Admin questions (separation physicals, PHAs, etc)

[TheTruckGuy]

For those of y'all in primary care/GMOs/etc., I need some help figuring some of this stuff out.

1) Separation physicals. What is their purpose exactly? And what all am I obligated to do? Is there an official instruction?

Background: Young, 22 year olds, come in with anywhere from one to 50 complaints on their DD2807 that they want to "have documented." Sometimes it's stupid stuff like "I spilled gasoline on my hand once and it turned red and itchy for a day." Sometimes it's legit stuff like "I fell off a tank and broke my collar bone, still have pain." I'm struggling to comment look through their AHLTA and comment on all these things, or other conditions, whether or not they followed up with PT like they were supposed to, and all that without falling really behind in my schedule.

I've heard all we have to do is make sure they aren't dying, I've heard I have to comment on everything they've written on their 2807, I've heard I only have to do a physical exam related to anything new for which they have never been seen for (again, this could be a dozen different new things for some people). I've never seen official guidance on what needs to be done, and no one seems to know. Is there an instruction?

2) Serious complaints on separation physicals. Let's say someone says they have headaches, wake them up from sleep, has possible neuro deficits on exam, does their whole EAS go on pause rigth there to do a work up? What happens when they EAS in like 2 days? Do I need to call radiology for a stat CT? This was a hypothetical, but I get a lot of folks who c/o headaches, and answer yes to almost all the red flag questions.

3) When people come in with all these complaints, do you do the physical (admin portion) and tell them they can set up an appointment to be seen for everything if they want. Or do you refer them to PT for their shoulder pain, podiatry for their bunion, etc?

4) PHAs. Do these things just disappear after you finish them unless you put it into AHLTA? If someone indicates they want to be seen for syncope, or shoulder pain, the PHA asks you how soon you think they need a referral. I say within a month, and tell them to come in for an appointment so I can do a full assessment before I refer them to cards or PT, then they never show up. Obviously the shoulder pain is less of an issue, but what if this person has actual cardiogenic syncope? To what extent do I need to chase this down and make him come in?

If anyone else has any admin headache questions, let's hear them, maybe we can help each other out.

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[d2305]

It's the suicidal ideation that is a problem on PHAs. Most SNM have already started a claim with the VA that want some sort of disability. You just have to document their complaints. If it is something strange like a suspected brain tumor or a arrhythmia, you can consult cards or neuro, but getting them seen can be difficult. My experience is dated.

 

[ArmyTiger]

For the person with multiple new complaints at the separation physical, I would do a chart review to see if it had ever been documented before and, if not, would add in the remark that it was never documented previously in the medical record. I usually had two clinic spots for the separation physicals so I could appropriately review the chart. If I was worried they had real complaints, I'd bring them back sooner for scheduled follow-up. I always made it clear that unless they had a significant physical exam finding, all I'd be doing is completing the required paperwork and screening tests. Seems most people around me did mostly the same.

For PHAs, I treated them as strictly admin appointments because the administrative work was so burdensome. If they had a complaint, I'd schedule follow-up, usually within the same week. If I'd previously seen someone for an issue and all they needed was a medication refill or a new referral for it, I'd usually do that as well, but new problems needed new appointments.

I'm not sure if either of those approaches were the right one, but at the end of the day, those appointments for administrative paperwork took so much time on their own that, in order to have an efficient clinic, that was the easiest way to do it. I wasn't going to stay at clinic doing paperwork until 2000 every night so I could listen to every separating soldier's story of their new all over joint pain.

 

[d2305]

Reenlistment/periodic physicals had almost no boxes checked on sf 93.

 

[absolutdokta]

For the separation physicals I handle it as such:
Two appointment slots, not because I will address their new complaints, rather so I can look over their chart and familiarize myself with some of their issues. I will jot down their frequent issues (ie the chronic ones)on a scrap piece of paper. Then when I look at their packet and what they wrote down I will write down any new issues that weren’t obviously seen in their chart. Then when I go into speak with them I will ask them about these new issues and if they were ever seen. I always will confirm with them verbally, “so you never made an appointment to get seen for this?” For the private or specialist with <3 yrs in service this question always seems to catch them off guard as if their thought process was “I can list anything and then make a claim for it.” They usually hesitate with the response while trying to come up with an explanation and it usually ends up being “I was in the field, I was TDY” or whatever other weak excuse they make up for never seeking care over the course of several years for a problem that was on going during that whole entire time. In those instances I will write down the number they checked yes to and then “did not seek care“ in the section for the physician to write in on the 2807. Been doing it that way for the last couple of years and have never had a packet kickback or run into any issues.

That leads to the next very common thing they note that is chronic but they never seek care for, which is headaches. Since they never sought care I tell them “since you have never been seen for this it will help me immensely to see some data. So what I need you to do over the next month is keep a journal of the days you get headaches, how often you take analgesic medicine, how long the headaches last, etc. and then schedule a follow up appointment”. Even if their exit date is before that months time I don’t change my plan because I’m not going to delay their exit for a problem that has been going on for several years but they never bothered to seek care. The caveat is if there is anything concerning on history or exam, and of course if I need to make a specialist referral I do so. I’m not trying to shortchange them on care and I treat them like I do anybody else with the same problem. The cross-my-heart-and-hope-to-die truth is that almost all of their actual ETS dates are well beyond the one month mark from when they see me but when I ask them to do this they never schedule that follow up appointment.

If its something like a sore shoulder, knee, ankle, etc and after gathering more information I will sometimes give them an HEP and advise them they need to follow up in about four weeks. If they are out before then, so be it. If we held up an ETS or chapter for every sore body part they would never get out. As I said above though, most of the time their ETS date is beyond one month but they rarely schedule follow up, at least in my unit that has been the case.

For PHAs it’s strictly admin. Unless they are suicidal any issues they bring up they are told to make an appointment. Between going through their forms and waiting for the system to load between clicks I don’t have time to deal with health concerns....again, unless it’s something acute, and the only real acute thing for a PHA is “I’m going to kill myself or __________(insert individuals name here)”

Just the way I handle things, seems to work well for me