The two min screen is for placing important orders that are highly scored. It is mostly meant for monitoring and setting up follow up appointments.
I would like to list the guidelines from ********** course.
********** summarizes two min screen strategy in to a couple of simple things : 1. Monitoring Orders 2. Case-specific screening orders 3. Case-specific important counseling orders.
1) If you started an intervention during the active screen, you will need to monitor that intervention most of the times. On 2-min screen, there is a calendar option specifically to set up monitoring orders. Monitoring can be two types a) monitoring for efficacy or b) monitoring for toxicity.
Efficacy monitoring examples a) You started a Statin in hyperlipidemia case. You want to place an order for Lipid panel in 1 month. You order Lipid panel and go to calendar and choose date 30 days away. Remember you can do this only on 2-min screen. You can not do this on active screen since you have no way to set up orders to take place at a "later" date. b) You treated a patient with an acute MI during active case and his EF was 30%. You want to set up a repeat ECHOcardiogram in 3months to see if EF has recovered. You set this up using later option on 2-min screen.
Apparently, all these are very highly scored. It makes sense since this is exactly what Step 3 is testing - not just diagnosis and treatment but also, monitoring.
Toxicity Monitoring examples: a) You started a Statin in hyperlipidemia case. You want to place an order for Liver function tests in 3 month. You order LFTS and go to calendar and choose date 90 days away.
b) You started INH in a Latent TB case who is also alcoholic. You probably already obtained baseline LFTs on the active screen. When you reach 2min case-end screen, you must not forget placing an order for LIVER FUNCTION TESTS in 1month.
c) You started Methotrexate in RA case. Since adverse effect is hepatitis, obtain LFTs in 3 months by choosing "later" option on 2-min screen. As per 2008 ACR recommendations, LFT monitoring at an interval of every 8 to 12 weeks is appropriate after three months of therapy and monitoring every 12 weeks can be performed beyond six months of therapy.
Methotrexate is a well known cause of acute clinically apparent liver injury which can be severe and is sometimes fatal - I know a rheumatologist that got sued because of not placing such monitoring order in real life practice. Now this is exactly what Step 3 is testing for. You can not miss certain monitoring orders which if missed can be potentially life threatening - you will get negative scoring for missing this on Step 3 CCS.
