many providers neglect to sign form and without provider signature, the form is invalid. This little pink piece of paper is letting us know to encourage patients to fill out form and tell patients to hand it to provider for review and signature. If the patient has finished the form, feel free to insert into red sleeve so provider can review. Place in front of encounter for good visibility. I attached a sample form for your review, but not that there are different forms for different age groups. The Adult form is attached. These forms are very important for patient’s insurance and we, as an agency, are required to fill them out. 6|Page Clinic Assistant Skills Update Level 1 - Basic CA Skills: Reminders Buddy with LEAD CA or Clinic Staff: All new Clinic Assistants should continue to work alongside a LEAD Clinic Assistant or MA, until receiving your designation as a Level 2 Clinic Assistant volunteer. Next-Gen: New volunteers that have not yet completed their Level 1 Clinic Assistant Skills Checklist, should refrain from utilizing Next-Gen until they complete their “Basic Skills Checklist” or are otherwise instructed by a VFC Staff member. If you do enter information into Next-Gen, please be sure to always get your work checked by Staff! Basic Skills Update: Please note that since Clinic Assistants will no longer be working with pediatric patients, we have removed pediatric skills from the Basic Skills Checklist. o New Clinic Assistants are no longer required to complete the following skills: Height & Weight (Child) Temperature (Axillary Blood Pressure (Child) Congratulations! You completed your Basic Skills Checklist: What’s Next? 1. Check your service hours in Volgistics! In order to level up, Clinic Assistants will need to complete the skills checklist on the back of their green name tag and complete a minimum of 30 hours of service as a Clinic Assistant. To check your service hours, log in to Volgistics and click the “My Service History” tab. 2. Alert Volunteer Services Once you have completed your checklist and 30 hours, please notify the Volunteer Services Department in order to receive your Level 2 name badge. Please email VFCvolunteer@mednet.ucla.edu and attach a photo of your completed checklist. 7|Page Oct. 17th, 2014 – Clinical Updates & Reminders: 1. SUMMIT Reminder: If you are not familiar with how to screen patients for the SUMMIT program, please review our step-by-step SUMMIT guidelines, which are available online on our Volunteer Resources page. It is very important that you thoroughly understand the screening process for SUMMIT and what to do with a positive screen. The SUMMIT survey should be reviewed with patients at the beginning of every work-up. When a patient has a positive screen, please refer that patient to the Nursing Staff for further assistance! This screening process allows medical providers to quickly identify patients with harmful levels of substance abuse, provide a brief intervention, and then refer patients to SUMMIT for further screening and treatment. 2. Flu Shot Reminder: It’s flu season, and VFC has started to offer flu shots to all patients! Please remember to ask every patient if they are interested in a flu shot as part of their work up. If the patient is interested in receiving a flu shot, give them the Vaccine Information Sheet (VIS) and the Flu Vaccine Screening Checklist/Consent. Please alert Nursing Staff that the patient is interested in receiving a flu shot, and give the Nursing Staff the completed consent form. o If the patient declines, please note this in “HPI details” Notate “Patient declines flu vaccine/shot. VIS given.” in the comments section Your note helps the provider know that we screened the patient, and the provider can then update their clinical care guidelines. 3. Ebola Screening - I’m sure you have all heard what is going on in the news regarding Ebola. Although we feel we are not at high risk for Ebola here at VFC, we wanted to share with you what Ebola precautions and procedures the clinic currently has in place. A. All front line staff (including the Nursing Staff) will be asking ANY patient that presents with fever if they’ve had recent travel (within the last month) out of the country. What does this mean for Clinic Assistants? o Be sure to screen anyone with fever, by asking if they have travelled out of country in the last month. o If the patient responds “Yes”, the next question is “Did you travel to West Africa?” o If your patient states “Yes” that they have travelled to West Africa, STOP what you are doing and take patient immediately to a designated “Isolation Room” . o If the patient has travelled to West Africa, be sure to ask which country they travelled to. The West African countries where Ebola has been confirmed are Guinea, Liberia and Sierra Leone. o Once you have escorted the patient to the designated Isolation Room, please close the door and notify an RN or Medical Provider ASAP. B. Signage will be placed on all ports of entry asking patients to disclose if they have recently travelled to West Africa and/or have fever. C. Personal Protective Equipment (PPE) has been sent to all locations. This PPE kit includes gloves, gown, shoe covers, goggles and mask. Please make sure you know where the PPE is 8|Page located. At Rose, the PPE kits are located in Room 15 and at the Triage area downstairs where we keep emergency supplies. D. Clinical Leads at every site will identify “Isolation Rooms”. The goal is to minimize exposure to other patients and staff. a. Rose: Alcove area on the 1st floor behind security and Room 15 on the 2nd floor b. Simms: Triage Room on the 1st floor and Room 11 on 2nd Floor c. Colen: Patient bathroom (potential isolation room) E. Attached are instructions on how to don PPE and how to remove it. F. In the event that a patient needs to be reported as an Ebola suspect - Contact Public Health Phone Line: (213)240-7941, After Hours: (213)974-1234. Oct. 2nd, 2014 – Clinical Updates & Reminders: 1. Tobacco Usage - The Next-Gen upgrade did NOT transfer patients’ “Tobacco Usage” information completely. When entering patient information into Next-Gen, please always make sure that the patient’s Tobacco Usage information is up-to-date. Always check to make sure both the “Smoking Status” box and the “Tobacco Use” box are filled in. “Smoking Status” and “Tobacco Use” fields are required in order for the clinic to meet Meaningful Use (MU) requirements. Applies to all patients that are 13 years of age and over. A. To update Tobacco Use Information, please click on “Tobacco Usage” on the right side of the screen 9|Page B. Complete “Tobacco Use Status” by selecting an option from the drop-down menu (see below) Please note: For children 12 and under, you will need to answer the questions under “Passive Smoke”. Please ask if you are not sure how to update these fields. 2. Flu Shots: It’s flu season, and VFC has started to offer flu shots to all patients! What does this mean for Clinic Assistants? o Always ask your patient if they are interested in receiving the flu vaccine. o If the patient is interested in receiving a flu shot, please alert Nursing Staff so that they can administer it. o If the patient declines, please note this in the “Comments” section of the Chief Complaint / Reason for Visit page Notate “Patient declines flu vaccine/shot” in the comments section Your note helps the provider know that we screened the patient, and the provider can then update their clinical care guidelines. Sep. 23rd, 2014 – Clinical Updates & Reminders: 1. Next Gen Updates: a. Tracking: We must now track patients when we start work up by selecting WITH NURSING and then track when we finish to WAITING FOR PROVIDER This new system will help the Clinic better track the flow of patients and, eventually, improve our efficiency and ability to serve more patients b. Height and BMI: Please use feet/inches or cm. Not total inches. It does not automatically calculate BMI. ERRONENOUS entry: 10 | P a g e CORRECT entry: c. Tobacco and Allergies: Please update Tobacco usage and update allergies at every visit This is how the templates should look like. Please see screen shots below. Please always feel free to ask nursing supervisors on staff and other medical assistants for help. 11 | P a g e 12 | P a g e *Be sure to scroll all the way down to the Save & Close button* 13 | P a g e 2. Clinic Assistant Skills Update (LEADS): We are proud to announce that we added the following skills to the Lead Clinic Assistant name tags: Visual Acuity Tests and Urine Dips. Just like all the skills on the CA nametags, staff must observe and sign off on volunteers’ lists ONLY when the volunteer demonstrates successful completion of that skill. Staff should only sign the checklist if the staff member is confident that the volunteer can move forward performing the skill on their own after accruing three signatures. Please note that urine dips still must be checked by staff even after Lead Clinic Assistants accrue the three signatures in order to ensure that the providers receive the correct information. Sep. 16th, 2014 – Clinical Reminder: Clinic Assistants will not be responsible for completing “Family Planning Notes”. This skill has been removed from the Clinic Assistant Special Skills Checklist. Sep. 2nd, 2014 – Clinical Reminder: As we move forward with Patient Centered Medical Home (PCMH), there are expectations that are being established for everyone in the care team. One goal of PCMH is to have everyone working at the top of their scope. Please remember that the role of the Clinic Assistant is to help our Nursing Staff and Medical Providers to be as productive as possible. There are many things that can be done to accomplish this, and little by little we will be working on improvements to better support our providers. Currently, the staff expects that the all of the following things are done: 1. Always make sure work-up rooms and exam rooms are well stocked. It is very frustrating for providers to run out of tongue depressors, q-tips, speculums, etc. **Judy has asked providers to give feedback on any room that is not well stocked 2. Always make sure everything works in the exam rooms (ex. table light, blood pressure cuffs (all sizes), etc.) Along with this we are expected to always anticipate and perform the following: **Please note that the Nursing Staff will perform all visual acuity exams and urine dips Visual Acuity if patient complains of eye problems Urine Dip if patient complains of ANY urinary complaint Blood Sugar for all diabetics Urine Dip for Blood Sugars 350 and over Aug. 11th, 2014 – Next-Gen Reminder: Only those volunteers that are Level II and attended the NextGen training should be entering in NextGen – unless otherwise instructed by Clinic staff. Please make sure you are thorough in your documentation, and be sure to have the Nursing Staff review your entries for any missing or incorrect information. Jul. 28th, 2014 – Next-Gen Reminder: Volunteers cannot chart under someone else’s Next-Gen Login. That is a HIPAA violation, which is viewed equally to sharing one’s login. I understand that this can be inconvenient, but it is part of the privacy policies we must follow. To make sure that we are HIPAA compliant, the Volunteer Services Department will be working to make sure that all Clinic Assistant volunteers have their own Next-Gen account. Please email us at VFCvolunteer@mednet.ucla.edu if you have any questions or concerns! 14 | P a g e Jul. 23rd, 2014 – Clinical Reminder: Don’t forget to track your patient. It is very important to track patients, so that we know where the patient is during their cycle time at the clinic. Once we finish our intake we must use tracking and change the status from “Appt. Kept” to “Waiting for Provider”. If we do not change the status it will seem as if the patient waited forever to have vitals done. It’s ok if you don’t have a room. You can use “Waiting Room” as location but make sure we change status to “Waiting for Provider”. Jul. 17th, 2014 – Clinical Reminders: 1. Patient Labels: It was mentioned that the patient labels are falling off of the red sleeves and the charts. If you happen to see a patient label on the floor, please pick it up! It is a HIPAA violation and a privacy issue to have the labels on the floor. 2. Well Child Checks (WCC): We have had a couple of recent instances where Clinic Assistants have completed the vitals for a Well Child Check (WCC) and the patient did not have the full work-up completed prior to seeing their provider. Please double check your work and ask the staff for assistance, if needed! Apr. 25th, 2014 – Clinical Reminder: Remember to select additional assessments when a patient only comes in for a follow-up test or diagnostic results. We can look at previous HPI’s for clues in chronic conditions. “Follow-Up test” should not be listed as the sole reason for visit because follow-up tests are not billable. Apr. 22nd, 2014 – Clinical Reminder: Blue Charts indicate that a patient should be worked up by STAFF ONLY! Paper Charts are slowly disappearing, but when there is a chart with a blue cover it that means that we’ve had some sort of issue with the patient, usually behavioral and it is a visual cue that only staff should work-up that patient. With EMR there will be a red alert box that appears on the upper left hand corner of the Intake OV template. You can see what the alert is by clicking the box. It will tell you if the chart should be handled by staff only. Apr. 22nd, 2014 – Clinical Reminder: Get into the habit of reading the last visit Master IM Assessment/Plan! It’s a great way to anticipate the patient’s needs and ensure that the patient has a complete work up. When working up your patient, remember to review the last visit “Master IM” first to better prepare for the visit you are working on. Reviewing the Master IM will often help you to see why the patient returned, and if the provider wants something done at this visit that you can perform before the provider sees the patient. For example, I was working up a baby and when I asked mom why they were here, she said she was not sure. I looked at the last visit Master IM and under Assessment/Plan the provider had written…Baby sound check at next visit. I was able to have that done as part of the work up. On another occasion when the parent did not know why they were at clinic, I read the last Master IM Assessment/Plan and the provider had written…..return to clinic for weight check. Viola! I had the reason for the visit. 15 | P a g e Apr. 18th, 2014 – Volunteer Dress Code Reminder: Please adhere to the following Dress Code regulations: For All Volunteers: Come dressed in business casual attire Appear generally neat and well-groomed (e.g. clothes should be free of wrinkles; hair should be tamed) Please refrain from wearing excessively-baggy clothing, shorts, sweatshirts, flip-flops, or revealing clothing For Clinic Assistants: Scrubs are suggested instead of business attire Short, clean, and unpolished fingernails are preferred Shoes must be close-toed and water resistant (rubber preferred); please refrain from wearing Toms, Uggs, or any other casual, cloth-based shoes As a volunteer here at the Venice Family Clinic, you are representing the Clinic each time you come in for your shift and we ask that you present yourself (and thus the Clinic) in a professional manner. Mar. 11, 2014 – Clinical Reminder: Please be mindful of the following situation, where we have to be careful which arm is selected for performing blood pressures: Patients on dialysis will usually have a fistula and this arm should be avoided. A fistula is a surgically created venous access used for dialysis. It is very important to keep the fistula patent, and therefore blood pressures should NEVER be performed on the arm with the fistula. Patients are informed of this when the fistula is created. They should be very guarded and not let anyone perform a B/P on that arm. As usual, always listen to your patient, they know best. Some patients might have preferences due to surgical histories or other reasons. Mar. 5, 2014 – Clinical Reminders: 1. Homeless Patient Screening – Next-Gen Procedure During a recent chart review, it was determined that only 20% of the charts reviewed included the pertinent information needed for the Homeless Adult Monthly Screening. Please remember to complete the Homeless Adult Monthly Screening form in Next-Gen for every Homeless Patient. This information is very important, and we kindly request that you complete all fields noted below. The orange arrows indicate the required fields. 2. Follow Up on ER Visit or Hospitalization When a patient is being seen for follow-up on ER visit or hospitalization, PLEASE RECORD in the Chief Complaint the NAME OF THE HOSPITAL where they were seen at! This information is extremely useful to our providers, so that they can look up the patient’s medical records before they see the patient. When recording this in Next-Gen, please enter this information in the “Comments” field in HPI Detail. Please review the Next-Gen screen shot below. The orange box indicates the field where you should be entering the name of the hospital where that patient was previously seen for an ER visit or hospitalization. 16 | P a g e 3. NO BMI Plans Effective immediately, we no longer need to calculate BMI plans for our overweight or obese patients. Please DO NOT calculate BMI plans in Next-Gen. It interferes with our billing process. This may change in the future, as NextGen gets updated. Please see the screen shot below. The orange box indicates where the “BMI Plan” prompt appears in NextGen (SKIP this step). Feb. 12, 2014 – Clinical Reminder: Patients that are in the Westside Partners Program (HIV Program) are to be worked up only by staff members in the Nursing Department! There are two major indicators that will help you to identify these patients: 1. First Indicator: “STAFF ONLY” indicated under the Details section of the Encounter Form o The Encounter Form is a paper form that will either be on the patient’s chart or (if the patient does not have a chart) in a red sleeve o If you are not sure where to look for this indicator, please ask a staff person ASAP! 2. Second Indicator: RED ALERT FLAG on the Intake OV Screen in the upper left hand corner o If you see this small red alert in NextGen, click on it and it will say “STAFF ONLY” o You will only see this indicator if you have access to NextGen and failed to note the first indicator on the Encounter Form In both of the cases above, you will need to hand the chart and the patient over to a staff person immediately. As always, please be sure to be thorough with your work. We have recently had charts that are incomplete (without all vitals / missing information such as, smoking status, LMP, etc.)! 17 | P a g e