At the MTF level, the CCEP record should include all CCEP forms and relevant medical data to the program.
Blank forms included with this guide supersede previous editions of these forms and are intended to be used with the new CCEP.
All individual forms will be complete and legible.
Forms forwarded to NMIMC and maintained in the participant record shall be in the following order:
Phase I completed:
MTF Phase I Diagnosis Form
Provider-Administered Symptom Questionnaire
Information Release Form
Phase II completed:
RMC Phase II Diagnosis Form
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--> Appendix B Outline of the CCEP Medical Protocol Form Requirements At the MTF level, the CCEP record should include all CCEP forms and relevant medical data to the program. Blank forms included with this guide supersede previous editions of these forms and are intended to be used with the new CCEP. All individual forms will be complete and legible. Forms forwarded to NMIMC and maintained in the participant record shall be in the following order: Phase I completed: MTF Phase I Diagnosis Form Patient Questionnaire Provider-Administered Symptom Questionnaire Information Release Form Declination/Completion Form Phase II completed: RMC Phase II Diagnosis Form Declination/Completion Form
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--> Medical Protocols The CCEP is based upon a thorough clinical evaluation which emphasizes comprehensive and continuous primary care. The local MTF primary care provider maintains responsibility for patient evaluation and care throughout the CCEP process. Medical Treatment Facility (Phase I): Phase I will consist of a comprehensive history and medical evaluation with completion of Phase I questionnaires and related forms. The examination, both in content and quality, should parallel an in-patient admission work-up. The Phase I examination will include a complete medical history including: family, occupation, social (including tobacco, alcohol, and drug use), exposure to possible toxic agents, psychosocial condition and review of symptoms. The provider will specifically inquire about the symptoms listed on the CCEP Provider-Administered Patient Questionnaire. A comprehensive medical evaluation, with focused attention to the patients symptoms and health concerns, should be conducted. Individuals who, after completing MTF Phase I evaluations do not have a clearly defined diagnosis which explains their symptoms should be reviewed by the CCEP designated physician for further evaluation and consultations needed and/or for referral to the RMC. Phase II Level Evaluations are performed only after complete clinically indicated evaluations (including appropriate specialty consultations) are conducted at the MTF and the RMC. Phase I Laboratory Tests CBC U/A SMA-12 Regional Medical Center (Phase II): Phase II evaluations consist of the following laboratory tests, consultations and as necessary, symptom-specific examinations. J Elements of the Phase II evaluation may be accomplished by the local MTF as needed in the comprehensive evaluation of the Phase I patient in order to obtain a definitive diagnosis.
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--> Phase II Laboratory Tests CBC Sedimentation rate (ESR) C-Reactive protein Rheumatoid factor ANA Liver function CPK Urinalysis TB skin test (PPD) with controls Chest X-ray Hepatitis serology HIV testing VDRL B12 and folate Thyroid function tests Phase II Consults (if not accomplished at MTF level) Dental: Dental only if participant's annual screening not done Infectious disease Psychiatry: With physician-administered instruments: Structured Clinical Interview for DSMIII-Rcm (SCID) (delete modules for mania and psychosis) Clinician-Administered PTSD Scale (CAPS) Neuropsychological Testing: Only as indicated by psychiatry consult Symptom-Specific Examinations The RMC CCEP Physician ensures that Phase II patients with the following undiagnosed symptoms receive the tests and consultations listed below. Diarrhea GI consult Stool for O and P Stool Leukocytes Stool culture Stool volume Colonscopy with biopsies EGD with biopsies and aspiration Abdominal GI consult EGD with biopsy/aspiration Colonscopy with biopsy Abdominal ultrasound UGI series with small bowel FT Abdominal CT scan Headache MRI—head LP (glucose protein, cell count, VDRL, oligoclonal myelin, basic protein, pressure) Neuro consult
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--> Muscle Aches/Numbness EMG/NCV Chronic Fatigue Polysomnography and MSLT Chronic Cough/SOB Pulmonary consult Pulmonary function Tests with exercise and ABG Methacholine challenge If PFTs are normal, consider bronchoscopy with biopsy/lavage Memory Loss (Only if verified by psych evaluation) MRI—head Lumbar puncture Neuro consult Neuro psych testing Chest Pain/Palpitations ECG Exercise stress test Holter monitor Reproductive Concerns Urology consult GYN consult Vertigo/Tinnitus Audiogram ENG BAER Skin Rash Dermatology consult Consider biopsy