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Service Level Management Process Kit

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					                                                                                      Depleted Uranium



Depleted Uranium Exposure Medical Management Process Flow
DoD Process Summary

1. Identification: Positive responses on DD Form 2796, Questions 14, 17, or 18; or identification
    with known exposure event or unit. Annotate DD 2796; send to AMSA.
2. Assessment: Identified personnel complete DU Exposure Questionnaire. Questionnaire and
    tracking forms to Service-designated labs; labs send to DHCC.
    Triage:
3. Triage Assign to DU Exposure Level I, II, III, or None.
4. Level III: Level III exposures do not require testing unless deemed appropriate by provider
    based on other information or patient request. Process complete.
5. Level I & II: Require 24-hr Urine Uranium Bioassay, including urine creatinine analysis according
    to Service-specific guidelines.
6. Lab Results: Returned to MTF lab and referring provider by processing lab; sent to Service
    Dosimetry Center and DHCC for archiving.
7. Results to Patient: Provider delivers results and risk communication to patient. MTF ensures
    quality control and patient’s receipt of results.
               Results:
8. Negative Results Results to patient and medical management complete.
9. Positive Urine Result: First positive requires second confirmation 24-hr urine and check for
    fragments, if none previously identified. Second positive requires referral through Service SME
    and DHCC to VA DU Follow-up Program.
                           Management:
10. Follow-up and Case Management DHCC facilitates referral to VA; narrative summary of care
    sent from VA to MTF for medical record and to DHCC for case management.


               DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                     PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
Depleted Uranium Exposure Medical Management Process Flow
Identification, Assessment, and Triage
Patient Process                                            Documentation & Process Flow
                                                           ICD-9 Coding
                            Service member
                                                           Always use:
                           completes DD 2796
                                                           • V70.5__6: Post-deployment visit
                                                           AND appropriate ICD-9 Codes, including:
                                 Positive
    No DU mgmt                                             • 985.9: Toxic effects of other unspecified metals
                               response Q
      needed       N            14,17,18?                  • E991.9: Injury due to war operations by other and
                                                             unspecified fragments
                                        Y                  • E993: Injury due to war operations by other explosion
                            Patient completes              Documentation
                              DU Exposure
                                                           • DD 2796 (record DU level assigned)
                             Questionnaire
                                                           • DU Exposure Questionnaire (SF 600 Overprint)
                                                           • Originals in Patient Health Record
                                  PCM/
                                                           • Copy of DD 2796 to AMSA
                              HCP assigns
                           patient to Level I, II          • Copy of DU Exposure Questionnaire to Service-
                                   or III                  designated lab with urine specimen


                                                           PCM: Primary Care Manager
                  To Level I, II            To Level III   HCP: Health Care Provider
                                                           SME: Subject Matter Expert


             DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                   PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
Depleted Uranium Exposure Medical Management Process Flow
Level I, II
Patient Process                                             Documentation & Process Flow
                                                            Documentation
     Level I or II patient
     visit to PCM/HCP                                       • DU Exposure Questionnaire (including suspected
                                                              exposure dates)
                                       Army: In-house
                                     creatinine analysis;   • SF 600 provider notation
    PCM/HCP orders 24
                                   results to CHPPM with    • Lab Request Tracking Form
    hour urine bioassay,
                                       urine specimen
    preferably NLT 180                                      • Lab Order Form
    days post exposure
                                                            • Urine Creatinine ordered in CHCS
                                    Air Force: In-house         or
   PCM/HCP gives patient            creatinine analysis;
                                                            • SF 513 Consultation Form (where HCP cannot order
     Patient Education             results to AFIOH with      bioassay, refer patient to PCM using SF 513)
    Handout/Fact Sheet                urine specimen
                                                            All Services Process Flow
                                                            • Originals in Patient Health Record
     PCM/HCP delivers                                       • Copies of required forms to Service-designated lab:
      appropriate risk                Navy/Marines:
    communication about              Send entire urine        - DU Exposure Questionnaire
                                      specimen to VA
     DU bioassay testing                                      - Lab Request Tracking and Order Forms
                                                              - Urine Creatinine Order or Results
                                                            • Removed fragments to Service-designated lab
          Service-                        To Lab
         specific DU                       Results           Submissions to CHPPM and AFIOH require:
         processing                                         - Urine volume with creatinine analysis
                                                            - Start/stop date/time with specimen
                                                            - Information on diagnosed or removed DU fragments

                    DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                          PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
Depleted Uranium Exposure Medical Management Process Flow
Level III
Patient Process                                            Documentation & Process Flow
                                                           Documentation
                    Patient Triaged to
                         Level III                         • Complete SF 600 notation
                                                           • Additional DD 2766 notation, if needed
                    Provider delivers                      • Additional DD 2796 notation, if needed
                    appropriate risk
                     communication                         • Patient Education Handout/Fact Sheet


                   Provider gives patent                   All Services Process Flow
                    Patient Education                      • Notation on DD 2796 prior to submission to AMSA and
                   Handout/Fact Sheet                        patient (record DU level assigned)
                                                           • Original SF 600 and DD 2796 in Patient Health Record
                                                           • Copy of DD 2796 to AMSA
           Patient                          Provider
       requests urine                    elects optional
         bioassay?                         bioassay?
                                                              AMSA
                        To Level I, II
                                                              Bldg T-20, Rm 213
               Y                             Y                Attn: MCHB-TS-EDM
                                                              6900 Georgia Ave., NW
                                                              Washington, DC
                         DU mgmt                              20307-5001
               N         complete            N                202.782.0471 DSN: 662


               DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                     PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
Depleted Uranium Exposure Medical Management Process Flow
Lab Results
Patient Process                                                                      Documentation & Process Flow
                                                                                     Documentation
                                  From Level I, II
                                                                                     •   Lab Results Form

        Army/AF: CHPPM/                     Navy/Marine Corps: VA sends letter       •   Provider and patient notification
      AFIOH process bioassay                 with bioassay results to PCM/HCP,       All Services Process Flow
                                                     Navy lab and DHCC
                                                                                     •   Service-designated lab processes bioassay
     Service SME develops risk                                                       •   Service SME evaluates results, creates risk assessment and medical
   assessment and medical mgmt                VA also send letter with results to        management plan, and consults with ordering PCM/HCP (providing
         recommendations                      patient with instructions to contact       PCM/HCP with additional information for results exceeding NHANES
                                                                                         population levels)
                                                       PCM/HCP or VA
                                                                                     •   Provider/MTF ensures results provided to patient
  SME provides all results to local
                                            PCM/HCP consults VA SME to receive       •   Originals in Patient Health Record
 MTF lab and to DHCC for archiving/
     case mgmt for Reservists                details, explanation, and health risk   •   Copies of all documents, letters, and results sent to DHCC for central
                                                 communication information               archiving


   SME sends ordering PCM/HCP
                                                                                     Army                      Air Force                    Navy/Marines
                                              All Services: PCM/HCP contacts
 summary letter and risk assessment                                                  - CHPPM SME               - AFIOH SME evaluates        - MTF lab receives VA
                                                patient with results feedback
        recommendations                                                              evaluates data,           data, provides bioassay      bioassay results, letter
                                                                                     provides bioassay         results to MTF lab and
                                                                                     results to MTF lab        PCM/HCP                      - NEHC archives
                                                                                     and PCM/HCP                                            results at the Navy
 PCM/HCP consults SME to receive                            Results?                                           - AFIOH archives             Dosimetry Center
                                                Positive               Negative      - CHPPM archives          results in Air Force
 details, explanation, and health risk                                                                                                      - VA forwards Navy/
                                                                                     results, forwards         Dosimetry Center’s Air
     communication information                                                                                 Force Master Radiation       Marine results to
                                          Positive: Schedule     Negatve: Phone or   to Army Dosimetry
                                                                                     Center                    Exposure Registry            DHCC for central
                                            appointment           mail notification                                                          archiving and case
                                                                                     - CHPPM forwards          - AFIOH forwards             mgmt
                                                                                     results to DHCC for       results to DHCC for
                                                                    DU medical       central archiving and     central archiving and
                                             To Follow-up          mgmt complete     case mgmt                 case mgmt


                       DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                             PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
Depleted Uranium Exposure Medical Management Process Flow
Follow-up
Patient Process                                                            Documentation & Process Flow
    PCM/HCP has received                                                   Documentation
    positive bioassay results
                                                                           • SF 600 provider notation
    PCM/HCP orders 2nd DU                                                  • SF 600 DU Exposure Form
      bioassay to confirm
                                                                           • Lab Request Tracking and Order Forms
                                N         PCM/HCP consults with SME        • Urine Creatinine ordered in CHCS
           Positive?
                                        for repeat bioassay requirements

           Y
                                                                           All Services Process Flow
             Known
                                N       PCM/HCP consults with SME on
           embedded
                                          skeletal scan requirements
                                                                           • Perform a skeletal survey, if required
           fragment?
                                                                           • Originals in Patient Health Record
           Y
   All removed fragments sent                        DU
                                                                           • Copies of required forms to
  to Service-designated lab for
                                    Y
                                                  fragment                   Service-designated lab with urine specimen:
                                                   found?
            analysis
                                                                             - DU Exposure Questionnaire
                                                  N                          - Lab Request Tracking and Order Forms
  DHCC initiates case mgmt
  and refers patient to VA DU       Repeat DU bioassay in 6 months           - Urine Creatinine Order or Results
           Program
                                                                           • Fragments sent to Service-designated lab
    VA enrolls all patients with
                                        DHCC provides case mgmt, VA
                                                                           • VA sends follow-up treatment summary
  embedded DU fragments and
                                        performs longitudinal follow-up      documentation to PCM/HCP and DHCC
 others on a case-by-case basis



                       DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                             PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003

				
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