Clinical_Documentation_UG - Allscripts Homecare Clinical...

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Unformatted text preview: Allscripts Homecare Clinical Documentation User’s Guide Copyright © 2011 Allscripts Healthcare Solutions, Inc. www.allscripts.com Copyright © 2011 Allscripts Healthcare Solutions, Inc. This document is the confidential property of Allscripts Healthcare Solutions, Inc. It is furnished under an agreement with Allscripts Healthcare Solutions, Inc. and may only be used in accordance with the terms of that agreement. The use of this document is restricted to customers of Allscripts Healthcare Solutions, Inc. and their employees. The user of this document agrees to protect the Allscripts Healthcare Solutions, Inc. proprietary rights as expressed herein. The user further agrees not to permit access to this document by any person for any purpose other than as an aid in the use of the associated system. In no case will this document be examined for the purpose of copying any portion of the system described herein or to design another system to accomplish similar results. This document or portions of it may not be copied without written permission from Allscripts Healthcare Solutions, Inc. The information in this document is subject to change without notice. The names and associated patient data used in this documentation are fictional and do not represent any real person living or otherwise. Any similarities to actual people are coincidental. CPT copyright 2009 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. International Statistical Classification of Diseases and Related Health Problems (ICD) is copyright 2009 World Health Organization (WHO). Microsoft® Excel and Microsoft® Word are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. Table of Contents About This Guide ........................................................................................................ 26 Chapter 1 ‐ Admissions and Discharges ............................................................ 27 Admissions and Discharges Workflows ......................................................... 28 Referral Workflow ..................................................................................................... 28 Admission Workflow ................................................................................................. 28 Discharge Workflow .................................................................................................. 29 Readmission Workflow .............................................................................................. 30 Patient Basic ............................................................................................................ 31 What is Patient Basic Information? ............................................................................ 31 Patient Basic Window ................................................................................................ 31 Open an Existing Patient ............................................................................................ 34 Enter or Edit a Patient’s Basic Demographic Information ............................................ 34 Enter a Patient’s Address and Phone Number ............................................................ 34 Edit a Patient’s Address and Phone Number ............................................................... 35 Make a Patient’s Address and Phone Number Active or Inactive ................................. 35 New Patient Window ................................................................................................. 36 Add a New Patient ..................................................................................................... 38 Pre‐Admissions Patients ..................................................................................... 39 Pre‐Admissions ......................................................................................................... 39 Pre‐Admit a Patient ................................................................................................... 39 Pre‐Admissions Authorizations .................................................................................. 40 Enter Insurance Authorization Information for Pre‐Admissions Patient ....................... 40 View or Print Pre‐Admissions Orders .......................................................................... 40 Orders Management Window .................................................................................... 41 Generate Pre‐Admissions Orders ............................................................................... 43 Sign Pre‐Admissions Orders ....................................................................................... 43 Retrieve a Signature .................................................................................................. 44 Print a Signature ........................................................................................................ 44 Clinical Documentation User’s Guide 3 Table of Contents Admitting and Deactivating Pre‐Admissions Patients ...................................................45 Adjust Clinical Items Window .....................................................................................45 Admit Pre‐Admissions Patient ....................................................................................46 Deactivate Pre‐Admissions Patient .............................................................................46 Admissions & Status ..............................................................................................47 About Patient Admissions and Status ..........................................................................47 Admissions ................................................................................................................47 Discharges .................................................................................................................47 Re‐Admissions ...........................................................................................................47 PPS Patients Information ............................................................................................48 NPI Options for Admissions & Status ..........................................................................48 Admissions & Status Window .....................................................................................49 Select Assessment Window ........................................................................................62 Hospice Benefit Information Window .........................................................................62 Admitting Patients .....................................................................................................64 Discharging Patients ...................................................................................................65 Entering Status Change Information for Patient ..........................................................65 Editing Status Change Information for a Patient ..........................................................66 Entering Referrals for a Patient ...................................................................................66 Entering Physicians for a Patient ................................................................................67 Overriding Patient’s Orders Certification Start Date ...................................................67 Readmit Action Window ............................................................................................68 Readmitting a Patient .................................................................................................69 Entering Visits Prior to Admission ...............................................................................69 Diagnosis ....................................................................................................................71 Diagnosis Window .....................................................................................................71 Patient Diagnoses Group Dates Window .....................................................................74 View Across Periods Window .....................................................................................75 Enter Diagnoses for a Patient .....................................................................................76 Find a Diagnosis .........................................................................................................76 Discontinue Diagnoses for a Patient ...........................................................................77 Create a Patient Diagnoses Group ..............................................................................77 4 Clinical Documentation User’s Guide Table of Contents Discharge Summary Report ................................................................................78 Discharge Summary Report Generated .......................................................................78 Discharge Summary Report Window ...........................................................................80 Discharge Summary Report ‐ Define Tab .....................................................................80 Generating Discharge Summary Report ......................................................................82 Patient Documents – Discharge Summary ...................................................83 Discharge Summary Window ......................................................................................83 Print or Preview Discharge Summaries ........................................................................84 Chapter 2 ‐ General Clinical Information ..........................................................85 General Clinical .......................................................................................................86 General Clinical Window ............................................................................................86 Enter General Clinical Information for the 485/CPOC ..................................................90 Enter or Edit General Clinical Information for Orders ...................................................90 Enter or Edit DME/Supplies, Safety, Diet, and Allergies Information .............................91 Enter or Edit Functional Limits, Activities Permitted, Mental Status, Advance Directives, and Precaution Protocols ...........................................................................91 Enter or Edit a Patient’s Prognosis ..............................................................................92 Review General Clinical Information ...........................................................................92 Assignments .............................................................................................................93 Assignments Window .................................................................................................93 Enter Patient Assignments ..........................................................................................95 Edit Patient Assignments ............................................................................................96 Assignments Report ..............................................................................................97 Assignments Report Window ......................................................................................97 Generating Assignments Report .................................................................................98 Clinical Notes ............................................................................................................99 Clinical Notes Window ...............................................................................................99 Entering Clinical Notes for Patient ............................................................................105 Clinical Documentation User’s Guide 5 Table of Contents Charts/Clinical Notes Report ...........................................................................106 Charts/Clinical Notes Report Window .......................................................................106 Preview or Print Charts/Clinical Notes ......................................................................107 Patient Documents – Charts/Clinical Notes ...............................................108 Charts/Clinical Notes Window ..................................................................................108 Print or Preview Charts/Clinical Notes ......................................................................110 Projected Visits ......................................................................................................111 Projected Visits Window ..........................................................................................111 Enter Projected Visits for a Patient ...........................................................................114 Edit Projected Visits for a Patient ..............................................................................115 View Certification Periods ........................................................................................115 Projected Visits Report .......................................................................................116 Projected Visits Report ‐ Generated ..........................................................................116 Projected Visits Report Window ...............................................................................120 Projected Visits Report ‐ Define Tab ..........................................................................120 Visit Record .............................................................................................................124 Visit Record Window (Orders>Accumulated Documents) ..........................................124 Visit Record Report – Generated ..............................................................................124 Visit Record Report ‐ Define Tab ...............................................................................128 Generating Visit Record Report ................................................................................129 Patient Documents – Visit Record .................................................................130 Visit Record Window (Patient) ..................................................................................130 486 Info ....................................................................................................................131 486 Info Window .....................................................................................................131 Enter 486 Information ..............................................................................................133 Edit 486 Information ................................................................................................133 6 Clinical Documentation User’s Guide Table of Contents Face Sheet Report ................................................................................................134 Face Sheet Report Window ......................................................................................134 Face Sheet Report – Generated ................................................................................134 Face Sheet Report ‐ Define Tab .................................................................................138 Patient Documents – Face Sheet ...................................................................140 Face Sheet Window ..................................................................................................140 Printing or Previewing Face Sheets ...........................................................................140 Patient Labels .........................................................................................................142 Patient Labels Window .............................................................................................142 Print or Preview Patient Labels .................................................................................143 Patient Education Report ..................................................................................144 Patient Education Report Window ............................................................................144 Generating Patient Education Report ........................................................................145 Patient Signature Document ............................................................................146 Patient Signature Document Window .......................................................................146 Generating Patient Signature Document ...................................................................148 Patient Tasks Report ...........................................................................................149 Patient Tasks Report Window ...................................................................................149 Generating Patient Tasks Report ...............................................................................151 On‐Call Summary Report ...................................................................................152 On‐Call Summary Report Window ............................................................................152 Generating On‐Call Summary Report ........................................................................153 Patient Expired ICD9 Report ............................................................................154 Patient Expired ICD9 Report Window ........................................................................154 Generating Patient Expired ICD9 Report ...................................................................155 Clinical Documentation User’s Guide 7 Table of Contents Chapter 3 ‐ Care Planning ......................................................................................156 Care Plan Report ...................................................................................................157 Care Plan Report – Generated ..................................................................................157 Care Plan Window ....................................................................................................166 Care Plan Report ‐ Define Tab ...................................................................................166 Generating Care Plan from Patient Component ........................................................168 Generating Demand Care Plan from Orders Component ..........................................169 Generating Care Plan from Reports Component ........................................................170 Patient Documents – Care Plan ......................................................................171 Care Plan Report ......................................................................................................171 Problems ..................................................................................................................172 Problems Overview ..................................................................................................172 Problems Window ....................................................................................................172 Profiles ....................................................................................................................173 Assigning Problems to a Patient ................................................................................174 Entering Goals for a Problem ....................................................................................174 Entering Interventions for a Problem ........................................................................175 Discontinuing Problem for Patient ............................................................................175 Problem Charting .................................................................................................176 Problem Charting Window .......................................................................................176 Documenting Progress for a Patient .........................................................................178 Charting History ....................................................................................................179 Charting History Window .........................................................................................179 Viewing Patient’s Progress in Charting History ..........................................................179 Charting History Report .....................................................................................180 Charting History Report Window ..............................................................................180 Preview or Print Charting Histories ...........................................................................181 8 Clinical Documentation User’s Guide Table of Contents Patient Documents – Charting History .........................................................183 Charting History Window .........................................................................................183 Printing or Previewing Charting History .....................................................................185 Active Patients by Problems Report ..............................................................186 Active Patients by Problems Report Window ............................................................186 Generating Active Patients by Problems Report ........................................................187 Active Problems by Discipline Report ...........................................................188 Active Problems by Discipline Report Window ..........................................................188 Generating Active Patients by Discipline Report ........................................................188 Chapter 4 ‐ Medications and MAR .....................................................................189 Medications ............................................................................................................190 Medications Window ...............................................................................................190 Medications Window – Medication Evaluation Tab ...................................................196 Evaluate Medications ...............................................................................................197 Medications Window – Medication Order Entry Tab .................................................198 Medications Window – ModificationDetails Tab .......................................................200 Medications Window – Medication Hold and Resumption Details Tab .......................202 Medications Window – Hold/Resume History Tab .....................................................204 Medications Window – Medication Group Details Tab ..............................................205 Enter Medications for a Patient ................................................................................207 Edit Medications for a Patient ..................................................................................208 Enter Special Instructions for a New Medication .......................................................208 Add Special Instructions to Existing Medication .........................................................209 Enter Medication Groups for a Patient ......................................................................209 Hold Medications for a Patient .................................................................................210 Resume Held Medications for a Patient ....................................................................211 Delete Medications for a Patient ..............................................................................211 Discontinue a Medication for a Patient .....................................................................212 Medi‐Span Prior Adverse Reaction Check Window ....................................................213 Check Medication Interactions .................................................................................214 Clinical Documentation User’s Guide 9 Table of Contents Check Prior Adverse Reactions to a Medication ........................................................214 Medication Kits Window ..........................................................................................215 Add Medication Kits to a Patient ..............................................................................216 Drug/Drug Interactions Dialog ..................................................................................216 Show Fields Dialog ...................................................................................................217 New Medication Dialog ............................................................................................218 Select Medication Dialog ..........................................................................................220 Medication Entry Dialog ...........................................................................................221 Medication Administration Record (MAR) .................................................223 MAR Window ...........................................................................................................223 MAR Window ‐ Patient Info Tab ...............................................................................226 MAR Window ‐ Filter Tab .........................................................................................228 Medications for Patient Window ..............................................................................229 Add Medication to MAR Window .............................................................................231 Define Frequency Window .......................................................................................232 Define Range Window ..............................................................................................233 New/Edit Entry Window ...........................................................................................234 New PRN Entry Window ...........................................................................................235 Patient’s Signature Capture Window ........................................................................237 Create New MAR .....................................................................................................239 Activate MAR ...........................................................................................................239 Deactivate MAR .......................................................................................................240 Mark MAR as Reviewed ............................................................................................240 Adding Scheduled Medication to MAR ......................................................................240 Add PRN medication to MAR ....................................................................................241 Update Active MAR with New Medications ...............................................................242 Change Medication Administration Time on MAR .....................................................242 Document Administration of Scheduled Medications on MAR ...................................243 Edit MAR Entries ......................................................................................................243 Document Administration of PRN Medications on MAR ............................................244 Document Response for PRN Medication on MAR ....................................................244 Append Patient’s Signature to MAR Medication ........................................................245 10 Clinical Documentation User’s Guide Table of Contents MAR Review Status Report ...............................................................................246 MAR Review Status Window .....................................................................................246 Generating a MAR Review Status Report ..................................................................247 Medication Administration Actual vs. Scheduled Report .....................248 Medication Administration Actual vs. Scheduled Report Generated ..........................248 Medication Administration Actual vs. Scheduled Window .........................................249 Medication Administration Actual vs. Scheduled ‐ Define Tab ....................................250 Generating Medication Administration Actual vs. Scheduled Report ..........................251 Medication Evaluation Report ........................................................................252 Medication Evaluation Report – Generated ..............................................................252 Medication Evaluation Window ................................................................................254 Medication Evaluation Report – Define Tab ..............................................................254 Generating Medication Evaluation Report ................................................................255 Print MAR Documents ........................................................................................256 Print MAR Window ..................................................................................................256 Generating MAR ......................................................................................................257 PRN Medications Administered Report .......................................................258 PRN Medications Administered With and Without Response Window .......................258 Generating a PRN Medications Administered With and Without Response Recorded Report ......................................................................................................259 Undocumented Medication Administration Report ...............................260 Undocumented Medication Administration Window .................................................260 Generating Undocumented Medication Administration Report .................................261 Medication Descriptions Report .....................................................................262 Medication Descriptions Report Window ..................................................................262 Generating Medication Descriptions .........................................................................263 Patient Documents – Medication Descriptions ........................................264 Medication Descriptions Window .............................................................................264 Generating Medication Descriptions Report ..............................................................265 Clinical Documentation User’s Guide 11 Table of Contents Medication Lists Report .....................................................................................266 Medication Lists Report Window ..............................................................................266 Generating Medication Lists Report ..........................................................................267 Patient Documents – Medication Lists ........................................................268 Medication Lists Window .........................................................................................268 Print or Preview Medication Lists .............................................................................269 Pharmacy Medication List Report ..................................................................270 Pharmacy Medication List Report Window ...............................................................270 Generating Pharmacy Medication List ......................................................................272 Chapter 5 ‐ Orders ....................................................................................................273 Creating Orders .....................................................................................................274 About Orders ...........................................................................................................274 Creating Orders ........................................................................................................274 Order Statuses .........................................................................................................275 Creating Corrected Orders ........................................................................................276 Managing Open Orders ............................................................................................276 Processing Orders ................................................................................................277 Processing Orders Workflow ...................................................................................277 Defining an Order Run ..............................................................................................277 Selecting an Order Run to Process ............................................................................278 Printing Orders ........................................................................................................279 Approving Orders .....................................................................................................279 Printing Corrected Orders ........................................................................................280 Reprinting Orders ....................................................................................................281 Reprinting Orders by Patient or Physician .................................................................281 Reprinting Orders by Order Run ...............................................................................282 Tracking Orders ........................................................................................................282 12 Clinical Documentation User’s Guide Table of Contents Managing Returned Orders ..............................................................................283 Processing Signed Orders .........................................................................................283 Updating the Status of Signed Orders .......................................................................284 Rejecting Orders ......................................................................................................285 Accelerated Posting of Signed Orders .......................................................................285 Active Orders Report ..........................................................................................287 Active Orders Report – Generated ............................................................................287 Generating Active Orders Report ..............................................................................289 Orders Signature Report ....................................................................................290 Orders Signature Report Window .............................................................................290 Orders Signature Report – Define Tab .......................................................................291 Generating the Orders Signature Report ...................................................................292 View Orders ............................................................................................................293 View Orders Window ..............................................................................................293 Previewing Orders ....................................................................................................294 Viewing Order Reports .......................................................................................295 Open Orders Report .................................................................................................295 Orders Alert Report ..................................................................................................295 Orders Audit Report .................................................................................................296 Chapter 6 ‐ Certification of Terminal Illness ..................................................297 Certification of Terminal Illness ......................................................................298 About Certification of Terminal Illness (CTI) ..............................................................298 Certification of Terminal Illness Window (Orders) .....................................................298 Printing CTIs from Orders Component ......................................................................299 Reprinting CTIs .........................................................................................................300 Inactivating CTIs .......................................................................................................300 Patient Documents – Certification of Terminal Illness ..........................301 Certification of Terminal Illness Window (Patient) .....................................................301 Printing CTIs from Patient Component ......................................................................301 Clinical Documentation User’s Guide 13 Table of Contents Process Signed CTIs .............................................................................................302 Process Signed CTIs Window ....................................................................................302 Processing Signed CTIs .............................................................................................303 CTI Status .................................................................................................................304 CTI Status Report .....................................................................................................304 Encounter Date Report ......................................................................................305 Encounter Date Report .............................................................................................305 Chapter 7 ‐ Time Log ................................................................................................306 TimeLog ....................................................................................................................307 About the TimeLog ...................................................................................................307 About Entering Bereavement Services ......................................................................307 About Entering Visits Prior to Admission ...................................................................307 About Verifying Visits ...............................................................................................307 About Resolving Visits in Host Mode .........................................................................308 User Defaults ...........................................................................................................308 TimeLog Window .....................................................................................................308 TimeLog Window – Authorizations Hint ....................................................................320 TimeLog Window Supplies Tab .................................................................................321 TimeLog Window Costs and Revenue Tab .................................................................323 TimeLog Window Negotiation Tab ............................................................................323 TimeLog Window Pay Cost Tab .................................................................................325 Start a TimeLog ........................................................................................................325 Complete a TimeLog ................................................................................................326 Record Indirect Time Related to a Patient Visit .........................................................326 Enter Visits Provided to a Patient ..............................................................................327 Enter Supplies for a Patient (TimeLog) ......................................................................327 Enter Times, Durations, Travel, and Mileage Related to a Visit or Other Service .........328 Indicate a PRN Visit in TimeLog .................................................................................328 Capture a Patient Signature for a Visit ......................................................................329 Clear Scheduled Times Window ................................................................................329 Clear All Scheduled Times for a Visit .........................................................................330 14 Clinical Documentation User’s Guide Table of Contents Batch Timelog ........................................................................................................331 About Batch Timelog ................................................................................................331 Setting Up Batch Timelog .........................................................................................331 TimeLog Window .....................................................................................................331 Batch Timelog Window ............................................................................................332 Edit Batch Numbers Window ....................................................................................334 Select Batch Number Window ..................................................................................336 Batch Number Creation Window ..............................................................................338 Edit Batch Window ...................................................................................................339 Batch Timelog Process Options Window ...................................................................340 Batch Timelog Processing Window ...........................................................................341 Create a Batch Number for Batch Timelog ................................................................342 Enter a Transaction in Batch Timelog Window ..........................................................343 Delete a Transaction in the Batch Timelog Window ...................................................343 Update Batch Number Control Totals .......................................................................343 Process a Single Entry in Batch Timelog Window .......................................................343 Process All Entries in Batch Timelog Window ............................................................344 Process Batches Using Batch Timelog Processing Window .........................................344 Chapter 8 ‐ Field Mode ...........................................................................................345 Field Mode Overview ..........................................................................................346 What Is Field Mode? ................................................................................................346 My Day for Field Mode Users ....................................................................................347 Clinical Monitoring Option for Field Mode Users .......................................................347 Field Mode Use .....................................................................................................348 What Functions Are Not Available in Field Mode? .....................................................348 Admission and Discharge ..........................................................................................348 Patient Numbers ......................................................................................................349 Printing in Field Mode ..............................................................................................349 Purge Cached Patients ..............................................................................................349 Set Up Connection to the Server in Field Mode .........................................................349 Override the Login Name When Logging in Field Mode .............................................350 Clinical Documentation User’s Guide 15 Table of Contents Admit a Patient in Field Mode ..................................................................................350 Perform a Patient Visit in Field Mode ........................................................................351 Manually Purge Cached Patients ..............................................................................352 Field Mode Administration ...............................................................................353 Field Mode System Administrators ...........................................................................353 Who “Owns” a Field Mode Device? ..........................................................................353 How Long Does a Field Mode Device Save Data? .......................................................353 Synchronization Setup .............................................................................................354 Patient List Management .........................................................................................354 Patient List ...............................................................................................................354 Scheduling Software Updates ...................................................................................355 Field Use Only Status Codes .....................................................................................355 Field Mode Setup Checklist ......................................................................................355 Define How Many Field Mode Units are Licensed for an Organization .......................356 Enable a User to Work in Field Mode Only ................................................................357 Enable a User to Work in Field Mode and Host Mode ................................................357 Set up a Field Mode Device for Initial Synchronization ..............................................358 Define How Long the Application Retains Historical Data on Field Mode Units ...........361 Define How Long the Application Retains Synchronization Logs and Audit Trails ........362 Define How Far in Advance Patient Information is Loaded in the Application .............362 Define the Type of Synchronization ..........................................................................363 Define Which Patients a User Can Download During Synchronization ........................363 Synchronizing Field Mode with Host Mode ...............................................364 Scheduling Lookahead ..............................................................................................364 Data Integrity During Synchronization ......................................................................364 Conflict Management ...............................................................................................364 Patient Code Handling ..............................................................................................365 Non‐Billable Service Codes and Synchronization .......................................................365 Field Mode Synchronization Reports ........................................................................366 Field Mode Data Synchronization Window ................................................................366 Select Patients for Quick Synch Download Window ...................................................370 Updating Allscripts Homecare ..................................................................................372 16 Clinical Documentation User’s Guide Table of Contents Data Conflict Window ..............................................................................................374 Perform Full Synchronization ....................................................................................376 Download Data for an Individual Patient ...................................................................377 Define Patients to Be Downloaded During Synchronization .......................................378 Perform Quick Synchronization to Download Patient Data ........................................378 Verify Data Before Uploading ...................................................................................379 Place Item on Hold to Prevent Uploading During Complete Synchronization ..............380 Place Item on Hold to Prevent Uploading During Partial Synchronization ...................381 Resolve Data Conflicts During Synchronization ..........................................................381 Electronically Sign Data Before Uploading .................................................................382 Define What to Do After Synchronization .................................................................382 Set Time to Perform Automatic Synchronization .......................................................383 My Day .....................................................................................................................384 About My Day ..........................................................................................................384 My Day Window .......................................................................................................385 My Schedule Section ................................................................................................386 Customize View: My Schedule ..................................................................................387 My Tasks Section ......................................................................................................388 Customize View: My Tasks ........................................................................................390 Show Fields Dialog ...................................................................................................391 Group By Dialog .......................................................................................................392 Sort By Dialog ..........................................................................................................393 Filter Dialog .............................................................................................................394 My Favorites Section ................................................................................................395 Customize View: My Favorites ..................................................................................396 My Patients Section .................................................................................................396 My Patients – Assignments Tab ................................................................................397 Customize View: My Patients – Assignments ............................................................398 My Patients – Recertification Alert Tab .....................................................................399 Customize View: My Patients – Recertification Alert .................................................400 My Patients – Reservations Tab ................................................................................401 Customize View: My Patients – Assessment Reservations ..........................................402 Clinical Documentation User’s Guide 17 Table of Contents My Patients – OASIS Due Alert Tab ...........................................................................402 Customize View: My Patients – OASIS Due Alert .......................................................403 My Patients – Imported Medications Tab ..................................................................404 Customize View: My Patients – Imported Medications ..............................................405 My Patients – Lab Results Tab ..................................................................................406 Customize View: My Patients – Lab Results ...............................................................407 My Patients – Therapy Services Tab ..........................................................................408 Set My Day as Default View on Field Device ..............................................................408 View My Schedule from My Day ...............................................................................409 View My Tasks from My Day .....................................................................................409 View My Favorites from My Day ...............................................................................409 View My Patients From My Day ................................................................................409 Generate and Print the Assignments Report From My Day ........................................410 Generate and Print the Recertification Alert Report From My Day .............................410 Generate and Print the Reservations Report From My Day ........................................410 Generate and Print the OASIS Due Alert Report From My Day ...................................411 Generate and Print the Lab Results Report From My Day ..........................................411 Generate and Print the List of Imported Medications From My Day ...........................411 Chapter 9 ‐ Assessments ........................................................................................412 Assessments ...........................................................................................................413 About Assessments ..................................................................................................413 OASIS Assessments ..................................................................................................414 Patient Condition Changes ..................................................................................414 OASIS Key Icons ..................................................................................................416 Synchronization ..................................................................................................417 Initiate Care Plans Through the Assessments .......................................................417 Defining Problems for the Patient .......................................................................417 Abbreviated OASIS Assessment ...........................................................................419 OASIS Assessments Validation ..................................................................................421 View an OASIS Assessments HIPPS Score ..................................................................421 Validate an OASIS Assessment ..................................................................................422 Correct Errors Found in Assessments During Validation .............................................422 18 Clinical Documentation User’s Guide Table of Contents Assessments Window ...............................................................................................423 Assessments Window ‐ Data Entry Tab .....................................................................428 Assessments Window ‐ Notes Tab ............................................................................431 Assessments Window ‐ Revision History Tab .............................................................431 New Assessment Window ........................................................................................432 Discharge/Transfer Summary Type Window ..............................................................436 Create New Assessment ...........................................................................................438 Create a Discharge or Transfer Summary ..................................................................439 Connect an Assessment to a Visit or Telephone Call ..................................................440 Enter Notes for an Assessment .................................................................................440 Indicate Normal Values for a Patient .........................................................................441 Deactivating an Assessment Tab ...............................................................................442 Activating an Assessment Tab ...................................................................................442 View the Progress of an Assessment .........................................................................442 View Previous Assessments for a Patient ..................................................................443 Activating or Deactivating Tabs for Reassessments ....................................................443 Additional Information About Inactivation ................................................................444 Editing Assessments .................................................................................................445 Modification to Locked Assessment Window ............................................................446 Edit an Assessment ..................................................................................................447 Delete an Assessment ..............................................................................................448 Run the Acute and Emergent Care Risk Assessment ..................................................449 Change the Reason for Assessment (RFA) .................................................................451 About Reserving Assessments ..................................................................................452 Reserve Assessment Window ..................................................................................453 Reserve an Assessment ............................................................................................454 About Releasing Assessments ...................................................................................455 Release a Reserved Assessment ................................................................................456 Reserved Assessments and Synchronization ..............................................................456 About Revision History .............................................................................................457 Review an Assessment’s Revision History ..................................................................458 Error Grid .................................................................................................................459 Adverse Events and Scales Assessments Enhancements ............................................459 Clinical Documentation User’s Guide 19 Table of Contents Condition Change Report .........................................................................................463 Generating Condition Change Report .......................................................................464 Changes To Skilled Nursing Template ........................................................................465 Surgical Diagnoses Prefill Logic .................................................................................471 Assessment Guidelines for Home Health and Hospice ..............................................472 Assessments Report ............................................................................................474 Assessments Report Window ...................................................................................474 Assessments Report – Generated .............................................................................475 Assessments Report – Select Disciplines ...................................................................477 Assessments Report – Select Patients and Time Scope ..............................................479 Assessments Report – Select Assessments ................................................................480 Assessments Report – Select Pages to Print ..............................................................482 Generating Assessments Report from Reports Component .......................................484 Generating Assessments Report from Patient Component ........................................484 Assessment History Report ..............................................................................485 Assessment History Window ....................................................................................485 Assessment History Report – Generated ..................................................................486 Assessment History Report – Select Patients and Time Scope ....................................488 Assessment History Report – Select Assessment Template ........................................489 Assessment History Report – Select Pages to Print ....................................................490 Generating Assessment History Report for an Individual Patient ...............................491 Generating Assessment History Report for Multiple Patients .....................................492 Patient Documents – Assessments ...............................................................493 Assessments Window ..............................................................................................493 Generating the Assessments Report .........................................................................494 Patient Documents – Assessment History ..................................................495 Assessment History Report .......................................................................................495 20 Clinical Documentation User’s Guide Table of Contents OASIS Export ...........................................................................................................496 Exporting OASIS Assessments ...................................................................................496 OASIS Export – Select Mode .....................................................................................497 OASIS Export – Select Assessments to View ..............................................................498 OASIS Export – Exported/Not Exported/Inactive Assessments ...................................499 OASIS Export – Select Export Parameters ..................................................................500 OASIS Export – Select Patients/Assessments/Payers ..................................................503 OASIS Export – Select Assessments to Export ............................................................504 Exporting the OASIS Assessments .............................................................................505 Assessments Export Report ......................................................................................506 Viewing the Assessment Export Report .....................................................................507 OASIS Due Alert Report ......................................................................................508 OASIS Due Alert Report Window ...............................................................................508 Generating OASIS Due Alert Report ..........................................................................509 Patient Documents – OASIS Due Alerts .......................................................510 OASIS Due Alerts Window ........................................................................................510 Printing or Previewing OASIS Due Alerts ...................................................................511 Assessment Editor ................................................................................................512 About Assessment Editor ..........................................................................................512 Starting Assessment Editor From the Business Units Window ....................................512 Allscripts Homecare Assessment Editor Window .......................................................514 Editing Item Text at the Notebook, Tab, Box, or Line Level ........................................515 Making Item Invisible in the Assessment Template ...................................................515 Checking the Spelling of the Item Text ......................................................................516 Saving Changes in the Assessment Editor ..................................................................516 Initiating Care Plans Through the Assessments ..........................................................517 Attaching Problems to the Assessment Questions .....................................................517 Changing the Assessment Editor Settings ..................................................................520 Template Edit Report ...............................................................................................521 Previewing, Printing, or Saving the Template Edit Report ..........................................522 Assessment Navigation Tree Icons ............................................................................522 Clinical Documentation User’s Guide 21 Table of Contents Assessment Viewer ..............................................................................................524 About Assessment Viewer ........................................................................................524 Starting Assessment Viewer .....................................................................................524 Viewing the Assessment Template ...........................................................................525 Changing the Template Colors ..................................................................................527 Creating a Distribution Package ................................................................................527 Chapter 10 ‐ Clinical Monitoring .........................................................................528 Clinical Monitoring ...............................................................................................529 About Clinical Monitoring .........................................................................................529 Setting Up Clinical Monitoring ..................................................................................529 Add/Edit Clinical Data .........................................................................................530 Add/Edit Clinical Data Window .................................................................................530 Vital Signs Tab – Temperature Subtab .......................................................................533 Vital Signs Tab – Pulse Subtab ..................................................................................534 Vital Signs Tab – Respiration Subtab .........................................................................535 Vital Signs Tab – Blood Pressure Subtab ....................................................................536 Measurements Tab – Height Subtab .........................................................................537 Measurements Tab – Weight Subtab ........................................................................538 Measurements Tab – Head Circumference Subtab ....................................................540 Measurements Tab – Extremity Subtab ....................................................................541 Measurements Tab – Chest Circumference Subtab ...................................................542 Measurements Tab – Abdominal Girth Subtab ..........................................................543 Labs Tab – Pulse Oximetry Subtab ............................................................................544 Labs Tab – Glucose Subtab .......................................................................................545 Labs Tab – PT/INR Subtab .........................................................................................546 Spirometry Tab – Peak Flow Subtab ..........................................................................547 Scales Tab ................................................................................................................548 Reading Level Note Window .....................................................................................550 Enter Clinical Monitoring Data ..................................................................................551 Link Clinical Monitoring Record to Clinical Notes .......................................................551 Link Clinical Monitoring Record to Patient Tasks .......................................................552 22 Clinical Documentation User’s Guide Table of Contents Create Trend from the Add/Edit Clinical Data Window ..............................................553 View Clinical Data .................................................................................................556 View Clinical Data Window .......................................................................................556 Access and View Clinical Data ...................................................................................560 Create Trend from the View Clinical Data Window ....................................................560 Create a Patient Data Report ....................................................................................563 Revision History ....................................................................................................565 Revision History Window ..........................................................................................565 Scales Report ..........................................................................................................567 Scales Report – Generated .......................................................................................567 Clinical Monitoring Window .....................................................................................569 Clinical Monitoring Window – Define Tab .................................................................569 Generating Scales Report .........................................................................................571 Lab Results Report ...............................................................................................572 Lab Results Report Generated ..................................................................................572 Lab Results Report Window ......................................................................................573 Lab Results Report Window – Define Tab ..................................................................574 Chapter 11 ‐ Adverse Events ................................................................................577 Adverse Events ......................................................................................................578 What Is Adverse Event? ............................................................................................578 About Falls ...............................................................................................................578 Falls Window ...........................................................................................................579 Injuries Tab ..............................................................................................................580 Observed/Reported/Notified Tab .............................................................................581 Documenting Patient’s Falls .....................................................................................582 About Infections ......................................................................................................583 Infections Window ...................................................................................................583 Infections Tab ..........................................................................................................585 Documenting Patient’s System Infections .................................................................586 Infectious Diseases Tab ............................................................................................586 Clinical Documentation User’s Guide 23 Table of Contents Documenting Patient’s Infectious Diseases ...............................................................587 Electronic Signature and Conflicts for Adverse Events ...............................................588 Adverse Events Electronic Signature ...................................................................588 Viewing Electronic Signature for Adverse Events .................................................588 Adverse Events Conflict Management ................................................................589 Adverse Event Report .........................................................................................592 Adverse Event Report – Generated ...........................................................................592 Adverse Event Report Window .................................................................................595 Adverse Event Report – Define Tab ...........................................................................595 Generating the Adverse Event Report .......................................................................597 Falls Report .............................................................................................................598 Falls Report – Generated ..........................................................................................598 Falls Report Window ................................................................................................599 Generating the Falls Report ......................................................................................600 Infections Report ..................................................................................................601 Infections Report – Generated .................................................................................601 Infections Report Window ........................................................................................602 Infections Report – Define Tab .................................................................................603 Generating Infections Report ...................................................................................604 Chapter 12 ‐ Co‐Signature .....................................................................................605 Co‐Signature Wizard ...........................................................................................606 What Is Co‐Signature? ..............................................................................................606 Co‐Signature Window ..............................................................................................607 Step 1 – Search ........................................................................................................607 Step 2 – Preview ......................................................................................................611 Step 3 – Denial Reason .............................................................................................613 Step 4 – Records Processing .....................................................................................615 Step 5 – Processing Results ......................................................................................618 Clinical Documentation Detailed Description ............................................................619 Co‐Signature Report .................................................................................................620 24 Clinical Documentation User’s Guide Table of Contents Save, Preview, or Print the Co‐Signature Report ........................................................623 Co‐Signature – Assessments Preview ........................................................................623 Co‐Signature Tasks ...................................................................................................626 Managing Co‐Signature Tasks ...................................................................................626 Clinical Documentation User’s Guide 25 About This Guide Contents at a Glance In this guide, you’ll find information about patient clinical documentation windows and processes in Allscripts Homecare such as assessments, medications documentation, problem charting, patient tasks, clinical notes, adverse events, and more. Also, you will find information about generation of related clinical reports for individual patients, all patients in the agency or several selected patients. The information in this document is classified and divided into the following chapters: • • • • • • • • • • • • Chapter 1 ‐ Admissions and Discharges Chapter 2 ‐ General Clinical Information Chapter 3 ‐ Care Planning Chapter 4 ‐ Medications and MAR Chapter 5 ‐ Orders Chapter 6 ‐ Certification of Terminal Illness Chapter 7 ‐ Time Log Chapter 8 ‐ Field Mode Chapter 9 ‐ Assessments Chapter 10 ‐ Clinical Monitoring Chapter 11 ‐ Adverse Events Chapter 12 ‐ Co‐Signature Each chapter starts with the general description of its content and the list of sections that can be found inside the chapter. 26 Clinical Documentation User’s Guide Chapter 1 ‐ Admissions and Discharges In This Chapter This chapter provides information on admitting and discharging patients and the related activities. It includes the following sections: • • • • • • • Admissions and Discharges Workflows Patient Basic Pre‐Admissions Patients Admissions & Status Diagnosis Discharge Summary Report Patient Documents – Discharge Summary Clinical Documentation User’s Guide 27 Admissions and Discharges Workflows Admissions and Discharges Workflows Referral Workflow To enter a referral into Allscripts Homecare, follow this general sequence of steps. Note Note Additional information can be entered in Demographics, Diagnoses, Payers, and Patient Tasks in Patient>General. 1. Search for the patient across Business Units using Patient>File>Select Patient. If the patient does not exist in Allscripts Homecare, add using Patient>File>New Patient. If the patient is found in the current Business Unit, follow the steps for readmission. If the patient is found in a different Business Unit, follow the steps for sharing from the master patient list. See Select Patients Dialog. 2. Enter the referred patient information in Patient>General>Basic. See Patient Basic. 3. Enter the referral source and status date in Patient>General>Admissions & Status. See Admissions & Status. 4. Enter patient’s emergency contacts in Patient>General>Family & Friends. See Family & Friends. Admission Workflow To enter an admission into Allscripts Homecare, follow this general sequence of steps: 1. Enter the patient’s information in Patient>General>Basic. See Patient Basic. 2. Enter the patient’s demographic information in Patient>General>Demographics. See Demographics. 3. Enter the patient’s diagnoses in Patient>General>Diagnosis. See Diagnosis. 4. Enter the patient’s payers in Patient>General>Payers. See Payers. 28 Clinical Documentation User’s Guide Admissions and Discharges Workflows 5. Enter the patient’s admission information in Patient>General>Admissions & Status. See Admissions & Status. 6. (Optional) Enter any follow‐up items for the patient in Patient>General>Tasks. See Patient Tasks. 7. (Optional) Depending on your agency’s policies and procedures, enter any authorizations in Patient>General>Authorizations. See Authorizations. 8. Enter your patient’s additional contacts (primary caregiver, next of kin, etc.) in Patient>General>Family & Friends. See Family & Friends. 9. Enter any basic patient information in Patient>General>Notes. See Notes. 10. (Optional) If you know which resource(s) will be responsible for this patient, enter them in Patient>Clinical>Assignments. See Assignments. Discharge Workflow To discharge a patient in Allscripts Homecare, follow this general sequence of steps: 1. Enter the patient’s discharge information in Patient>General>Admissions & Status. See Admissions & Status. 2. Check for any outstanding patient tasks in Patient>General>Tasks. See Patient Tasks. 3. End all of the patient’s goals and interventions in Patient>Clinical>Problems. OR End all of the patient’s goals in Patient>Clinical>Outcomes. See Problems. Clinical Documentation User’s Guide 29 Admissions and Discharges Workflows Readmission Workflow When you readmit a patient, you add a new admission for the patient; do not alter information in an admission that already exists for a patient in Allscripts Homecare. To readmit a patient in Allscripts Homecare, you will follow this general sequence of steps: 1. Search for the patient using Patient>File>Select Patient. See Select Patients Dialog. 2. Enter or update the patient’s information in Patient>General>Basic. See Patient Basic. 3. Enter or update the patient’s demographic information in Patient>General>Demographics. See Demographics. 4. Enter or update the patient’s diagnoses in Patient>General>Diagnosis. See Diagnosis. 5. Enter or update the patient’s payers in Patient>General>Payers. See Payers. 6. Enter a new admission for the patient in Patient>General>Admissions & Status. See Admissions & Status. 7. Enter or update any basic patient information in Patient>General>Notes. See Notes. 30 Clinical Documentation User’s Guide Patient Basic Patient Basic What is Patient Basic Information? Patient Basic information is information about a patient such as name, Social Security number, date of birth, sex, marital status, address, and phone number. Information contained within this window, such as name, address and date of birth, will appear on documents such as patient orders and claims as well as many reports in the system. When a patient is added to Allscripts Homecare using the New Patient window, most of the information entered there automatically appears in the Patient Basic window. Therefore, when completing Patient Basic, you should verify the existing information before adding new information. Patient Basic Window Patient>General>Basic With the Patient Basic window, you can enter information about a patient such as name, sex, marital status, birthdate, address, phone, and e‐mail address. You can use the Master field to enter free text such as a hospital medical record number. You can also designate the patient as a VIP by checking the VIP box. If you are adding a new patient, the information added in the New Patient window will populate this window. Basic Window Clinical Documentation User’s Guide 31 Patient Basic Patient Basic Window Fields Last Enter the patient’s last name. First Enter the patient’s first name. Middle Enter the patient’s middle name. VIP Select the check box to designate this patient as a VIP. This designation may prevent some operators from viewing this patient’s information in the Patient and Schedule components of the application. SS# Enter the patient’s 9‐digit Social Security number. Sex Click and select the patient’s sex. DOB Enter the patient’s date of birth, or click and select it from the calendar. The patient’s age is automatically calculated and appears in red text next to this field. M/S Click and select the marital status of the patient. Master ID If your agency associates master ID numbers to patients, enter all or part of the patient’s master ID number here. 32 Clinical Documentation User’s Guide Patient Basic Account # Enter the patient’s account number here. Description Enter a description for this address, such as “Home,” or “Daughter’s house.” Address 1 Enter the street number and street name of this address. Address 2 Enter any additional address information, such as an apartment number. City Enter the city of this address. State Enter the two‐letter abbreviation for the state of this address, or click and select it. Zip Enter the zip code of this address. Directions Enter directions to this address. Phone Enter the patient’s phone number at this address. E‐mail Enter an e‐mail address for this patient. Active Select the check box if this is the current patient address. This address will appear on patient orders and claims. Clinical Documentation User’s Guide 33 Patient Basic One active address must be defined. Add New Click Add New to add a new address for this patient. Open an Existing Patient 1. Open the Patient component. 2. On the toolbar, click search window. to open an existing patient, then select the appropriate patient from the OR Click and select the patient from the list. This list includes the most recently‐accessed patients. 3. Click OK. Enter or Edit a Patient’s Basic Demographic Information Caution As with all edits, be sure you follow your agency’s policy. 1. Open the Patient component. 2. Select a patient. 3. Go to General>Basic. 4. Complete or edit the fields as appropriate. Note Help is available for each field within this window by pressing F1 while in the field. 5. Save your changes. Enter a Patient’s Address and Phone Number 1. Open the Patient component. 2. Click and select the appropriate patient. 3. Go to General>Basic. 34 Clinical Documentation User’s Guide Patient Basic 4. In the Addresses section, click the Add New... tab. 5. Complete the fields on the tab. Note Help is available for each field within this window by pressing F1 while in the field. 6. (Optional) Click the Add New... tab again to add more addresses for the patient. 7. Save your changes. Note Only one address can be active. Edit a Patient’s Address and Phone Number As with all edits, be sure you follow your agency’s policy. 1. Open the Patient component. 2. Click and select the appropriate patient. 3. Go to General>Basic. 4. In the Addresses section, click the tab for the address you want to edit. 5. Make the appropriate changes to the fields on the tab. 6. Save your changes. Make a Patient’s Address and Phone Number Active or Inactive Caution As with all edits, be sure you follow your agency’s policy. Note Note A patient can have only one active address at a time. By default, all address other than the active one are inactive. The active address appears on face sheets and claims. 1. Open the Patient component. 2. Select the appropriate patient. 3. Go to General>Basic. Clinical Documentation User’s Guide 35 Patient Basic 4. In the Addresses section, click tab for the address you want to edit. 5. To make an address active, check the Active box. OR To make an address inactive, uncheck the Active box. Note Note Help is available for each field within this window by pressing F1 while in the field. 6. (Optional) Click the Add New... tab again to add more addresses for the patient. 7. Save your changes. New Patient Window File>New Patient With the New Patient window, you can quickly add the information needed to register a patient in the application. The information entered in this window also appears in the Patient>General>Basic. New Patient Window New Patient Window Fields Patient Code Enter the code for the patient in this field. If it is already present, your agency uses autonumbering. Last Name Enter the patient’s last name in this field. 36 Clinical Documentation User’s Guide Patient Basic First Name Enter the patient’s first name in this field. Middle Name Enter the patient’s middle name in this field. Social Security Number Enter the patient’s Social Security number, excluding dashes. Allscripts recommends that you add the patient's SSN upon referral, if possible. Date of Birth Enter the patient's date of birth in this field, or click to select it. Sex Enter the patient's sex in this field, or click to select it. Marital Status Enter the patient's marital status in this field, or click to select it. Master Enter additional information about the patient in this field. You can use this field to indicate a medical record number for the patient, so you can include this number on the patient's claim or clinical order. Initial Status Date Enter the date of patient’s registration or click & Status window. Clinical Documentation User’s Guide to select it. This date appears in the Admissions 37 Patient Basic Add a New Patient 1. Open the Patient component. 2. Select New Patient from the File menu. OR Click on the toolbar. The New Patient window appears. 3. Complete the fields as appropriate. 4. Click OK. 38 Clinical Documentation User’s Guide Pre‐Admissions Patients Pre‐Admissions Patients Pre‐Admissions If pre‐admissions is activated in a Business Unit, a patient can be added with a pre‐admission date. This allows users to generate, print, and sign orders prior to the actual admission date. A pre‐admissions date is entered in the Anticipated Admission Date field on the Admissions & Status window. The date must be greater than or equal to the current date. You must also enter a prospective status as well as a primary physician, diagnosis, and specify a payer (these are required to generate orders, but not when initially entering the Admission screen date). When the patient is officially admitted, the system handles the admission date accordingly. If the anticipated admission date is equal to the admission date, then no user intervention is required. If the anticipated admission date is not equal to the admission date, Allscripts Homecare alerts the user that clinical items are adjusted. On the Adjust clinical items dialog box, you can then accept or reject the changes. Note Note If the Allow pre‐admission orders check box is not selected in Configuration>Business Units>Settings>Order Settings tab, you cannot use pre‐admissions in Allscripts Homecare. Pre‐Admit a Patient 1. Go to Patient>General>Admissions & Status. 2. Select the patient’s record, or create a new patient record. 3. Enter an anticipated admit date. 4. Complete the Status Date, Class, Acuity and Status fields. 5. Enter a diagnosis and physician (optional). 6. Complete any other pertinent information as needed. 7. Save all changes. Clinical Documentation User’s Guide 39 Pre‐Admissions Patients Pre‐Admissions Authorizations Authorizations are used as a means of pre‐approving payment for certain types of services in advance of providing service. When a patient is a pre‐admissions patient, you can enter authorizations for them. Prior to entering authorizations for a pre‐admissions patient, payer information must be stored for the patient in Allscripts Homecare. Note that all billing functionality is disabled until the patient is admitted. After the authorization is saved, scheduling visits for the patient decrements authorizations accordingly, by visits or hours. Enter Insurance Authorization Information for Pre‐Admissions Patient 1. Open the Patient component. 2. Select the appropriate patient. 3. Go to General>Authorizations. The Authorizations window appears. 4. Click the Add New tab. 5. Complete the fields in the window. Note Help is available for each field within this window by pressing F1 while in the field. 6. (Optional) Click the Add New tab again to add more authorizations for the patient. 7. Save your changes. View or Print Pre‐Admissions Orders Note Note This option is now available in Field Mode as well as Host Mode. 1. Open the Patient component. 2. Select the correct patient. 3. From the Patient menu, select Documents>View Orders. The View Orders window opens. 40 Clinical Documentation User’s Guide Pre‐Admissions Patients 4. Complete the fields on the Define tab as appropriate to include the orders you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected orders. OR Choose the Preview tab to preview the selected orders onscreen. Orders Management Window Orders>General>Orders Management Note Note This window is available only when Allow pre‐admission orders is checked in the Orders Settings tab of Administration>Configuration>Business Units>Settings. The Orders Management window allows you generate orders, review orders, and electronically sign them. You can view the order as you are signing it. After you click Generate to generate orders, they are available to review or sign. If there is more than one order on the screen, you can select the Use check box for the orders you want to sign, then click Sign. To view orders not generated and the reasons, run an Orders Alert report under Orders>Demand Documents. After an order is approved and signed in the field, if you edit the order, the signature is removed and the order is no longer in an approved, signed status. If a patient has orders added and synchronized to the host, you can no longer sign the order from the field device. You can only perform edits to them. You may want to hold the patient if additional changes may be forthcoming for the patient’s orders. Note that the Orders Management functionality is designed to be used in Field Mode, but is viewable (with buttons disabled) in Host Mode. Clinical Documentation User’s Guide 41 Pre‐Admissions Patients Orders Management Window Orders Management Window Fields Select Orders By Click Physician to select orders by physician. Click Patient to select orders by patient. For Enter the ID of the physician or patient whose orders you want to select, or click ... and select it. Received Enter the date the orders you want were received, or click and select it. Regenerate Click to regenerate the selected orders. View Sign Click to view signed orders. Print Sign Click to print signed orders. 42 Clinical Documentation User’s Guide Pre‐Admissions Patients Sign Click to sign the selected orders. Clear All Click to clear all selected items from the grid. Select All Click to select all items on the grid. Generate Pre‐Admissions Orders 1. Open the Orders component. 2. Select the correct patient or physician. 3. From the General menu, select Orders Management. The Orders Management window appears. 4. Select the Use check box for the orders you want to generate. 5. Click Generate to generate the selected orders. Sign Pre‐Admissions Orders Note Note An order must be generated before it can be signed. 1. Open the Orders component. 2. Select the correct patient or physician. 3. From the General menu, select Orders Management. The Orders Management window appears. 4. Select the Use check box for the order(s) you want to sign. . 5. Click Sign to sign the selected order(s). The Signature window appears. 6. Sign the order(s) with your stylus, then click OK. Clinical Documentation User’s Guide 43 Pre‐Admissions Patients Retrieve a Signature Once an order is signed, a user can retrieve it to view or print. 1. Open the Orders component. 2. Select the correct patient or physician. 3. From the General menu, select Orders Management. The Orders Management window appears. 4. Select the orders to view. 5. Click View Sign. An image of the signature on the order appears. Print a Signature 1. Open the Orders component. 2. Select the correct patient or physician. 3. From the General menu, select Orders Management. The Orders Management window appears. 4. Select the orders to view. 5. Click the Preview tab. 6. Click Print. 44 Clinical Documentation User’s Guide Pre‐Admissions Patients Admitting and Deactivating Pre‐Admissions Patients Pre‐admissions patients must either be admitted or deactivated within a certain time frame in Allscripts Homecare (determined by Business Unit settings). Admitting a pre‐admissions patient is a standard procedure on the Admissions & Status window. However, the admission date and the anticipated admission date determine how the orders and certification periods are handled when the patient is admitted. If the admission date equals the Anticipated Admission Date, and primary payer does not change, then all existing orders are retained. If the admission date does not equal the Anticipated Admission Date the following occurs: > Allscripts Homecare displays a warning message informing you about clinical items that are affected. > Clinical items are modified the appropriate number of days. You can accept or reject the changes. > Existing periods and orders are marked inactive, but are available for reprinting and reconciling through Post Signed Orders. > New periods and orders are generated. If a pre‐admissions patient needs to be deactivated, you can do so from the Admissions & Status window by applying a discharge status. > Certification periods and orders after the discharge date are marked inactive, but are available for reprinting. > Certification periods and orders before the discharge date are retained for historical purposes. Note Note Projected visits are systematically readjusted. If you want to change them, you must do so from the Projected Visits window manually. They will not appear on the Adjust Clinical Items window. Adjust Clinical Items Window This window also includes a Select All, Clear All, Yes, No, and Cancel buttons. > Show All – Select Show All to view all clinical items associated with this patient’s orders. > Show Items with Start Date equal to Anticipated Admit Date – Select Show Items with Start Date equal to Anticipated Admit Date if you want to view clinical items with a start date equal to the anticipated admission date. Clinical Documentation User’s Guide 45 Pre‐Admissions Patients Adjust Clinical Items Window Admit Pre‐Admissions Patient 1. Go to Allscripts Homecare>Patient. 2. Open the patient’s record. 3. On the Admissions & Status window enter a new status line with an admission status code. 4. Save all changes. Deactivate Pre‐Admissions Patient 1. Go to Allscripts Homecare>Patient. 2. Open the patient’s record. 3. On the Admissions & Status window enter a new status line with a discharge prospective status. 4. Save all changes. 46 Clinical Documentation User’s Guide Admissions & Status Admissions & Status About Patient Admissions and Status Patients retain the same patient codes regardless of the number of admissions and discharges they may have. The Admissions & Status window tracks admission and discharge time periods as well as status changes within them. With each new admission, you record physicians, referral source, and team for a patient. Admissions The admission of a patient denotes the agency’s acceptance to provide care for a patient. Admitted patients are considered as active patients in the system. A patient can either be referred first, then admitted or can be referred and admitted on the same day. When a patient is added to the application, a unique one‐time identification number, known as the Patient Code, is assigned to the patient. You do not have to complete this window for a referral; however, to fully admit a patient, you must indicate a primary physician, team, referral source, caregiver type, CBSA/MSA code (if your agency has more than one CBSA/MSA), class, primary diagnosis, acuity level, and status. Discharges The discharge of a patient denotes the termination of care for a patient. After patients are discharged, they are no longer considered as an active patients in the system for searching, reporting and billing purposes. A discharge can indicate that patient’s care is no longer necessary or that the patient has died. Re‐Admissions The re‐admission of a patient denotes a subsequent admission for a patient that was previously admitted and discharged. For each patient’s re‐admission, a separate tab will appear in the Admissions & Status window. If the Deceased patient status was used, the system prevents re‐ admission. Since it may be inappropriate for problems, goals, and interventions to be carried over from one admission to another, the application may prompt you to close all active problems, goals, and interventions when you re‐admit a patient. This function is based on the Readmit Action setting in Administration>Configuration>Business Units>Settings>Clinical Miscellaneous. Clinical Documentation User’s Guide 47 Admissions & Status If Readmit Action = 1 (Retain prior care plan for this admission), then the application continues saving the re‐admission with no additional action. If Readmit Action = 2 (Retain prior care plan for historical purpose only), then the application checks if any active problems exist as of the patient's last discharge date. If they do, then the following warning message appears: “Active problems from the prior admissions are detected. You should discontinue them before your re‐admit transaction may complete.” When you click OK, the application displays the standard Discontinue Problem window for each active problem so that you can end any open goals. If Readmit Action = 0 (no system standard ‐ specify action for each patient) and there are active problems as of the previous patient’s discharge date, then the Readmit Action window appears with the following options: > Retain prior care plan for this admission. > Retain prior care plan for historical purposes only. These options correspond to Readmit Actions 1 and 2. Depending on your choice, the application then follows the process outlined above for the appropriate readmit action. PPS Patients Information When you add a status line for an active PPS patient and select a valid HHRG acuity level as defined for PPS, you cannot save the new status line unless the PPS assessment information is entered. If you complete OASIS assessment collection in Allscripts Homecare, the status line is automatically updated with the correct information. If you enter OASIS assessments outside of Allscripts Homecare, you must enter the information before saving the status line. In addition to manually entering information, you can also select an existing OASIS assessment date performed for the episode and the data will populate the appropriate fields. Note: If the information is entered manually, the OASIS Matching Key must be entered in Claim Constants FL‐63. NPI Options for Admissions & Status With the NPI options on the Admission & Status window you can choose group or individual NPI (National Provider Identification) numbers for the physicians in each admission period. Note: Field Mode users can not edit NPI numbers on the Admissions and Status window. The drop‐down fields NPI#1, NPI#2, NPI#3, NPI CTI and NPI Ref are enabled for physician type resources and will populate with values from resource/roles when they are defined. If no NPI is 48 Clinical Documentation User’s Guide Admissions & Status defined for a resource, the field will be saved without an NPI value. If an NPI is defined, the system will save the NPI associated with the physician NPI in the Resource>General>Roles>Individual NPI field. If an Individual Physician NPI has not been defined for a resource, this field will remain blank. Users can select a group NPI value if one has been defined in Resource>General>Roles>Group NPI table. The NPI Ref control is enabled only when the referral source is a physician. The drop‐down fields contain Group NPI numbers with descriptions for the groups to which this physician belongs, as defined for all the roles of the physician. Also, they contain individual NPI numbers for all the roles of the physician (if any) with the description of Individual Physician NPI. Admissions & Status Window Patient>General>Admissions & Status The Admissions & Status window contains information about a patient’s admission and status. Using this window, you can admit a patient, indicate status change, change acuity level, and discharge a patient. The Admissions & Status window consists of the following tabs: > Admission: <Date> ‐ Displays information concerning the certain patient’s admission. > Add New ‐ Is used to create a new admission for the patient. This tab is displayed only if the last status line of the previous admission is closed. > Status ‐ Displays information on the patient’s status. > PPS Information ‐ Displays patient’s Prospective Payment System (PPS) information. The PPS Information tab is displayed in the Admission tabs that begins after 01‐01‐2008 (or other effective date as determined by CMS) if: • • > At least one status line has a patient class type 'H' or 'O'. At least one status line has PPS acuity. Encounter Information ‐ Displays the scheduled date and the date on which the clinical face‐to‐ face encounter actually took place. For details, see Encounter Information. The window also contains two sections: > Hospice Benefit ‐ Provides access to Hospice Benefit Information Window, where you can define the CTI chain for hospice patients and enter additional information for patients who have been active on the Hospice Benefit prior to their admission in Allscripts Homecare. Note: The Hospice Benefit section of the window only appears if the patient’s pay source mode is Benefit or Hybrid. > HPCANYS ‐ Displays the data which will be imported to the Hospice and Palliative Care Association of New York State (HPCANYS) Hospice Information and Reporting System (HIRS). Clinical Documentation User’s Guide 49 Admissions & Status Admissions & Status Window Admissions & Status Window Fields MD#1‐3 Select the physician that is associated with this patient. If the physician is not part of the list, add a new one by clicking . The system searches for all resources whose Resource Type has a special discipline code of Physician associated. Note: You should follow your agency’s process for adding physicians. The primary physician’s UPIN will appear on the claim form if defined in Administration>Financial>Insurance Codes>Print Variations. If you edit the MD#1 field to change the primary physician and have already posted orders for this physician as signed in Transactions>General>Post Signed Orders, recalculating orders certification periods in Administration>Maintenance>Recalculate Orders Cert Periods and selecting option #2 will cause the new orders to be re‐queued under the new primary physician’s name and will need to be posted and then reconciled as signed when returned. MD CTI Physician certifying terminal illness. This value is required only for Medicare Hospice patients and is reported on NOEs and claims: in FL78 and/or FL79 for UB‐04 form and in Loop 2310C for electronic claims. Also, CTI physicians are required for the Certification of Terminal Illness (see Certification of Terminal Illness Window (Orders)) This field is available only if the Can edit CTI physician privilege is granted. 50 Clinical Documentation User’s Guide Admissions & Status When you complete this field, the NPI CTI field becomes active and is automatically completed with the CTI physician’s individual NPI number. If there is no individual NPI assigned to the CTI physician, you can select group NPIs if any from the drop‐down list. The MD CTI value is printed in FL78 or FL79 of the UB‐04 form only if the Print CTI physician’s information with NPI print variation is selected in Administration>Financial>Insurance Codes under the Locator 78 or Locator 79 section. You can view CTI physician’s information on the Care Plan Report and Face Sheet Report. You can view Hospice claims that are missing CTI physician on the Claim Alerts report. Encounter Information Specify the date when the clinical face‐to‐face encounter is scheduled and when it actually took place. These dates are used in the Encounter Date Report for tracking what patients need face‐to‐ face meeting. According to regulations, encounters for Home Health patients must occur up to 90 days prior to initial start of care or within 30 days after the start of care. For Hospice patients, encounter is required no sooner than 30 days prior to the third benefit period and every subsequent recertification. SNF If this patient is currently in a skilled nursing facility, click and add a new facility for the patient. and select the facility, or click New Referral Identify the person or organization that referred your patient to the agency. You can select an existing or add a new referral source for a patient. When you select a resource with multiple roles, you need to select the necessary role in the Available Roles for Resource dialog. For each referral, the point of origin code is applied based on the settings defined for the selected resource in Resource>General>Roles or Administration>General>Resource Types. Information stored in Locator 15 of the UB‐04 billing form is obtained from the Referral field for claims that require point of origin reporting. Available Roles for Resource This dialog opens when the resource selected as a referral has more than one role. The dialog contains all resource’s roles and displays additional information, such as resource type, status date, point of origin code, active/inactive status, and credentials. The point of origin code displayed in this dialog is pulled from Resource>General>Roles or from Administration>General>Resource Types if not defined on the roles level. Clinical Documentation User’s Guide 51 Admissions & Status You should select the necessary role for the resource to save the referral information. For old data where point of origin is not defined neither on the roles nor on the resource type levels, ‘?’ is shown next to the referral resource name until the proper role is selected. View Referral Click the View Referral button to go to the selected patient details on the Referral Manager web page. You can use this link when the following conditions are met: a. The Referral Manager Interface is properly installed and licensed. b. Appropriate privileges are granted for the current operator. c. Patient was originally created from an Allscripts Referral Manager. Refer to the Operator's Supplement for the Allscripts Referral Manager Interface section of the HL7 Interface Configuration User’s Guide for more information. Admission Code Admission codes provide a way for patients to have an identification number for each admission. Admission codes are used in the charges export process only. To enter an admission code for this patient, enter a value in this field using up to 12 characters. NPI#1‐3 Associating a physician to a patient in the MD#1‐3 field(s), activates the NPI (National Provider Identification) field(s). The individual NPI number defaults from Resource>General>Roles. NPI CTI This field is available only if the MD CTI field is completed. When you complete the MD CTI field, the system searches for the individual NPI number of the CTI physician and automatically completes the NPI CTI field with it. If there is no individual NPI assigned to the CTI physician, you can select group NPIs if any from the drop‐down list. NPI numbers are assigned to physicians in Resource>General>Roles. The NPI CTI value is printed in FL78 or FL79 of the UB‐04 form and NOE only if the Print CTI physician’s information with NPI print variation is selected in Administration>Financial>Insurance Codes in the Locator 78 or Locator 79 section. The NPI CTI value is included in Loop 2310C of electronic claims. If the MD CTI field is completed and the NPI CTI field is blank (no NPI selected), the Claim Alerts report will display the corresponding alert. 52 Clinical Documentation User’s Guide Admissions & Status NPI Ref Identifying a referral physician in the Referral field, activates the NPI Ref field. Once the NPI Ref field is activated, enter the identified referral physicians NPI number. The Individual Physician NPI will default if it has been defined in Resource>General>Roles. Team To assign this patient to a team, click and select the team. Teams are defined in the Teams & Legal Entities tab of Administration>Configuration>Business Units. In addition, there is another setting in Administration>Configuration>Business Units>Settings>Administration>Use Teams. This setting identifies at which point (admission or referral) a patient must have a team associated. Teams are used in various reports as a mode (a method of sorting) of reporting. Caregiver To record the patient’s caregiver, click and select the caregiver type. Caregiver types are defined in Administration>General>Caregiver Types and may reflect the relationship of the caregiver to the patient and the ability for that person to assist the patient. Anticipated Admission Date Enter the date you anticipate this patient to be formally admitted. Once the patient status is updated from Referred to Admitted, this field is not be available. If the actual admission date does not match the date identified here, orders must be re‐signed by the physician. You must also enter a response in MD1, Patient Class, and Primary Diagnosis to generate orders for the patient. Note This field is only available if the Allow pre‐admission orders check box is selected in Business Unit>Settings>Orders. Orders Certification Override (For administrator use only) The Orders Certification Override is used to generate orders for this patient admission as of this date. This field is generally only used during patient migration from a legacy system to Allscripts Homecare. All new patients do not require data to be entered in this field in order to have patient orders generated. An example of using this field would be: Patient admitted January 2, 2001. You begin using Allscripts Homecare on June 1, 2005. The first certification after go‐live will be June 10, 2005. In Clinical Documentation User’s Guide 53 Admissions & Status the OCSTO field, you could enter 06/10/2005 and the system will begin generating orders as of 6/10/05 for that patient. To generate all certification periods for the patient, leave this field blank and move to the next field or button. To generate certification periods from a specified date and forward, enter the new start date, or click and select the date. The application recalculates orders for this patient based on this date and will update the Projected Visits window accordingly. You must have the appropriate privilege assigned in Administration>Configuration>Operators to use this option. Note Changing this date affects previously generated orders. You might need to run Recalculate Certification Periods to remove the orders generated prior to this date (Administration>Maintenance). Changing this date affects previously entered clinical data such as projected visits, medications, problems, clinical notes and assessments. You might need to change start dates to reflect the new certification periods. If you set the orders certification with a date after the patient’s initial admission date, all orders will be regenerated and orders with a start date prior to the new orders certification start date will be deleted and cannot be regenerated. Verbal Start of Care Date The Verbal Start of Care Date is defined for printing on the patient orders in box 23 of the 485 or by the signature line of the generic order. Physician Ordered SOC Date Enter the date of the Physician ordered SOC. For Home Health patients, the date will appear in the M0102 field for RFA 1. The field is not available for Business Units with the Hospice agency type. Physician Ordered ROC Date Enter the date of the Physician ordered ROC. For Home Health patients, the date will appear in the M0102 field for RFA 3. The field is not available for Business Units with the Hospice agency type. 54 Clinical Documentation User’s Guide Admissions & Status One‐Line Display Select this check box to display the status information on one line only. One‐line display may necessitate scrolling across the screen. However, a one‐line display is often easier to read than a wrapped line. The Associated Facility field is not available in one‐line display. Status Date Type the date of this admission or the status change, or click the drop‐down calendar. T = today’s date. to select it from PPS Episode Displays the PPS Episode number. The field will be shown only if Patient Class is ‘H’ or ‘O’ and Primary or Primary CSP payer is of ‘PPS’ type. An agency can obtain this information by checking the patient’s record in CMS’ Common Working File (CWF) through the Fiscal Intermediary’s HIQA System. Branch To assign this patient to a specific branch of your agency, click and select the branch. Branches are used to associate patients with various physical offices. Branches may be used in sorting reports. This field only appears if branches are defined and if the option Use Branches is selected in Administration>Configuration>Business Units>Settings>Administration. Branches are defined in Administration>Configuration>Business Units>Branches. CBSA/MSA (Core Based Statistical Area/Metropolitan Statistical Area) To assign this patient to a specific CBSA/MSA, click and select the CBSA/MSA. The CBSA/MSA code can be filled automatically when a new associated facility is entered if the new facility has a CBSA/MSA code assigned (through the facility zip code in Administration>Financial>CBSA/MSA Codes>Zip Codes). If the facility has more than one CBSA/ MSA code assigned, the user can select the necessary CBSA/MSA code. The CBSA/MSA Code may appear on claims if set to do so in Administration>Financial>Insurance Codes>Print Variations or Administration>Financial>Insurance Company>Plans>Print Variations. It is also used for PPS reimbursement calculations. Clinical Documentation User’s Guide 55 Admissions & Status Class To assign this patient to a specific patient class, click Administration>General>Patient Classes). and select the class (defined in Classes may be used as a method of tracking patients that are part of programs within your organization such as Maternal Child/Pediatric. Classes are used for sorting reports. Diagnosis To select the primary diagnosis for this patient, click and select the diagnosis. Only diagnoses already associated with this patient in the Diagnosis window are available. If you are using the Patient Diagnoses Groups functionality, this field is read only and is populated by the primary diagnosis in the group. Acuity This field displays the acuity level for the patient. This value can be editable or calculated automatically depending on the following: • Beginning from 01‐01‐2008 (or other effective date as determined by CMS) the acuity is the HIPPS code calculated from the OASIS. It is comprised of the new equation number used, the HHRG and the new NRS (Non‐Routine Supplies Severity). When user moves the pointer over acuity field the word balloon displays the components that make the individual PPS acuity. • For the episodes beginning before 01‐01‐2008 the drop‐down list contains the list of all acuities. To choose an acuity level for the patient, click and select it. For Hospice patients, this is the level of care that is used for billing. For Medicare PPS patients, the value in this field should match the HHRG code from the OASIS assessment. Acuity levels are defined in Administration>General>Patient Acuity Levels. Note If an OASIS assessment already exists before you add the corresponding admission status line, Allscripts Homecare completes the Acuity field at the time you add the new status line. The application uses the information contained in the assessment of the same date as the admission status line. For Medicare or Prospective Payment System (PPS) patients, select the acuity of the pending OASIS. The acuity will be updated with the correct HHRG code when the actual OASIS assessment is entered and saved. Fee for Service (FFS) payers do not need to have a hospice acuity or HHRG/HIPPS code associated. This is a required field, so your organization may consider defining a “not applicable” acuity. 56 Clinical Documentation User’s Guide Admissions & Status Status Select the status code to identify the patient’s stage in the admission and discharge process. Status codes are also used to indicate changes such as transfer to and return from facilities. The patient’s status code may determine what prints in Locator 20 of the UB92/UB04. Field Mode users can enter and change only status codes designated as Field mode use only (defined in Administration>General>Patient Status Codes). In Field Mode, the application does not perform the entry completion checks. If there is no appropriate field‐use status code, send a task to the appropriate Clinical Supervisor to resolve this issue. Status Description Displays the status description (the field is not editable). Status description is stored in Administration>General>Patient Status Codes. ID Displays the Associated Facility ID. The ID field is used when a status code requires to indicate what facility the patient is going to due to a transfer or discharge. To enter an associated facility for this patient, enter the facility ID, or click to select it. If the selected facility has CBSA/MSA code assigned (through the facility zip code in Administration>Financial>CBSA/MSA Codes>Zip Codes), the CBSA/MSA field populates automatically. If the facility has more than one CBSA/MSA code assigned, you will be able to select the appropriate one from the dialog. Note If the status code used for this admission or re‐admission line is set to ID Required, you must enter it in this field. This setting is defined in Administration>General>Patient Status Codes. If you enter OASIS assessments in Patient>Clinical>Assessments, this field populates automatically. The information in this field is the answer to M0090 of the OASIS assessment. If an OASIS assessment already exists before you add the corresponding admission status line, Allscripts Homecare completes the following PPS‐related fields at the time you add the new status line. The application uses the information from the assessment of the same date as the admission status line. Once these fields are completed, you cannot edit them. Associated Facility Displays the name of the associated facility. If more than one exists, then the resource type of the associated facility is provided in parentheses. This field in available only if the One‐line display check box is clear. Clinical Documentation User’s Guide 57 Admissions & Status Notes Enter a note about this admission or status change. These notes do not print on any standard reports or documents. HHRG Displays the HHRG patient’s code. For the status lines after 01.01.2008 and within episodes beginning after 01.01.2008 (or other effective date as determined by CMS) the HHRG field can be populated in the following ways: • Automatically, when an appropriate OASIS assessment is saved on original entry or update (when the user enters an OASIS in Allscripts Homecare and validates successfully at 100%, the system stores the HHRG in Admissions & Status>PPS Information tab). • User can enter or select HHRG from the drop‐down list. The all HHRG codes are displayed at PPS HHRG Case‐Mix table in Administration>Configuration>PPS. The HHRG field is disabled for the status lines before 01.01.2008 and for the status lines after 01.01.2008 but within episodes beginning prior to 01.01.2008 (or other effective date as determined by CMS). NRS Displays the patient’s NRS code. For the status lines after 01.01.2008 and within episodes beginning after 01.01.2008 (or other effective date as determined by CMS) reimbursement calculations for PPS include NRS (Non Routine Supplies Severity). NRS field can be populated in the following way: • Automatically, when an appropriate OASIS assessment is saved on original entry or update. (When the user enters an OASIS in Allscripts Homecare and validates successfully at 100%, the system shows this value in the NRS field in Admissions & Status>PPS Information tab). • User can select NRS from the drop‐down list. The NRS field is disabled for the status lines before 01‐01‐2008 and for the status lines after 01‐ 01‐2008 but within episodes beginning prior to 01/01/2008 (or other effective date as determined by CMS). HIPPS Displays the patient’s HIPPS code. For the status lines after 01‐01‐2008 and within episodes beginning after 01/01/2008 (or other effective date as determined by CMS) HIPPS code is shown in Admissions & Status> PPS Information. It is a read‐only field and is calculated from the HHRG, NRS, episode level, and 58 Clinical Documentation User’s Guide Admissions & Status therapy threshold for the appropriate OASIS assessment. The HIPPS matches value in the Acuity field on the Status tab. The HIPPS field is disabled for the status lines before 01‐01‐2008 and for the status lines after 01‐ 01‐2008 but within episodes beginning prior to 01/01/2008 (or other effective date as determined by CMS). PPS Date Enter or select the date of the PPS OASIS assessment. If you enter OASIS assessments in Patient>Clinical>Assessments, this field auto‐populates. The information in this field is the answer to M0090 of the OASIS assessment. This information pulls to box 63 of the UB92/UB04 on HH PPS RAP and final claims as well as to electronic claim files for Medicare PPS. RFA Specify the reason for the PPS OASIS assessment (RFA). Note: If you enter OASIS assessments in Patient>Clinical>Assessments, this field will be populated automatically. The information in this field is the answer to M0090 of the OASIS assessment. This information pulls to box 63 of the UB92/UB04 on HH PPS RAP and final claims as well as to electronic claim files for Medicare PPS. For the lines with dates on or after 01‐01‐2008 OASIS RFA‐ 05 will no longer be available for selection in the status line since the SCIC reimbursement has been removed from PPS. Validity Enter or select the appropriate validity of the PPS OASIS assessment. Note: If you enter OASIS assessments in Patient>Clinical>Assessments, this field will be populated automatically. The information in this field is the answer to M0090 of the OASIS assessment. This information pulls to box 63 of the UB92/UB04 on HH PPS RAP and final claims as well as to electronic claim files for Medicare PPS. Therapy Visits Displays the number of therapy visits. Clinical Documentation User’s Guide 59 Admissions & Status Assessment ID If there is a PPS OASIS assessment for this patient entered in Allscripts Homecare, click to select it. The information in the PPS OASIS Assessment Date, PPS OASIS Assessment Reason, and PPS OASIS Assessment Validity will auto‐populate once the assessment is selected. Known LUPA Select this check box if you anticipate a care plan of four or fewer visits for this patient. Doing so will identify a no‐RAP LUPA. By selecting this option, the system will not generate a RAP. It will only generate a final claim as of the first day of the new episode, date of death, or date of discharge, whichever event occurs first. If you do not wish to identify a no‐RAP LUPA scenario, leave this check box clear. SCIC Override This check box is used to identify patients that have had a SCIC, where for reasons identified by your organization, you wish to suppress the SCIC HIPPS code from appearing on your Final claim. Reasons may include an increase to the patient’s HIPPS code that, based on Medicare’s calculation rules, will result in a payment decrease. In that instance, your process may be to suppress the second HIPPS from billing. To apply a PPS SCIC Reimbursement Override to this admission, select this check box. If selected, this field will suppress the SCIC information (new HIPPS) from appearing on the final claim. This field may be used in conjunction with the Business Unit setting located in Administration>Configuration>Business Units>Settings>Financial>Automatic SCIC Reimbursement Override. Note This setting is not available for status lines dated 01.01.2008 and later since the SCIC reimbursement has been removed from PPS. Benefit Info If you need to specify the hospice benefit information for a patient who has been active on the Hospice Benefit at another agency or to define CTI chain generation, click Benefit Info. The Hospice Benefit Information Window opens. Discharge Date Specify the date the patient was discharged. 60 Clinical Documentation User’s Guide Admissions & Status The following fields appear only for New York Medicaid Hospice. To activate these fields, please contact Allscripts Homecare Client Support Services. HPCANYS Care Location To select the place where the patient is receiving care, click and select the HPCANYS Care Location. The information in this field is exported for HPCANYS. HPCANYS Referral Source The information in this field is required on admission and is exported for HPCANYS. Enter or select the provider or resource that referred the patient. HPCANYS Discharge Type The information in this field is exported for HPCANYS. It is required when there is a termination due to death or discharge. The application completes this field automatically when a patient is discharged with a “death” status. Enter or select the place to which the patient was discharged. HPCANYS Discharge Reason The information in this field is exported for HPCANYS. It is required when there is a termination due to death or discharge. The application completes this field automatically when a patient is discharged with a “death” status. Enter or select the reason why the patient was discharged. HPCANYS Admission Code The information in this field is exported for HPCANYS. It is required on admission. Enter or select the admission code. HPCANYS Ethnicity The information in this field is exported for HPCANYS. It is required on admission. Enter or select the ethnicity of the patient, such as 1 – Spanish/Hispanic origin, 2 – Not of Spanish/Hispanic origin, and 99 – Unknown. HPCANYS Race The information in this field is exported for HPCANYS. It is required on admission. Enter or select the race of the patient. Clinical Documentation User’s Guide 61 Admissions & Status Select Assessment Window Patient>General>Admissions & Status>Select Assessment This window opens if an OASIS assessment already exists for the patient. The Select Assessment window enables you to select the appropriate assessment from a list of assessments done for the selected patient. The window displays information about each assessment, such as the discipline it was completed by, date of assessment, reason for assessment, HHRG code, and who completed the assessment, that enables you to identify the assessment you need. When you select the assessment, the system populates a system‐generated code into the Admissions & Status window that is related to the assessment. Select Assessment Window Hospice Benefit Information Window Patient>General>Admissions & Status>Hospice Benefit Information With the Hospice Benefit Information window, you can define the CTI chain generation for hospice patients and enter information about patients who have been active on the hospice benefit prior to their admission in Allscripts Homecare (the previous admission may have been to another hospice or to your organization prior to implementation of Allscripts Homecare). In the Transfer In section, you can enter the date when the patient was first elected for the hospice benefit, the facility they are transferring from, which certification period they are in, and when that certification period began. In the CTI section, you can specify the CTI chain generation in Patient>Documents>Certification of Terminal Illness. For details, see CTI. 62 Clinical Documentation User’s Guide Admissions & Status This window is available only if the patient’s pay source mode is Benefit or Hybrid (defined in the Administration>Financial>Insurance Codes>General tab and for insurances other than Medicare Benefit, the hospice recertification periods should be defined on the Per Diem tab). When you admit such patient, the Hospice Benefit section appears at the bottom of the Admissions & Status window. Click Benefit Info to access the Hospice Benefit Information window. Hospice Benefit Information Window Hospice Benefit Information Window Fields First Election Date Specify the date when this patient was first elected for the hospice benefit. The first election date may be a date prior to the patient’s admission date. This date identifies the patient’s first admission into hospice. Transfer Facility Specify the facility from which the patient is transferring. Number Specify the number of the certification period for this election which will allow the system to calculate the appropriate number of days for the certification. For example, if a 3 is indicated here for a Medicare Benefit patient, the system calculates a 60‐day certification, if the certification periods are defined as 90, 90, and 60. Clinical Documentation User’s Guide 63 Admissions & Status Start Date Specify the start date for this certification period which will allow the system to calculate the end of the certification if the patient transferred in mid‐certification. CTI In this grid, you can define the start and end date for the CTI chains. Forms A and B are generated for 90 days, form C and all subsequent certifications—for 60 days. For example, if you want to generate CTI chain starting from the B form, add a row, select B ‐ Second 90 Days and specify its start date. The system will generate the B form for 90 days, then the C form for the next 60 days, and so on. If you need to generate a new chain, for example, due to payer change, enter the end date for the CTI form to stop the previous CTI chain and define a new one. Admitting Patients 1. Open the Patient component. 2. Before entering a new admission, check if the patient already exists in Allscripts Homecare: click to search for the patient using the last name. If the patient does not exist, click New to add the patient. 3. Complete the Basic, Demographics, Diagnosis, Payer, and Admissions & Status windows. There are other windows that can be entered for the patient, however the five stated above are required for a patient to be admitted to the application. In the Admissions & Status window, add a new row, and then select the appropriate admission code in the Status Code field. Note The status code your agency has set up for “admitted” patients may vary, and is set up in Administration>General>Patient Status Codes with a status code type of A or X. If you are admitting a patient on the same day the patient was referred, you must update the Status Code to the appropriate admission code. Your agency may wish to create an admit code called “Refer/Admit Same Day”, if you do not already have one defined. 4. If you are admitting a Hospice patient, there are additional fields that may be necessary in the Admissions & Status window, such as Benefit Info. 5. Click Save All. 64 Clinical Documentation User’s Guide Admissions & Status Discharging Patients 1. In the Patient component, select the patient you want to discharge. 2. In the Admissions & Status window, click Add Row, and then select the appropriate discharge status code. Note The status code set up by your agency for “discharged” patients in Administration>General>Patient Status Codes may vary. Discharge codes have a status code type of D or F. When you enter a new discharge line or change the date on an existing discharge line to an earlier date, Allscripts Homecare checks if there are scheduled visits or visits with patient signatures for the patient after the discharge date. If they exist, you will be warned that all scheduled visits from the next day after the date of termination will be deleted. You can click OK to delete the visits and continue, or Cancel to cancel the discharge. Next, the system checks for verified non‐bereavement billable visits or visits with clinical documentation after the discharge date. If there are any, the application will not allow you to save current discharge until you review and change the services to non‐billable or delete them. You will see a list of the services in question following the message. You must manually change or delete the services as appropriate before you can complete the discharge. 3. Save your changes. Entering Status Change Information for Patient 1. In the Patient component, select the needed patient. 2. Go to General>Admissions & Status. 3. Click Add Row. 4. Complete the fields in this grid. Caution The order of the lines in this grid is important. When generating claims, the most recent (the last line) is used as the current status line. 5. Save your changes. Clinical Documentation User’s Guide 65 Admissions & Status Editing Status Change Information for a Patient Caution As with all edits, be sure you follow your agency's policy. 1. In the Patient component, select the needed patient. 2. Go to General>Admissions & Status. 3. Make changes as appropriate to the fields in the upper part of the window. When you change the date on an existing admission line to a later one, the system checks for billable verified services prior to the new admission date. If so, the application displays a warning message. This same message appears when you change the active admission line to a prospective admission or when you delete an admission line. Following this message is a list of the services in question. You must manually change or delete the services as appropriate before you can complete the admission. When you edit a prior admission, the application checks for illogical status changes and overlapping admission periods and ensures that: • discharge dates from prior admissions are not equal to or greater than admission dates for subsequent admissions. • patient status on previous admissions cannot be changed to “death” status. • patient status on previous admission cannot be changed to “non‐death” status without first deleting current admission. • patient status records cannot be added and/or deleted on prior admission records. 4. Make changes as appropriate to the fields in the grid in the lower part of the window. Caution The order of the lines in this grid is important. When generating claims, Allscripts Homecare uses the most recent, or bottom line, as the current status line. 5. Save your changes. Entering Referrals for a Patient 1. In the Patient component, select the needed patient. 2. Select General>Admissions & Status. 3. Identify the person or organization that referred your patient to the agency in the Referral field. When you select a resource with multiple roles, you need to select the necessary role in the Available Roles for Resource dialog. 66 Clinical Documentation User’s Guide Admissions & Status For each referral, the point of origin code is applied based on the settings defined for the selected resource in Resource>General>Roles or Administration>General>Resource Types. 4. Save your changes. Entering Physicians for a Patient 1. In the Patient component, select the needed patient. 2. Select General>Admissions & Status. 3. Complete the MD#1 field in the upper part of the window. MD#2 and MD#3 are optional. 4. In the NPI#1 ‐ 3 field, enter the appropriate NPI number. Note Help is available for each field within this window by pressing F1 while in the field. 5. Complete the MD CTI field for hospice patients. 6. If you entered the CTI physician, complete the NPI CTI field. 7. Save your changes. Overriding Patient’s Orders Certification Start Date 1. In the Patient component, select the needed patient. 2. Go to General>Admissions & Status. 3. In the Orders Certification Start Date field, enter the appropriate date. Important: Entering a date in this field affects previously generated orders. You might need to run Recalculate Orders Certifications Periods to remove those orders (in Administration>Maintenance). If you run Recalculate Orders Certifications Periods, orders are recalculated based on the date entered in this field and the original certification period in the Projected Visits window is replaced with the new date. Note: Help is available for each field within this window by pressing F1 while in the field. 4. Save your changes. Clinical Documentation User’s Guide 67 Admissions & Status Readmit Action Window Patient>General>Admissions & Status>Readmit Action This window opens when the Business Unit you are using is set to use Readmit Action 0 that requires you to choose, on a patient‐by‐patient basis, which Readmit Action to take when re‐admitting a patient. This window does not include the End Date field. Instead, the application automatically enters the discharge date as the End Date. If you choose the Retain prior care plan for this admission option, no additional action is required. All problems that were not ended at the previous discharge of the patient will be active when the you go to the Problems and Problem Charting windows. Be sure to review each problem and add new/ changed goals and/or interventions when necessary. If you do not validate each problem, it will be hard to demonstrate that complete assessment of the patient’s treatment and service needs was accomplished on this admission. If you choose the Retain prior care plan for historical purposes only option, the application reviews the previous care plan for open problems. If there are any, you must end any goals that are not already closed. The application keeps the care plan as it was for the previous admission, with the Outcomes entered against the goals at the point of re‐admission. When Retain prior care plan for historical purposes only is chosen, the application will display an empty Problem window for the patient. Note Note A complete Discharge or Transfer Summary requires that you end each goal in order to display the outcome/disposition of that goal at the time of discharge/transfer. Readmit Action Window Fields Retain prior care plan for this admission Select Retain prior care plan for this admission if you want to retain the patient’s prior care plan for this admission. Retain prior care plan for historical purposes only Select Retain prior care plan for historical purposes only if you want to retain the patient’s prior care plan only for historical purposes. 68 Clinical Documentation User’s Guide Admissions & Status Readmitting a Patient 1. In the Patient component, select the needed patient. Note When readmitting a patient, the original patient code must be used. 2. Complete the Basic, Demographics, Diagnosis, Payer and Admissions & Status windows. There are four additional windows that can be entered for the patient, however the five stated above are required for a patient to be re‐admitted to the application. 3. Add a new row in the Admissions & Status window, and then select Re‐admitted for the Status Code field. The status code your agency has setup for “re‐admitted” patients may vary, and is setup in the Administration component. 4. Save all changes. Entering Visits Prior to Admission If you enter a visit for a patient prior to admission, and then change the admit date to be that of the visit date, the visit will still appear as a preadmission visit on the Productivity report until you run either Recalculate Service Amounts or Recalculate Staff Service. When you enter a service, its amounts are calculated based on the rate effective at the moment the service is entered. To ensure that the service picks up the correct rates when the service type changes (based on an admit date change, for example) and that the correct amounts are reflected on the Productivity report, you must run either Recalculate Service Amounts or Recalculate Staff Service to refresh patient status after changing the admit date (or termination date). Both of these functions now refresh the patient status as well as service amounts. When you change the date on an existing admission line to a later one, Allscripts Homecare checks to see if there are billable verified services prior to the new admission date. If so, the application displays the following warning message: “There are verified billable visits in the period the patient is inactive. The system will not allow you to save current admission until you review and change the services to non-billable or delete them.” This same message appears when you change the active admission line to a prospective admission or when you delete an admission line. Following this message is a list of the services in question. You must manually change or delete the services as appropriate before you can complete the admission. Clinical Documentation User’s Guide 69 Admissions & Status When you edit a prior admission, the application performs the following checks to prevent illogical status changes and overlapping admission periods: > > Ensures that patient status on previous admissions cannot be changed to the death status. > Ensures that patient status on previous admission cannot be changed to the non‐death status without first deleting current admission. > 70 Ensures that discharge dates from prior admissions are not equal to or greater than admission dates for subsequent admissions. Ensures that patient status records cannot be added or deleted on prior admission records. Clinical Documentation User’s Guide Diagnosis Diagnosis Diagnosis Window Patient>General>Diagnosis With the Diagnosis window, you can associate nonsurgical and surgical diagnoses with a patient. You can select diagnoses from a list of diagnoses in the application or you can add a new diagnosis. For each diagnosis, you can enter a start date and end date to indicate the period of time during which the diagnosis applies to the patient. You can also enter a special diagnosis indicator such as onset or exacerbation. You can select the patient diagnoses group date to view the patient diagnoses for the certain period. You can also create and edit patient diagnoses group dates using Patient Diagnoses Group Dates Window or view all patient diagnoses group dates using View Across Periods Window. If a patient has an expired diagnosis code assigned, the description of the invalid diagnosis includes “***” and the application displays a warning message. You must change the expired diagnosis code to a valid one. You do not have to complete this window for a referral; however, you must enter at least one diagnosis when completing the patient’s admission. Note Note When adding a new diagnosis not available in the system, follow your agency’s policy. Diagnosis Window Clinical Documentation User’s Guide 71 Diagnosis Diagnosis Window Fields Patient Diagnoses Group Dates Enter or click down arrow and select the necessary time period filter for diagnoses. and view only diagnoses active during the selected period in the grid below. Select All diagnoses to view all the diagnoses for the selected patient. Create/Edit Patient Diagnoses Group Dates Click this button to edit or create new patient diagnoses group dates. The Patient Diagnoses Group Dates Window appears. View All Patient Diagnoses Groups Click this button to view the diagnoses information across the periods. The View Across Periods Window appears. ICD9 Select the diagnosis ICD9 code. To search for a diagnosis, click . The Select Diagnosis window appears. To add a new diagnosis, click . The Add New Diagnosis window appears. Diagnosis codes are defined in Administration>Clinical>Diagnosis Codes. Note When adding a new diagnosis that is not in the application database, follow your agency’s policy. If the diagnosis code is invalid, the description includes “***” and the application displays a warning message. Change the diagnosis code to a valid one. Description Displays the diagnosis description. The field is not editable. The description depends on the diagnosis code selected in the ICD9 field. Diagnosis codes and descriptions are defined in Administration>Clinical>Diagnosis Codes. Special To enter a special diagnosis indicator click 72 and select the correct indicator. Clinical Documentation User’s Guide Diagnosis The option for Onset indicates that the date defined is the date when the patient was diagnosed. Exacerbation indicates a worsening of the diagnosis. Diagnosis codes associated with OASIS reference are not included in orders, claims, or assessments. Note Functionality associated with OASIS reference prevents the diagnosis from appearing in orders, claims, or assessments. Start Date Enter the date the diagnosis became effective for the patient. End Date Enter the date the diagnosis became ineffective if the diagnosis no longer applies to the patient. No Start Supp Select this check box not to produce supplemental orders for start diagnosis. This column is available if the For Start Diagnosis check box is selected for the appropriate Business Unit in the right section of the Settings window (Administration>Business Units>Basic>Settings>Orders Settings). The check box is active if the start date is entered for the selected diagnosis in the Start Date field. No End Supp Select this check box not to produce supplemental orders for end diagnosis. This column is available if the For End Diagnosis check box is selected for the appropriate Business Unit in the right section of the Settings window (Administration>Business Units>Basic>Settings>Orders Settings). This option is active if the end date is entered for the selected diagnosis in the End Date field. Sequence With the sequence columns, you can enter the ranking for the diagnosis. You can arrange all diagnoses inside the group if needed. Diagnosis with the sequence 1 is primary diagnosis. After changing primary diagnosis in a group, patient status records are updated automatically (primary diagnosis is updated). After changing start date of the group, the primary diagnosis may also change and it will be updated in the patient status record. This field is available only if one of the group dates is selected in the Patient Diagnoses Group Dates field. If you view all diagnoses, the Sequence field is not displayed. Clinical Documentation User’s Guide 73 Diagnosis M1024 (M0246) The M1024 (M0246) column is available for the diagnosis group with the patient class for which OASIS is used when entered in the ICD9 column. Diagnosis sequence range is 1 ‐ 6. By default, both M1024 (M0246) diagnosis 3 and 4 columns are inactive. For the V‐code diagnosis selected in the ICD9 column, the M1024 (M0246) diagnosis 3 column is active for PPS Case Mix diagnosis entry. After M1024 (M0246) diagnosis 3 selection, M1024 (M0246) diagnosis 4 column becomes active for PPS Case Mix diagnosis entry. The M1024 (M0246) diagnosis entry is not required. The M1024 (M0246) instructions from CMS are displayed as a hint to the M1024 (M0246) diagnosis columns. The description of PPS Case Mix diagnosis code is shown as a hint for the code entered in the M1024 (M0246) diagnosis 3 and 4 columns. Patient Diagnoses Group Dates Window Patient>General>Diagnosis>Patient Diagnoses Group Dates To open the Patient Diagnoses Group Dates window, click the Create/Edit Patient Diagnoses Group Dates button on the Diagnosis Window. Use the Patient Diagnoses Group Dates window to create or edit the existed patient diagnoses group dates. The groups are created according to the time periods. You can create diagnosis groups within the earliest date in the Start Date column and the latest date in the End Date column of the Diagnosis window. If you break these frameworks, the system makes the incorrect date in red. The groups created in this window can be selected from the drop‐down list of the Patient Diagnoses Group Dates field of the Diagnosis Window. 74 Clinical Documentation User’s Guide Diagnosis View Across Periods Window Patient>General>Diagnosis>View Across Periods To open this window, click the View All Patient Diagnoses Groups button on the Diagnosis Window. With the View Across Periods window, you can view all the group dates created for the selected patient and all the diagnoses in these groups. The diagnosis is included into the group if one of the following conditions is met: • The diagnosis was active before the group start date and became inactive within the group date range. • The diagnosis became active and was discontinued within the period date range. • The diagnosis became active within the period date range and remains active after group end date. • The diagnosis was active before the group start date and remains active after group end date. You can also print this information using the Print Friendly Version button. View Across Periods Window Clinical Documentation User’s Guide 75 Diagnosis Enter Diagnoses for a Patient Caution Making edits, be sure you follow your agency’s policy. 1. Open the Patient component. 2. Click and select the appropriate patient. 3. From the menu bar, select General>Diagnosis. The Diagnosis window appears. 4. Click in the Non Surgical Diagnoses section of the window to add a nonsurgical diagnosis. OR Click in the Surgical Diagnoses section of the window to add a surgical diagnosis. A new line appears in the panel you selected. 5. Complete the fields in the grid line. To add a new diagnosis, click in the ICD9 field of the grid line. The New Diagnosis window appears. You can add new diagnoses only if you have the appropriate permission. You can also add diagnoses using the Diagnosis Codes window (Administration>Clinical>Diagnosis Codes). Note Help is available for each field within this window by pressing F1 while in the field. 6. Save your changes. Find a Diagnosis 1. Open the Patient component. 2. Click and select the appropriate patient. 3. From the menu bar, select General>Diagnosis. The Diagnosis window appears. 4. In the ICD9 field, click . The Select Diagnosis window appears. 5. Complete the following fields if needed: • • ICD9 – Enter the ICD9 code of the diagnosis. • 76 Diagnosis – Enter the diagnosis name. Group Description – Enter the diagnosis group description. Clinical Documentation User’s Guide Diagnosis The more fields you fill, the more specific the search result willbe. 6. Click Search to start searching. The search results appear in the grid. 7. Find the appropriate diagnosis code, double‐click it or select it and click OK. The Patient Diagnosis window appears, with the diagnosis you selected. Discontinue Diagnoses for a Patient 1. Open the Patient component. 2. Click and select the appropriate patient. 3. Select General>Diagnosis. The Diagnosis window appears. 4. Select the diagnosis you want to discontinue. 5. In the End Date field, enter the discontinue date. Note Help is available for each field within this window by pressing F1 while in the field. 6. Save the changes. Create a Patient Diagnoses Group 1. Open the Patient component. 2. Click and select the appropriate patient. 3. From the menu bar, select General>Diagnosis. The Diagnosis window appears. 4. Click the Create/Edit Patient Diagnoses Dates button. The Patient Diagnoses Group Dates window appears. 5. Click to add a row in the bottom of the grid. 6. Enter the group start date in the From column and the group end date in the To column. 7. Click OK. The diagnosis group is now available in the Patient Diagnoses Group Date drop‐down list. 8. Save the changes. Clinical Documentation User’s Guide 77 Discharge Summary Report Discharge Summary Report Discharge Summary Report Generated The Discharge Summary report displays discharge summaries for the selected group of patients. Information on the Discharge Summary Report Field Name Patient Name First and last name of the patient entered in Patient>General>Basic. Patient Code Date of birth of the patient entered in Patient>General>Basic. Date of Birth Date the patient was born entered in Patient>General>Basic. Date Completed Date the patient was discharged. Team Team of the patient entered in Patient>General>Admissions&Status. Marital Status Marital Status of the patient entered in Patient>General>Basic. Age Age of the patient entered in Patient>General>Basic. Advanced Directives Advanced directives for the patient entered in Administration>Clinical>Advanced Directives. County Name of the county where the patient lives entered in Administration>General>Demographics. Ethnicity Ethnicity of the patient entered in Administration>General>Demographics. Living Status Living status of the patient entered in Administration>General>Demographics. Religion Religion of the patient entered in Administration>General>Demographics. Date of Referral Date when the patient was referred to last time entered in Patient>General>Admissions&Status. Date of Admission Date when the patient was admitted entered in Patient>General>Admissions&Status. Discharge Reason Reason why the patient was discharged entered in Patient>General>Admissions&Status. Mental Status at Discharge/Transfer Mental status of the patient at discharge or transfer entered in Patient>General>Admissions&Status. Final Date of Service 78 Description Final date the service for the patient was provided. Clinical Documentation User’s Guide Discharge Summary Report Field Name Description Services Provided Names of the services provided for the patient. No. Vis Number of visits for the patient. LOS Patient’s length of stay. Days/Hours Number of days or hours spent for the certain service. Goals/Expected Outcome Description and dates of the expected outcomes and potential results of treatment. The information is stored in Patient>Clinical>Problems. Outcome Outcome of treatment. The information is stored in Patient>Clinical>Problems. Ended Date of the goal termination. Example of the Discharge Summary Report Clinical Documentation User’s Guide 79 Discharge Summary Report Discharge Summary Report Window Reports>Clinical>Discharge Summary With the Discharged Summary window, you can preview and print discharge summaries for the selected patients. You can either choose the patients individually or include all patients who were discharged within the certain period of time. There are two tabs in this window: > Discharge Summary Report ‐ Define Tab > Preview tab Discharge Summary Report ‐ Define Tab Use the Define tab to choose the information you want to include in the report. You can also use the Preview Tab to view a sample report onscreen. Discharge Summary Report ‐ Define Tab 80 Clinical Documentation User’s Guide Discharge Summary Report Discharge Summary Report ‐ Define Tab Fields As of Date Enter the date to include all discharge summaries as of a certain date or click down arrow to select it from the drop‐down calendar. Sequence by Team Select this check box to sort the information on the report by patient team. Patients Click Patients to select the patients for the report manually. The Select Patient dialog appears. Summary Type Select one of the types of summary discharge you want to generate the report for. > > > > > Discipline Discharge ‐ Select this radio button to print the summary of patients who were discharged from a certain discipline. The Discipline field becomes active. Agency Discharge ‐ Select this radio button to print the summary of patients who were discharged from your agency. Discharge Due to Death ‐ Select this radio button to print the summary of patients who were discharged due to death. Transfer ‐ Select this radio button to print the summary of patients who were transferred from your agency. Class Discharge ‐ Select this radio button to print the summary of patients who were discharged from the certain class. Print Score and Overall Index Select this check box to print the Score and Overall Index in the report. Print Signature Select this check box to print patients’ signatures in the report. Clinical Documentation User’s Guide 81 Discharge Summary Report Discipline This field becomes active if the Discipline Discharge radio button is selected in the Summary Type field. > > > Include ‐ Displays the disciplines that will be included in the report. By default, all check boxes are clear, so you need to select the check boxes opposite the disciplines you want to be in the report. Code ‐ Displays the codes of the available disciplines. Description ‐ Displays the names of the available disciplines. Use the following buttons for managing the information: > > Click Select All to select all the check boxes in the Include column. Click Clear All to clear all the check boxes in the Include column. Generating Discharge Summary Report 1. Open the Reports component. 2. From the menu bar, select Clinical>Discharge Summary. 3. The Discharge Summary window appears with the Define tab active. Enter the values in the fields as appropriate. 4. Select the Preview tab to view the report onscreen. 5. Click Print to print the report. Note If you change the criteria on the Define tab after preview, those changes do not take effect the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 82 Clinical Documentation User’s Guide Patient Documents – Discharge Summary Patient Documents – Discharge Summary Discharge Summary Window Patient>Documents>Discharge Summary Using the Discharge Summary window, you can preview and print the care history for a patient's stay at your agency. The Discharge Summary includes the number of visits a patient received, variance information based on the patient's problems, and general admission/discharge information. Clinical notes might also appear on the Discharge Summary. Allscripts Homecare users with the appropriate privileges may define the final outcomes index, index code, description and index. Allscripts Homecare calculates the final outcomes based on the index. If enabled to do so, this value is included in the “Overall Achievement Index” on the patient’s Discharge Summary. You can also print discharge summaries for a selected group of patients through the Demand Documents option of the Orders component and in Reports>Clinical. You can view and print Discharge Summaries in Field Mode. If the selected RFA is 06 or 07, the header reads “Transfer Summary.” For all other RFAs, the header reads “Discharge Summary.” Discharge Summary Window Clinical Documentation User’s Guide 83 Patient Documents – Discharge Summary Discharge Summary Window Fields As of Date Enter a date to include all discharge summaries as of a certain date, or click and select it. You will probably enter today’s date in this field. For example, if you enter 01‐22‐2006, you will see all the patient’s discharge summaries on your laptop (that have not yet been automatically purged) dated on or before 01‐22‐2006. Because you are discharging the patient today, you want to include the discharge summary dated with today’s date. Summary Type Select whether the discharge summary type you want is a discipline discharge, agency discharge, discharge due to death, or transfer. Discipline Select the check boxes for the disciplines you want to include in the discharge summary. Print or Preview Discharge Summaries The Discharge Summary document in the Patient and Orders components allows you to preview/ print the discharge summary for a particular patient. 1. In the Patient component, go to Documents>Discharge Summary. 2. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 3. Click Print to print the discharge summary. OR Choose the Preview tab to preview the discharge summary onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Discharge summaries are also available in the Orders and Reports components. 84 Clinical Documentation User’s Guide Chapter 2 ‐ General Clinical Information In This Chapter This chapter provides guidelines on managing general clinical information for a patient. By reading it, you can learn about patient’s assignments, clinical notes, projected visits, and much more. It also contains information about generating various reports that let you view clinical information about patients. The chapter consists of the following sections: • • • • • • • • • • • • • • • • • • General Clinical Assignments Assignments Report Clinical Notes Patient Documents – Charts/Clinical Notes Projected Visits Projected Visits Report Visit Record Patient Documents – Visit Record 486 Info Face Sheet Report Patient Documents – Face Sheet Patient Labels Patient Education Report Patient Signature Document Patient Tasks Report On‐Call Summary Report PatientExpired ICD9 Report Clinical Documentation User’s Guide 85 General Clinical General Clinical General Clinical Window Patient>Clinical>General Clinical Within the General Clinical window, you can manage general clinical information for a patient within the admission. The General Clinical window appears blank for each new patient’s admission with tabs for all previous admissions with general clinical information. Most of the fields in this window (DME/ Supplies, Safety, Diet, and Allergies values) are defined in the Quick‐Entry Phrases window, and precaution protocol values are defined in Precaution Protocols window (Administration>Clinical). All the information you enter in General Clinical window appears on the 485/487 except advanced directives and precaution protocols information. The values of the Functional Limits, Activities Permitted, and Mental Status sections are hard‐coded within the application. Your agency defines Advance Directives values to be used for the entire organization. This information appears on the 485 for each admission as listed below: > DME/Supplies ‐ Box 14 > Safety ‐ Box 15 > Diet ‐ Box 16 > Allergies ‐ Box 17 > Functional Limits ‐ Box 18A > Mental Status ‐ Box 19 > Prognosis Codes ‐ Box 20 Advance directives appear on the patient's face sheet. Two fields in the window, Is Patient Homebound? and Rehabilitation Potential, capture information required for the D20 Texas Medicaid Home Health Services Plan of Care form. These fields are optional for all other users and the data in these fields currently do not transfer to the 485 document. 86 Clinical Documentation User’s Guide General Clinical General Clinical Window The General Clinical window contains the following controls: DME/Supplies Enter durable medical equipment and supplies for the patient or click on the left to select the needed predefined items from the dialog. If no information is entered on this tab, you can select the default system value by clicking the link at the bottom of the tab. Safety Enter safety issues or procedures for this patient or click on the left to select the needed predefined safety types from the dialog. If no information is entered on this tab, you can select default system value by clicking the link with the default value name at the bottom of the tab. Diet Enter special diet requirements or restrictions for this patient or click on the left to select the needed predefined diet types from the dialog. If no information is entered on this tab, you can select default system value by clicking the link with the default value name at the bottom of the tab. Clinical Documentation User’s Guide 87 General Clinical Allergies Enter allergies this patient has or click on the left to select the needed predefined allergy types from the dialog. If no information is entered on this tab, you can select default system value by clicking the link with the default allergy value at the bottom of the tab. Note All entered allergies in this field appear in the Medications window, that is why this field is required. Select Quick Entry Phrases To select the predefined values for the DME/Supplies, Safety, Diet, or Allergies tabs, click and select the values form the window that appears. This window has identical appearance for the DME/Supplies, Safety, Diet, and Allergies tabs except for the window title, which depends on the type of phrases you want to choose. Note The items available for selection in each window and their default values are defined in the Quick Entry Phrases window in the Administration>Clinical. Functional Limits If the patient has a functional limitation, select the corresponding check box next to the needed limitation type. If this patient has a functional limitation not listed in this section, enter the limitation in the Other (specify) field. Activities Permitted Specify what activities the patient is allowed to perform by selecting the corresponding check boxes in the list. If this patient is allowed to perform functions not listed in this section, enter this activity type in the Other (specify) field. Mental Status Select mental or emotional conditions of the patient by selecting the needed check boxes in the list. If a mental or emotional condition of this patient is not listed in this section, enter this activity type in the Other (specify) field. Advance Directives If the patient has any advance directives, choose the needed for of the advance directives by selecting the corresponding check boxes in the list. 88 Clinical Documentation User’s Guide General Clinical Precaution Protocols If the precaution protocols should be used for the patient contact (for example, hand washing protocol, respiratory protocol, etc) select the corresponding check boxes next to the needed items. Prognosis Select prognosis for the patient’s condition from the following values: Poor, Guarded, Fair, Good, and Excellent. Is Patient Homebound? Note This is a required field for users of the Texas Medicaid D20 HHS Plan of Care form. It is optional for all other users. Click > > > and select one of the following options: Yes – If the selected patient is homebound. No – If the selected patient is not homebound. N/A – If this question is not applicable to this patient. Rehabilitation Potential Note This is a required field for users of the Texas Medicaid D20 HHS Plan of Care form. It is optional for all other users. Click > > > > and select one of the following actions: Good – If the selected patient has good potential for rehabilitation. Fair – If the selected patient has fair potential for rehabilitation. Poor – If the selected patient has poor potential for rehabilitation. N/A – If this question is not applicable to this patient. Clinical Documentation User’s Guide 89 General Clinical Enter General Clinical Information for the 485/CPOC 1. Select the needed patient in the Patient component. 2. Go to Clinical>General Clinical. Note The General Clinical window is admission specific. A blank window appears for each new patient admission. You can click tabs to view general clinical information for the patient’s previous admissions. 3. Complete the DME/Supplies, Safety, Diet, and Allergies tabs as appropriate. For more information, see Enter or Edit DME/Supplies, Safety, Diet, and Allergies Information. 4. Complete the Functional Limits, Activities Permissions, Mental Status, Advance Directives, and Precaution Protocols tabs as appropriate. For more information, see Enter or Edit Functional Limits, Activities Permitted, Mental Status, Advance Directives, and Precaution Protocols. 5. Select the appropriate patient’s condition prognosis form the Prognosis drop‐down list. 6. Save your changes. Enter or Edit General Clinical Information for Orders Caution As with all edits, be sure to follow your agency’s policy. 1. Select the needed patient in the Patient component. 2. Go to Clinical>General Clinical. 3. Enter or Edit DME/Supplies, Safety, Diet, and Allergies Information as appropriate. 4. Enter or Edit Functional Limits, Activities Permitted, Mental Status, Advance Directives, and Precaution Protocols as appropriate. 5. Save your changes. 90 Clinical Documentation User’s Guide General Clinical Enter or Edit DME/Supplies, Safety, Diet, and Allergies Information Caution As with all edits, be sure to follow your agency’s policy. 1. Go to Patient>Clinical>General Clinical. 2. Enter or edit the free text information or click completing the following tabs: to select a preformatted phrases when • The DME/Supplies tab – Enter durable medical equipment and supplies. • The Safety tab – Enter safety issues or procedures. • The Diet tab – Enter special diet requirements or restrictions. • The Allergies tab – Enter allergies. All entered allergies appear in the Medications window. Caution The Allergies tab is mandatory to complete. You should select NKA (no known allergies) or NKDA (no known drug allergies) from the allergies list in the General Clinical window. 3. Save your changes. Enter or Edit Functional Limits, Activities Permitted, Mental Status, Advance Directives, and Precaution Protocols Caution As with all edits, be sure to follow your agency’s policy. 1. Go to Patient>Clinical>General Clinical. 2. Complete or edit information in the following tabs by choosing the needed options or enter other additional information in the Other section: • The Functional Limits tab – If the patient has a functional limitation. • The Activities Permitted tab – Specify what activities the patient is allowed to perform. • The Mental Status tab – Specify mental status type of the patient. • The Advance Directives tab – If the patient has any advance directives. • The Precaution Protocol tab – If the precaution protocols should be used for the patient contact. 3. Save your changes. Clinical Documentation User’s Guide 91 General Clinical Enter or Edit a Patient’s Prognosis Caution As with all edits, be sure to follow your agency’s policy. 1. Select the needed patient in the Patient component 2. Go to Clinical>General Clinical. 3. In the Prognosis field, click and select the appropriate prognosis. 4. Save your changes. Review General Clinical Information 1. Select the needed patient in the Patient component 2. Go to Clinical>General Clinical. 3. Verify the information in the tabs. Note Be sure to verify and update these fields on each recertification visit. Also, verify and update the Advance Directives tab if necessary, although advance directives do not appear on the 485/CPOC. 4. Save your changes. 92 Clinical Documentation User’s Guide Assignments Assignments Assignments Window Patient>Clinical>Assignments The Assignments window enables you to identify staff and businesses and agencies that are associated with a patient. Staff members associated are typically persons that will be visiting the patient. This information will appear on the patient's face sheet. Your application administrator defines assignment types in the Assignment Types window of the Administration component. If an assignment type allows multiple resources (for example, a patient may have multiple home health aides), the application enables you to select more than one resource for the assignment. There are three different methods for assigning patient information: > select a resource for the assignment type > match a resource for the assignment type > add a new resource for the assignment type It is not a system requirement to enter assignments in order to complete an admission or to create a clinical order. Follow your agency’s policies and procedures for when this window should be completed. You can select one of the resources assigned to a patient in this window to print on the HCFA 485/487 to satisfy regulatory and compliance requirements. The selected resource's electronic signature will print on all 485’s in box 23 and 487’s in box 11. If multiple pages are required for the 487, the signature will print on each page. The date the order was printed will print in box 23 for the 485 and box 1for the 487. You can also select one of the resources assigned to a patient in this window to print on generic orders to satisfy regulatory and compliance requirements. On generic orders (cert/recert or supplemental), the signature will print on the agency signature line. The date will print after the name and additional text. Clinical Documentation User’s Guide 93 Assignments Assignments Window Show All Types This field provides the ability to indicate that you wish to see all the various types of assignments regardless of whether an assignment is made. If this check box is not selected, the display will be only of those types that have an assignment defined. For example: if a case manager, nurse, and aide are associated with this patient when the check box is deselected, those are the only three fields displayed. Type The Type column displays the description of the organization or resource that is associated with the patient. The types are defined in Administration>Clinical>Assignment Types. ID Click ... to select a resource for this assignment type. OR Click Match to select a resource by matching required qualifications or skills. Qualifications are skill sets or other matching criteria defined for the purpose of association with resources. These options are defined for each resource in Resource>General>Qualifications. The Qualifications selection options are defined by your organization in Administration>General>Resource Qualifications. OR Click New to add a new resource for this assignment type. 94 Clinical Documentation User’s Guide Assignments Signature for Orders If you want to print this resource's electronic signature on the 485/487, select the check box. If not, do not check this box or uncheck it if it is already checked. You can select one of the resources assigned to a patient in this window to print on the HCFA 485/ 487 to satisfy regulatory and compliance requirements. The selected resource's electronic signature will print on all 485’s in box 23 and 487’s in box 11. If multiple pages are required for the 487, the signature will print on each page. The date the order was printed will print in box 23 for the 485 and box 1for the 487. You can also select one of the resources assigned to a patient in this window to print on generic orders to satisfy regulatory and compliance requirements. On generic orders (cert/recert or supplemental), the signature will print on the agency signature line. The date will print after the name and additional text. You can select only one resource for this option. When defining assignment types in Administration, it is possible to allow a type to have more than one resource assigned. For example, if more than one home health aide is visiting the patient you can add a new row on this screen and select Aide in the Type column, then associate the second home health aide. This is only possible if the type has “Allow Multiple” selected in the setup of the data definition file. Enter Patient Assignments 1. From the Patient component, select the appropriate patient. 2. Select Clinical>Assignments. The Assignments window appears. 3. In the ID field of the assignment type to which you want to assign a resource, click ... and select the appropriate resource. OR Click Match and select the qualifications you want the resource to have. OR Click Match to view the results of the match. Right‐click to select the resource. Note Note Click New to add a new resource for the assignment type if the resource is not present in the application. 4. Repeat the steps above for each assignment type for which you want to assign a resource. 5. Save your changes. Clinical Documentation User’s Guide 95 Assignments Edit Patient Assignments Caution As with all edits, be sure to follow your agency’s policy. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assignments. The Assignments window opens. 4. In the ID field of the assignment type to which you want to assign a resource, click ... and select the appropriate resource. OR Click Match and select the qualifications you want the resource to have. OR Click the Match button to view the results of the match. Right‐click to select the resource. Note Note Click New to add a new resource for the assignment type if the resource is not already present in the application. 5. Repeat the steps above for each assignment type for which you want to assign a resource. 6. Save your changes. 96 Clinical Documentation User’s Guide Assignments Report Assignments Report Assignments Report Window Reports>Clinical>Assignments Patient>Documents>Assignments The Assignments report window enables you to preview and print a listing of the patients assigned to your agency’s staff members and volunteers, including the names, patient codes, phone numbers, primary physicians, and assignment types for each patient the employee provides services to. The report can be run by patient or by staff member/volunteer. When running the report by staff member, you can choose to select specific staff members or volunteers to be included in the report, or you can run it by resource type. Note Note When you run the report from the Patient component, it will only display information on one currently selected patient. Options on the Define tab related to multiple patients reporting (like selecting patients, sequencing by team or branch, and so on) will not be available. Assignments Report Window Mode > > Click By Employee to run the Assignments report by staff member/volunteer. Click By Patient to run the report by patient. Clinical Documentation User’s Guide 97 Assignments Report Page Break Check this box to insert a page break between each employee, resource type, or patient in the report. Specific Staff/Volunteers/Resource Types If you want to include: > > Specific staff or volunteers, click Specific Staff/Volunteers. To group all resource's assignments for all resource types together under resource’s name, use the Specific Staff/ Volunteers option. Specific resource types, click Specific Resource Types. To list a resource's assignments separately by resource type, use the Specific Resource Types option. Generating Assignments Report 1. Open the Reports component. 2. Go to Clinical>Assignments. The Assignments window opens with the Define tab visible. 3. Select whether you want to run the report by employee or by patient. 4. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 5. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 6. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. 98 Clinical Documentation User’s Guide Clinical Notes Clinical Notes Clinical Notes Window Patient>Clinical>Clinical Notes With the Clinical Notes window, you can enter notes that appear on the specified documents such as Orders, Charting, Care Plans, On‐Call Summary, Intermediate Summary, Discharge Summary, HCFA‐ 486, and various reports or view all notes for a patient. You can also attach clinical notes to the service. Use codes define areas or documents on which clinical notes will appear. The default use codes are predefined on the Business Units level. For Hospice patients, to be able to enter clinical items relating to bereavement plans of care, the application generates an open‐ended certification period which begins on the day of death. All prior clinical items are terminated with the death. Only clinical items that are done on the day of death generate supplemental orders. Clinical Notes Window Clinical Documentation User’s Guide 99 Clinical Notes Clinical Notes Window Fields Show History Select this check box to view all clinical notes including active (without the defined end date or greater than the current date) and historical (with the end date entered). Show Prior Admissions Select this check box to view clinical notes entered during all patient’s admissions. When this check box is clear, you see the notes for the current admission. Show Detail Select this check box to view the detailed description of each clinical note. The description appears in the line below the note and shows brief clinical note summary. Clinical Notes Section Clinical notes for the selected patient appear in the top section of the Clinical Notes window which contains the following columns: Discipline, Use, Effective Date, End Date, and Clinical Notes. You can sort, group, or filter information in this grid to find the needed clinical note. To group data by any column, drag the needed column header to the free space above the grid. Click the needed column header to sort by that column data. To filter by specific data, click next to the Discipline or Use columns and select the criteria you want to filter by. You may filter by multiple columns at once by using the Custom Filter dialog. When data are filtered by any of the parameters, the down arrow becomes highlighted in blue ( arrow and select (All) from the drop‐down list. ). To clear all filters, click down Note Enter the clinical note text summary in this field. You can type your name at the end of the text to indicate the end of the note. Discipline Select the discipline for the clinical note. 100 Clinical Documentation User’s Guide Clinical Notes Use Code In the Use Code field, select the items on which this clinical note should appear in the Use Codes window. Use Code Purpose O ‐ Orders Patient’s orders (Patient>Documents>View Orders and the Orders component). C ‐ Charting Patient’s clinical charge and chart notes. P ‐ Care Plans Patient’s care plan (Patient>Documents>Care Plan). N ‐ Communication Communication between staff members and offices. M ‐ Memorandum for On‐Call Notes The On‐Call Summary report (Reports>Clinical). L ‐On‐Call Charting To document calls received from patients and families and the actions taken or not taken. These notes are printed as a part of the medical record and are available as a part of an admission. I ‐ Intermediate Summary (uncombinable) Used by various therapies on a monthly basis to document patient’s progress. It is often used with recertification in many skilled nursing cases. These notes go to the physician but not for signature, are printed as a part of the clinical record, and appear on 485 and 487 items. D ‐ Discharge Summary (uncombinable) The Discharge Summary document (Patient>Documents>Discharge Summary; Reports>Clinical>Discharge Summary; Orders>Demand Documents & Accumulated Documents>Discharge Summary). 6 ‐ HCFA‐486 For viewing purposes only in Patient>Clinical>486 info. S ‐ Physician Signed Orders To document changes made to the signed orders on Physician Portal. Notes that came from Physician Portal are noneditable and appear on the signed order. E ‐ HH Face‐to‐Face Encounter (uncombinable) To document clinical findings for initial certification orders (Home Health) after the face‐to‐face meeting. The date and type of the encounter are required. You can use the Print Corrected functionality to update the notes for the order. Note: Which encounters are used for initial orders depend on the setting on the Initial Cert Order Settings tab. Clinical Documentation User’s Guide 101 Clinical Notes Use Code Purpose H ‐ HO Face‐to‐Face Encounter (uncombinable) To document clinical findings for Certification of Terminal Illness (Hospice) after the face‐to‐face meeting. The date of the personal encounter is required. Physicians need to select whether they can or cannot recertify that the patient’s life expectancy is six months or less. Notes that came from Physician Portal are noneditable. B ‐ CTI Brief Narrative Statement (uncombinable) To document brief narrative statements for CTIs. CTI physicians can use these notes as a supplement to the HO encounter note (“H”) if it was written by a Nurse Practitioner. Notes that came from Physician Portal are noneditable. Start Physician Enter the physician ID who started the order for this clinical note or select the needed physician from the drop‐down list. This field is available only if Orders or Intermediate Summary is selected in the Use field. The supplemental order is generated for this physician. If clinical note is entered with a start date that is equal to the certification start date, this clinical note also appears on the certification order. Each alternative physician produces a supplemental order only with the items assigned to that physician. End Physician Specify the physician who ended the order for this clinical note. This field is available if Orders or Intermediate Summary is selected in the Use field, the end date for this clinical note is entered, and the 485 Item # is 10. The supplemental order will be generated for this physician. If clinical note is entered with a start date that is equal to the certification start date, this clinical note also appears on the certification order. Each alternative physician produces a supplemental order only with the items assigned to that physician. Effective Date Enter the date when this note should become effective. End Date If this clinical note is to become ineffective on a certain date, specify this date. 102 Clinical Documentation User’s Guide Clinical Notes Encounter Date Enter the date when the actual encounter took place. Encounter Type Select the type of the encounter: personal, telehealth, or non‐physician practitioner. Can/Cannot Recertify Select the corresponding radio button to state that you can or cannot recertify that the patient is still considered terminally ill with a life expectancy of six month or less if the terminal illness runs its normal course. This option is available only for the CTI physicians who document encounter notes or brief narrative statements as a supplement to the encounter notes. 485 Item Number Select the box in which the note should appear on the 485 from this drop‐down list. For example, if you are using Medi‐Span for medications, and the patient is taking a medication that is not in Medi‐Span, you can enter the medication in Clinical Notes, then specify here that it should appear in box 10 of the 485. Print on Cert/Recert Select this check box if you want to print clinical note on certification or re‐certification orders. Include Intermediate Summary to Cert/Recert Orders Select this check box if you want to include intermediate summary of this clinical note on certification or re‐certification orders. No Start Supplemental Order Select this check box to suppress generation of a supplemental order for the O type of clinical note. Generate End Order Select this check box to generate the end order. This field appears if the clinical note has the end date entered. Clinical Documentation User’s Guide 103 Clinical Notes Problem To associate the clinical note with a specific problem, select the problem from the drop‐down list which contains problems defined for this patient in Patient>Clinical>Problems. Connect Note to Visit or Staff By default, this field is set to No Visit or Staff assigned to this note or automatically populated with the operator’s name. If you want to associate clinical note with a specific patient visit, phone call, or the resource who provided the service, click Change and define the needed options in the Select Date Dialog. When you connect clinical note to a patient’s visit or resource, the appropriate information appears about the connected visit or resource who provided service. For the notes that came from Physician Portal, you can see who added these notes (this information is noneditable). Select Date Dialog With the Select Date dialog, you can link clinical item either to a service or to a resource. Select one of the following options: • Connect to Visit or Telephone Call – Select this radio button to attach the selected clinical item to a visit or telephone call in the Select Service window. Only visits and telephone calls listed in TimeLog as services for the selected patient appear in the Select Service window. • Select Associated Resource – Select the Provided By radio button to define resource who provided a visit that you want to associate with the selected clinical item. You can click the Select Myself icon ( ) to attach clinical item to yourself or search for another resource. If the selected resource has more than one associated role, you must also select the appropriate role for that resource. In the On field, enter the date of the service. 104 Clinical Documentation User’s Guide Clinical Notes Entering Clinical Notes for Patient Caution As with all edits, be sure to follow your agency’s policy. 1. In the Patient component, select the needed patient. 2. Go to Clinical>Clinical Notes. 3. To add a new note, click Add Row. To edit, make changes or additions to the notes as appropriate. 4. Select the clinical documents where the note should appear. 5. Complete the fields as appropriate. Note Help is available for all fields within this window by pressing F1 while in the field. 6. Enter the notes as appropriate. 7. Save your changes. Clinical Documentation User’s Guide 105 Charts/Clinical Notes Report Charts/Clinical Notes Report Charts/Clinical Notes Report Window Reports>Clinical>Charts/Clinical Notes The Charts/Clinical Notes window enables you to preview and print patient charts and clinical notes (progress notes) for a specified period of time. You can include discontinued clinical notes and start a new page for every clinical note. You can also include a particular discipline or all disciplines and print the reports in order by team. You can also print charts and clinical notes for individual patients through Patient>Documents and through the Orders component. Charts/Clinical Notes Report Window All or This Admission If you want to include: All clinical notes for previous and current admissions, click All. Only clinical notes for the current admission, click This Admission. Branch If you want to include only a specific branch in this Business Unit on this report, click select it 106 and Clinical Documentation User’s Guide Charts/Clinical Notes Report Discipline If you want to include only a specific discipline in this Business Unit on this report, click select it. and Team If you want to include only a specific team in this Business Unit on this report, click it. and select Use Type If you want to select specific use types to include on this report, click the ellipses and then in the box, check the use type or types to include. All/This Admission > > Select All to include all the clinical notes for the previous and current admission. Select This Admission to include only clinical notes for the current admission are included. (This is the default selection.) Preview or Print Charts/Clinical Notes 1. Open the Reports component. 2. Go to Clinical>Charts/Clinical Notes. The Charts/Clinical Notes window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 107 Patient Documents – Charts/Clinical Notes Patient Documents – Charts/Clinical Notes Charts/Clinical Notes Window Patient>Documents>Charts/Clinical Notes Using the Charts/Clinical Notes window, you can preview and print a patient’s charts and clinical notes (progress notes) for a specified period of time. You can include discontinued clinical notes and start a new page for every clinical note. You can also include a particular discipline or all disciplines. This information also appears on patient orders, care plans, on‐call summaries, discharge summaries, or appear in charting, as indicated when the note was added. You can also print charts and clinical notes for a selected group of patients in Orders>Demand Documents and in Reports>Clinical. You can view and print charts and clinical notes in Field Mode. Charts/Clinical Notes Window 108 Clinical Documentation User’s Guide Patient Documents – Charts/Clinical Notes Charts/Clinical Notes Window Fields Begin Date Specify the earliest date in the date range to include on the report all charts and clinical notes entered within a certain date range. End Date Specify the latest date in the date range to include on the report all charts and clinical notes entered within a certain date range. Only show notes for the current or most recent admission within the time period Select this check box to include only notes for this patient’s current or most recent admission within the selected date range. Include discontinued clinical notes Select this check box to include discontinued clinical notes on the report. Start new page for every clinical note Select this check box to start a new page for every clinical note. Discipline Select the discipline to include in the document. Use To include a grid item, select the check box beside the item you want. Select All Click to select all items in the grid to include. Clear All Click to deselect all items in the grid that are currently included. Clinical Documentation User’s Guide 109 Patient Documents – Charts/Clinical Notes Print or Preview Charts/Clinical Notes The Charts/Clinical Notes document in the Patient component allows you to preview/print the Charts/Clinical Notes for a particular patient. The Charts/Clinical Notes document in the Orders component allows you to preview/print the Charts/Clinical Notes for a group of patients or a particular patient as well as sequence the document(s) by teams. 1. Open the Patient component. 2. Select the correct patient. 3. Go to Patient>Documents>Charts/Clinical Notes. The Charts/Clinical Notes window appears. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Print or preview the selected charts/clinical notes. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Charts/clinical notes are also available in the Orders and Reports components. 110 Clinical Documentation User’s Guide Projected Visits Projected Visits Projected Visits Window Patient>Clinical>Projected Visits The Projected Visits window enables you to enter projected visits for each applicable discipline. Projected visits are used to show the anticipated visits by disciplines for both order generation and for scheduling. If a patient has more than one certification period, the application creates a separate tab labeled with the certification date for each period. The most current certification period appears first by default. The remaining periods appear in descending date order. For Hospice patients, it is necessary to be able to enter clinical items relating to bereavement plans of care after the discharge date (date of death). The application generates an open‐ended certification period for Hospice patients who die (based on patient class at the time of death). This certification period begins on the day of death. All prior clinical items are terminated with the death so only the new items that are needed for the bereavement care plan are generated. Only supplemental orders that are done on the day of death generate orders. In this window, you can distinguish between a regular visit made by a clinician to perform specific functions per a doctor's orders, and a PRN visit, made as needed. If a scheduled visit causes a variance, the Scheduling component displays a warning. Because a projected visit frequency often changes during an episode, requiring a clinician to enter a new projected visit schedule (and therefore to end all other projected visit schedules even if they are in the future), you can end a projected visit whose start date is in the future. You must enter projected visits in order for the patient to complete a certification period for the 485. When you enter a projected visit for a patient, the application generates a supplemental order. Scheduling notes you enter in the Projected Visits window appear in the Scheduling component. You can print projected visits on certification/re‐certification orders. If the order has already been generated for the certification period, this check box is not available and supplemental orders will be generated based on the appropriate settings in Administration>Configuration>Business Unit>Settings>Orders tab. Clinical Documentation User’s Guide 111 Projected Visits Projected Visits Window Discipline Enter the discipline you want to associate with this series of visits, or click to select it. Low Enter the fewest number of visits you expect to make in the time period you select, or click and select it. If you want to indicate a number of visits rather than a range of visits, delete the 0 from this field and do not enter anything else in the field. If you do not remove the 0, the projected visits will appear as a range (such as 0‐3) rather than just 3 visits. High Enter the number of visits you expect to make in the time period you select. If you are entering a range of visits, enter the highest number of visits you expect to make in the time period you select, or click and select it. Period Enter the time period during which you expect to make these projected visits, or click select it. and For example, if you expect to make these visits over a period of six weeks, enter W. Duration Enter the number of time periods during which you expect to make these projected visits, or click and select it. For example, if you expect to make these visits over a period of six weeks, enter 6. 112 Clinical Documentation User’s Guide Projected Visits Hours Low Enter the fewest number of hours you expect each visit to last. Hours High If you are entering a: > > Single amount of time, enter the number of hours you expect each visit to last, or click select it. (Depending on the Require Hours setting for your discipline (set up in Administration>General>Disciplines), you might be required to enter hours.) Range of time, enter the highest number of hours you expect each visit to last. and PRN If you want to enter a number of visits to make as needed, enter the number of visits, or click and select it. PRN Reason Enter the reason for the PRN visits, or click ... and enter the reason, up to 25 free‐text characters. Note If you enter a number greater than 0 in the PRN field, an entry in the PRN Reason field is required. Change Reason If you want to enter text that describes the reason a projected visit changed, click ... In the memo box, enter text. Cert/Recert If you want to print these projected visits on certification/re‐certification orders, select the check box. Otherwise, clear the check box or leave the box unchecked if it is not checked. Start Enter the date of the first of these projected visits, or click and select it. You must enter a start date. This date should be the same as the From date on the 485. Clinical Documentation User’s Guide 113 Projected Visits End If you want to enter the date of the last of these projected visits, enter the date, or click select it. and No Start Supp Select this box if you do not want the system to generate a supplemental order due to the visit frequency change. This option will suppress the generation of a start supplemental order. No End Supp Select this box if you do not want the system to generate a supplemental order due to the visit frequency change. This option will suppress the generation of an end order. Physician If you want to allow a verbal order to be sent to another physician for these visits, click select the physician. and Choose Select another physician if the physician you want is not listed. The Select Physician window appears. Physician Name Displays the name of the physician, selected in the Physician field. Scheduling Notes Enter the notes you want to attach to these projected visits. Enter Projected Visits for a Patient 1. In the Patient component, select a patient. 2. Select Clinical>Projected Visits. Note Help is available for all fields within this window by pressing F1 while in the field. 3. Verify you are on the correct certification period tab. If a patient is new, he probably has only one certification tab. Patients who have been in Allscripts Homecare longer or who have been discharged and readmitted may have more than one certification tab. 114 Clinical Documentation User’s Guide Projected Visits 4. Click Add Row to add projected visits. 5. In the Disc field, choose and select the appropriate discipline. 6. Complete the fields in the grid line as appropriate. 7. Save your changes. Edit Projected Visits for a Patient Caution As with all edits, be sure to follow your agency’s policy. 1. In the Patient component, select a patient. 2. Select Clinical>Projected Visits. Note Help is available for all fields within this window by pressing F1 while in the field. 3. Verify you are on the correct certification period tab. 4. Select the projected visits you want to edit. 5. Edit the fields in the grid line as appropriate. 6. Save your changes. View Certification Periods 1. In the Patient component, select a patient. 2. Select Clinical>Projected Visits. The Projected Visits window appears, with a separate tab for each certification period. Clinical Documentation User’s Guide 115 Projected Visits Report Projected Visits Report Projected Visits Report ‐ Generated The report consists of three parts: > Patient Over Projected Limits for Both (Projected vs. Actual + Scheduled) ‐ Shows the patients who have scheduled and actual visits greater then projected visits and hours. > Patient Under Projected Limits for Both (Projected vs. Actual + Scheduled) ‐ Shows the patients who have scheduled and actual visits less than projected visits and hours. > Patient Met Projected Limits for Both (Projected vs. Actual + Scheduled) ‐ Shows the patients who have scheduled and actual visits equal to projected visits and hours. Information on the Projected Visits Report Field name Description Patient Patient names, entered in Patient>General>Basic. Min Minimum number of visits available for the patient. It is entered in Patient>Clinical>Projected Visits and is the low end of the range entered. Max Maximum number of visits available for the patient. It is entered in Patient>Clinical>Projected Visits and is the high end of the range. Start Date Start date of the visits that are included into the date period that you entered on the Define tab. End Date End date of the visits that are included into the date period that you entered on the Define tab. Scheduled and Actual Number of scheduled and actual visits available for the patients. Total Scheduled Total Actual Total number of actual visits verified from the Schedule or Time Log. PRN Number of additional visits. The information is entered in Patient>Clinical>Projected Visits and a visit must be marked as a PRN visit in Schedule or Time Log to count in this column. Total Projected Total number of the projected visits available for the patients. Over 116 Number of scheduled unverified visits on the Schedule or Time Log. Number of scheduled and actual visits over the number of projected visits. Clinical Documentation User’s Guide Projected Visits Report Field name Description Under Number of scheduled and actual visits less than the number of projected visits. Example of the Projected Visits Report Clinical Documentation User’s Guide 117 Projected Visits Report 118 Clinical Documentation User’s Guide Projected Visits Report Clinical Documentation User’s Guide 119 Projected Visits Report Projected Visits Report Window Reports>Clinical>Projected Visits Report Use the Projected Visits Report to preview and print the quantity of visits projected for a patient versus the amount of visits scheduled, and the quantity of visits projected versus the actual visits performed. The report displays total number of PRN visits that were scheduled versus those actually performed, and the number of PRN visits that were scheduled over the projected visits limits versus those actually performed. The report also shows PRN, change reasons, and all the project visits if you select to include them on the report. There are two tabs on this window: > Projected Visits Report ‐ Define Tab > Preview tab Projected Visits Report ‐ Define Tab Use the Define tab to choose what information to include in the report. You can also use the Preview tab to view a sample report onscreen. Projected Visits Report ‐ Define Tab 120 Clinical Documentation User’s Guide Projected Visits Report Projected Visits Report ‐ Define Tab Fields Date Range Select the time period the report should be generated for. Use Begin Date and End Date fields for this purpose > > Begin Date ‐ Enter the date you want the application to use as the beginning date for this report or select a date from the drop‐down calendar. End Date ‐ Enter the date you want the application to use as the end date for this report or select a date from the drop‐down calendar. Selection Criteria Use this section to choose the group of patients, for which you want to generate the report. You can use the following options: > > > > Team ‐ To include only patients of the certain team, click down arrow and select the team from the drop‐down list. All Patients ‐ Select this radio button to run this report for all patients in the Business Unit. Specific Patients ‐ Click this button to run the report for the specific patients in the Business Unit. The Select Patient dialog appears. Medicare Patients Only ‐ Select this check box to run the report only for the medicare patients. Include In Report Select the check boxes in the Include in Report section to comprise the following options to the report: > > > Select the Include “In Process Visits” check box to consider all the unverified visits actual and include them into the report. If you select this check box, the Include In Process Visits section becomes available. Select the Show PRN Reason check box to include all the PRN visits to the report. Select the Show Change Reason check box to include all the change reasons to the report. Visit Range Option Select the visit options you want to use for the report. Choose from the following ones: > > Use Both Low and High Number of Visits to Determine Exceptions – Select this radio button to include both high and low numbers for projected visits in the report. Use High Number of Visits Only to Determine Exceptions – Select this radio button to include only high numbers for projected visits in the report. Clinical Documentation User’s Guide 121 Projected Visits Report Hour Range Option Select the hour range options you want to use for the report. Choose from the following ones: > > Use Both Low and High Number of Hours to Determine Exceptions – Select this radio button to include both the high and low numbers for projected hours in the report. Use High Number of Hours Only to Determine Exceptions – Select this radio button to include only high numbers for projected hours in the report. Note Hour Ranges are usually entered for Home Health Aides and must be entered into Patient>Clinical>Projected Visits>Hours>Low/High. Include Select the options you want to use to the report. Choose from the following ones: > > > > All Patients Over/Under/Met Projected Limits – To include all the patients over projected limits, under projected limits, and who met projected limits. The report lists patients over projected visits first, then patients under projected visits, and then patients who met projected visits limit. All Patients Over Projected Limits – To include all the patients who have scheduled and actual visits greater than projected visits and hours to appear in the report. Exception: the patients whose scheduled and actual visits are more than the high number of visits per period + PRN visits are not included. All Patients Under Projected Limits – To include all the patients who have scheduled and actual visits less than projected visits and hours to appear in the report. Exception: the patients whose scheduled and actual visits are less than the high number of hours per period + PRN visits are not included. All Patients Over/Under Projected Limits – To include all the patients who have scheduled and actual visits greater than projected visits and hours and the patients who have scheduled and actual visits less than the projected visits and hours to appear in the report. The report lists patients over projected visits first, and then patients under projected visits. Include In Process Visits Select the options you want to use for the report. Choose from the following ones: > > 122 Treat “In Process” Visits as Actual – Select this radio button if you want the system to treat the in process visits as actual visits. Treat “In Process” Visits as Scheduled – Select this radio button if you want the system to treat the in process visits as scheduled visits. Clinical Documentation User’s Guide Projected Visits Report Show Select the way you want to format the report. Choose from the following options: > > > Both (Projected vs. Actual + Scheduled) ‐ Select this radio button if you want to print projected visits opposite to actual visits and projected visits opposite to scheduled visits. Projected vs. Actual + Scheduled – Select this radio button if you want to print projected visits opposite to actual visits. Projected vs. Scheduled ‐ Select this radio button if you want to print projected visits opposite to scheduled visits. Clinical Documentation User’s Guide 123 Visit Record Visit Record Visit Record Window (Orders>Accumulated Documents) Orders>Accumulated Documents>Visit Record (in Host Mode only) Orders>Demand Documents>Visit Record (in Host Mode only) Patient>Documents>Visit Record (in Host and Field Modes) Using the Visit Record window, you can preview and print the detailed information about the visits performed for the selected patients. The Visit Record window consists of the Define tab (for more information, see Visit Record Report ‐ Define Tab) and the Preview tab. Use the Define tab to specify the information you want to include in the report. Use the Preview tab to view a sample report onscreen. Visit Record Report – Generated The Accumulated Visit Record (also called the Clinical Encounter Record) reflects most of the clinical evaluations performed during any individual visit. The report includes all visits that have been entered within the current Business Unit and not yet printed. To set up a Business Unit for accumulated printing, use the Accumulated Orders settings (Administration>Configuration>Business Units>Orders Settings). The Visit Record report includes patient basic information, diagnosis codes and descriptions, clinical observations, such as vital signs, problems, goals, interventions, clinical notes, and medications. The report also displays the clinician ID, name, discipline, date, time, and duration of the visit. Finally, the report lists all assessments performed during the visit. You can specify the date range or include all visit records that have not been printed. You can limit the Visit Record report to visits for a certain discipline, branch, team, for all, or for specific patients. You can include start dates for all goals and interventions on this document. In addition, you can underline all changes since a specified date. The Visit Record includes three sections for Vital Signs meaning that clinicians can take Vital Signs up to three times during a visit. After you print the report and confirm that it printed correctly, the application resets the print flag on the included visits. 124 Clinical Documentation User’s Guide Visit Record Information on the Visit Record Report Field Name Description Agency Name and address of an organization entered in Administration>Configuration>Organizations>Basic. Telephone Phone number of the organization. Patient First and last names of the patient. ID Code of the patient. The codes are assigned to patients in Patient>General>Basic. Team Team the patient belongs to. Teams are associated with the patient in Patient>General>Admissions & Status. Clinician First and last names of the clinician who provided a visit to the selected patient. Discipline Discipline of the patient’s clinician. Resource Type Resource type of the clinician. Visit Date Date when the visit was performed. Time In Time when the clinician started the patient’s visit. Time Out Time when the clinician finished the visit. Visit Code Code of the performed visit. Direct Time Time spent by the resource directly for providing service. Indirect Time Time spent by the resource for actions not directly connected with providing the service. Travel Time Time spent by the resource for traveling to the patient. Insurance Patient’s insurance code. Diagnosis Patient’s primary diagnosis entered in Patient>General>Diagnosis. Homebound Status Indicates whether the patient has the homebound status. VITAL SIGNS The list of vital signs that were changed or measured in the defined time period. The changes include patient’s clinical monitoring data such as vital signs, measurements, labs, spirometry, and scales. ASSESSMENT The list of patient’s assessments completed during the visit. Clinical Documentation User’s Guide 125 Visit Record Field Name CARE PLANNING The list of patient’s problems, goals, and interventions. The detailed description contains problem code, description, and reason. If the Show Start Days for Goals and Interventions check box is selected on the Define tab, the goals and interventions contain start dates before the codes and descriptions. DAILY PROGRESS NOTES The patient’s progress notes including the note, note date, and discipline of the resource who entered this note. MEDICATIONS Medications the patient was taking for the defined period. The information about the medications includes description, dose, frequency, and route of administration. Also, if the medication group was selected, the medication group details are displayed. Report Footer 126 Description Contains the number of the page, patent’s code, first and last name, admission date, visit date, and the name and discipline of the resource who provided a visit. Clinical Documentation User’s Guide Visit Record Example of the Visit Record Report Visit Record Report – Generated Clinical Documentation User’s Guide 127 Visit Record Visit Record Report ‐ Define Tab Use the Define tab to set the date range and specify other criteria for the report. Date Range > Begin Date – Enter the beginning date for the report. > End Date – Enter the last day to include information on the visits. By default, the date is set to the current (today). All Visit Records that have not been Printed Select to include in the report all visit records that have not been previously printed. Options > Show Start Dates for Goals and Interventions – Select to include the start date in the descriptions of all goals and interventions on the report. The start date appears in parentheses at the beginning of the description. If the start date is within the previous nine months, the year is omitted. > Highlight Changes Since – Select to highlight all changes since a certain date on this document, and then enter the necessary date. > Print Medications – Select to include detailed medication information for the selected patients in the report. Optional Selection Criteria > > 128 Discipline – Select to include information only from a certain discipline. Branch – Select to include only information from a certain branch. Clinical Documentation User’s Guide Visit Record > Team – Select to include only information from a certain team. > Resources – Select to include only information for a certain resource. > All Patients – Select to include visit record data for all patients. > Specific Patients – Select to include visit record data only for the selected patients. Generating Visit Record Report 1. Open the Visit Record report. You can open the Visit Record report from the following components: Orders>Accumulated Documents>Visit Record, Orders>Demand Documents>Visit Record, or Patient> Documents>Visit Record. 2. On the Define tab, select the date range and specify the optional selection criteria to filter the information which will be included in the report. 3. Click Preview to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 4. If needed, print or save the report in the necessary format using the Preview Toolbar. Clinical Documentation User’s Guide 129 Patient Documents – Visit Record Patient Documents – Visit Record Visit Record Window (Patient) Patient>Documents>Visit Record Using the Visit Record window, you can preview and print detailed information about the individual visits performed for the currently selected patient. For more information about generating the Visit Record reports, see Visit Record Window (Orders>Accumulated Documents) 130 Clinical Documentation User’s Guide 486 Info 486 Info 486 Info Window Patient>Clinical>486 Info The 486 Info window enables you to enter additional information for a patient. This information appears on the HCFA 486. You can enter an unlimited amount of free text in the Functional Limitation, Supplementary Plan of Treatment, Unusual Environment, Patient Not Home for Visit and Patient Regularly Leaves Home fields. 486 Info Window Last Physician Visit If you want to enter the date of the patient’s last visit to a physician, enter the date, or click and select it. Last Physician Contact If you want to enter the date of the patient’s last contact with a physician (such as a phone call), enter the date or click Clinical Documentation User’s Guide and select it. 131 486 Info Admission If you want to enter the date the patient was last admitted to a health care facility, enter the date or click and select it. Discharge If you want to enter the date the patient was last discharged from a health care facility, enter the date or click and select it. Type of Facility Enter the type of health care facility the patient was admitted to or discharged from, or click and select it. Limited Function If you want to enter any information relating to the patient’s limited function, enter the information. Supplementary Plan of Treatment If you want to enter any information about a supplementary treatment plan the patient has, enter the information. Unusual Environment If you want to enter any concerns about the patient’s living environment or other people in the patient’s household, enter the information. Patient Not Home for Visit If you want to enter any information about the patient’s failure to be home for scheduled visits, enter the information. Patient Regularly Leaves Home If you want to enter any information about how often and why the patient leaves home, enter the information. 132 Clinical Documentation User’s Guide 486 Info Enter 486 Information 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>486 Info. The 486 Info window appears. Note Help is available for all fields within this window by pressing F1 while in the field. 4. Complete the fields as appropriate. 5. Choose Save to save your changes. Edit 486 Information Caution As with all edits, be sure to follow your agency’s policy. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>486 Info. The 486 Info window appears. Note Help is available for all fields within this window by pressing F1 while in the field. 4. Edit the fields as appropriate. 5. Choose Save to save your changes. Clinical Documentation User’s Guide 133 Face Sheet Report Face Sheet Report Face Sheet Report Window Reports>Clinical>Face Sheet Using the Face Sheet report, you can preview and print face sheets for the selected patient or group of patients. You can include clinical notes, surgical codes, and all applicable ICD9/surgical codes on the face sheets. You can print face sheets for all patients added to the database after a certain date. If needed, you can print the face sheets in order by team and for a specific branch. The Face Sheet window consists of the Define tab (for more information, see Face Sheet Report ‐ Define Tab) and the Preview tab. Use the Define tab to specify the information you want to include in the report. Use the Preview tab to view a sample report onscreen. Face Sheet Report – Generated Information on the Face Sheet Report Field Name Code Code of the patient entered in Patient>General>Basic. Name Name of the patient entered in Patient>General>Basic. DOB Patient date of birth entered in Patient>General>Basic. Sex Sex of the patient entered in Patient>General>Basic. M/S Marital status of the patient entered in Patient>General>Basic. Address Address of the patient entered in Patient>General>Basic. Directions Information on how to get to the patient’s house entered in Patient>General>Basic. Latest Admit Date Latest admission date entered in Patient>General>Admissions & Status. SSN Social security number of the patient entered in Patient>General>Admissions & Status. Age Patient’s age entered in Patient>General>Admissions & Status. Date 134 Description Admission date entered in Patient>General>Admissions & Status. Clinical Documentation User’s Guide Face Sheet Report Field Name Description Class Patient’s class entered in Patient>General>Admissions & Status. Acuity Acuity option entered in Patient>General>Admissions & Status. Status Status option entered in Patient>General>Admissions & Status. Associated Facility Associated facility option entered in Patient>General>Admissions & Status. County Patient’s county entered in Patient>General>Demographics. Ethnicity Patient’s ethnicity entered in Patient>General>Demographics. Living Status Patient’s living status option entered in Patient>General>Demographics. Religion Patient’s religion entered in Patient>General>Demographics. ICD9 ICD9 code entered in Patient>General>Diagnosis. Diagnosis Diagnosis for the patient entered in Patient>General>Diagnosis. Special Special diagnosis options entered in Patient>General>Diagnosis. Start Diagnosis start date entered in Patient>General>Diagnosis. Surgical Diagnosis Surgical diagnosis for the patient entered in Patient>General>Diagnosis. Caregiver Caregiver types entered in Patient>General>Admissions & Status. SNF Skilled nursing facility entered in Patient>General>Admissions & Status. Ref References to hospitals entered in Patient>General>Admissions & Status. Team Patient’s team entered in Patient>General>Admissions & Status. W Phone number of the hospital entered in Patient>General>Admissions & Status. Directives Patient’s directives entered in Patient>Clinical>General Clinical. Allergies Patient’s allergies entered in Patient>Clinical>General Clinical. Safety Safety properties entered in Patient>Clinical>General Clinical. Clinical Documentation User’s Guide 135 Face Sheet Report Field Name Diet Patient’s diet information entered in Patient>Clinical>General Clinical. DME/Supplies Supplies for the patient entered in Patient>Clinical>General Clinical. Functional Limits Patient’s functional limits entered in Patient>Clinical>General Clinical. Activities Permitted Activities permitted to the patient entered in Patient>Clinical>General Clinical. Mental Status Patient’s mental status entered in Patient>Clinical>General Clinical. Prognosis Prognosis for the patient entered in Patient>Clinical>General Clinical. MD#1, MD#2, MD#3 Doctors’ names entered in Patient>General>Admissions & Status. MD CTI Physician certifying terminal illness entered in Patient>General>Admissions & Status. First and last names are reported. Addr Physician’s address entered in Resource>General>Address & Phones. W Physician’s work phone entered in Resource>General>Address & Phones. Family and Friends Information concerning the family and friends of the patient, their home and work phone numbers. It is entered in Patient>General>Family & Friends. Active Pay Sources Information on active pay sources entered in Patient>General>Payers. Code Code of the Pay Source entered in Patient>General>Payers. Source Name of the Pay Source name entered in Patient>General>Payers. Plan Information on insurance company plan entered in Patient>General>Payers. Insurance ID Insurance ID Code entered in Patient>General>Payers. Group Insurance group number entered in Patient>General>Payers. Rel Patient’s relationship to the ensured person. The information is stored in Patient>General>Payers. Other Insured 136 Description Other insured people. The information is stored in Patient>General>Payers. Clinical Documentation User’s Guide Face Sheet Report Field Name Description S Pay Source Status entered in Patient>General>Payers. F Billing Flags entered in Patient>General>Payers. Assignment Assignment properties for the patients entered in Patient>Clinical>Assignments. Name Resources responsible for the corresponding assignments. The information is entered in Patient>Clinical>Assignments. Home Phone Resource’s home phone entered in Patient>Clinical>Assignments. Work Phone Resource’s work phone entered in Patient>Clinical>Assignments. Example of the Face Sheet Report Clinical Documentation User’s Guide 137 Face Sheet Report Face Sheet Report ‐ Define Tab Use the Define tab to select what information to include in the report. You can specify report general options (see Options), sorting criteria (see Sort By), and print options (see Print Options). Options > > Sequence by Team – Select to print the report by team order. This option is not available if you print face sheet from Patient>Documents. > Include Notes – Select to include clinical notes in the report. > Print Surgical Codes – Select to include all surgical codes for a patient in the report. > Print All Applicable ICD9/Surgical Codes – Select to include all ICD9 and surgical codes in the face sheet. > Print Agency Name – Select to include the agency name in the report. > Show CTI Physician’s Information – Select to display CTI physician’s first name, last name, address, work and fax phone numbers in the report. MD CTI is entered in Patient>General>Admissions & Status. > Patients – Click the Patients button to choose the patients you want to run the report for. This option is not available if you print face sheet from Patient>Documents. > 138 As of Date – Specify the date to include only the patients added to the database after a certain date. Branch – Select the appropriate branch to generate the report for the patients in the specific branch. This option is not available if you print face sheet from Patient>Documents. Clinical Documentation User’s Guide Face Sheet Report Sort By > Patient Name – Select to sort the information by patient name. > Patient ID – Select to sort the information by patient ID. Print Options Use this section to set the rules according to which the report will be printed. With the Mask the Following Fields (Print as Asterisks) section, you can mask the information you are going to print. > Social Security Number – Select to mask the information about the social security number. > Insurance ID Number – Select to mask the information about the insurance ID number. Clinical Documentation User’s Guide 139 Patient Documents – Face Sheet Patient Documents – Face Sheet Face Sheet Window Patient>Documents>Face Sheet In the Face Sheet window, you can preview and print face sheets for a patient. Face sheets include basic patient information such as admit date, demographic selections, diagnoses, caregiver information, family and friend information, physicians, payers, and directions to the patient's home. You can choose whether to include clinical notes, surgical codes, and all applicable ICD9/surgical codes on the face sheets. You can choose to include on face sheets a section that includes the patients' surgical codes. This section directly follows the ICD9 section on the Diagnosis screen. You can also list all ICD9 and surgical codes associated with the patient. Friends and family who are denoted as “Emergency Contact” appear on the face sheet with “(EC)” after the contact name. Additional information from Patient>General>Clinical appears on the face sheet. This information includes DME/Supplies, Safety, Diet, Functional Limits, Activities Permitted, Mental Status, and Prognosis. The format is the same as the Directives information that currently appears. The patient address appears on a single line directly under the patient name and ID. The physician name, address, and phones appear on the face sheet. Active pay sources are identified as CSP, Co‐Insurance, and Eligible. You can view and print face sheets in Field Mode. You can also print face sheets for patients through Reports>Clinical>Face Sheet and Orders>Demand Documents>Face Sheet. For more information, refer to the Face Sheet Report. Printing or Previewing Face Sheets The Face Sheet document in the Patient component allows you to preview/print the face sheet for a particular patient. The Face Sheet document in the Orders component allows you to preview/print the face sheets for a group of patients or a particular patient. 1. Open the Patient component. 2. Select the correct patient. 3. Select Documents>Face Sheet. The Face Sheet window appears. 140 Clinical Documentation User’s Guide Patient Documents – Face Sheet 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected face sheet. OR Choose the Preview tab to preview the selected face sheet onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Face sheets are also available in the Orders and Reports components. Clinical Documentation User’s Guide 141 Patient Labels Patient Labels Patient Labels Window Patient>Documents>Patient Labels Using the Patient Labels window, you can preview and print labels for a patient. You can select the number of labels to print as well as the label format to use. You can also print labels for a selected group of patients in Orders>Demand Documents. You can view and print Patient Labels in Field Mode. Patient Labels Window Patient Labels Window Fields As of Date Specify the date to include on the report only patients that were added to the database after that date. Number of Labels Specify the number of labels you want to print. 142 Clinical Documentation User’s Guide Patient Labels Type of Label Select the type label you want to print for this patient. Print or Preview Patient Labels The Patient Labels document in the Patient component allows you to preview/print patient labels for a particular patient. The Patient Labels document in the Orders component allows you to preview/ print patient labels for a group of patients or a particular patient. 1. Open the Patient component. 2. Select the correct patient. 3. Go to Documents>Patient Labels. The Patient Labels window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected labels. OR Choose the Preview tab to preview the selected labels onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Patient labels are also available in the Orders component. Clinical Documentation User’s Guide 143 Patient Education Report Patient Education Report Patient Education Report Window Reports>Clinical>Patient Education The Patient Education Report enables you to preview and print patients' medication profiles (teaching sheets). If your agency has installed Medi‐Span, then the descriptions for each medication will come directly from Medi‐Span for medications contained in the Medi‐Span database. If your agency has chosen to manually enter additional medications in the Administration component, then the medication descriptions come from the manually‐entered information. Medi‐Span medications and non‐Medi‐ Span medications print in separate sections. You can choose to print selected patients or select specific drugs. You can also choose to include all, only Medi‐Span, or only non‐Medi‐Span medications on the report. Mode If you want to print medications for: > > 144 Selected Patients, click Select Patients, Print Current Meds. Selected Medications, click Select Drugs to Print. Clinical Documentation User’s Guide Patient Education Report Generating Patient Education Report 1. Open the Reports component. 2. Go to Clinical>Patient Education. The Patient Education window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 145 Patient Signature Document Patient Signature Document Patient Signature Document Window Patient>Documents>Patient Signature The Patient Signature window allows you, with the appropriate privileges assigned in Administration>Configuration>Operators>Privileges, to retrieve details associated with the collection of a patient signature, or the indication that the signature was not collected. Details compiled in the Patient Signature document include: > Date of service > Service code > Resource collecting the information > Resource ID > Actual patient signature, with the ability to compare the baseline signature to the actual signature. The Patient Signature document provides a summary level that provides a visual indicator that a signature was collected, with the ability to drill down to the actual signature when available. Note Note The Patient Signature document is available in Field Mode until the signature image has been synchronized to the host. Patient Signature Window 146 Clinical Documentation User’s Guide Patient Signature Document Patient Signature Window Fields This window also includes Begin Date and End Date fields. Signed Services Select this check box to generate a document that includes all signature activity for the selected patient within the specified date range. Baseline image Select this check box to include an image of the patient’s baseline signature associated to the visit date in the Patient Signature document. The signer can be the patient or the alternate as defined in Patient>General>Family & Friends. Signature image Select this check box to include an image of the signature captured at the time of the visit(s) within the specified date range. Unable to obtain signature Select this check box to include visits where the clinician was unable to obtain the selected patient’s signature in the document. Clinical Documentation User’s Guide 147 Patient Signature Document Generating Patient Signature Document 1. Open the Patient component. 2. Select the correct patient. 3. Go to Documents>Patient Signature. The Patient Signature window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click the Preview tab to preview the Patient Signature document onscreen. 6. Click to print the Patient Signature document. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. 148 Clinical Documentation User’s Guide Patient Tasks Report Patient Tasks Report Patient Tasks Report Window Patient>Documents>Patient Tasks Using the Patient Tasks report, you can preview and print a report of patients tasks for a selected patient for specified date range. You can print all tasks, incomplete tasks, incomplete tasks that are overdue, complete tasked, or cancelled tasks. You also have the option to only show tasks assigned since the last time they were printed. You can print a report of patient tasks by patients, resources, or branches from Reports>General>Tasks Report. Patient Tasks Window Patient Tasks Window Fields Begin Date Specify the first date in the range for which you want to report. The report includes all tasks associated with the mode defined within the date range. Clinical Documentation User’s Guide 149 Patient Tasks Report End Date Specify the last date in the range for which you want to report. The report includes all tasks associated with the mode defined within the date range. Only Show Tasks assigned to me since last print Select this check box to include only those tasks assigned since the last time they wereprinted. Sort by Task Category Select this check box to sort the Patient Tasks report by task category. Categories are defined in Administration>General>Patient Task Categories. Optional Selection Criteria Select one of the following criteria: • All Tasks – To include all tasks. • Only Show Incomplete Tasks – To include only incomplete tasks (tasks without an end date). • Only Show Incomplete Tasks that are overdue – To include only overdue, incomplete tasks based on a due date in the past and that do not have an end date. • Only Show Complete Tasks – To include only complete tasks (tasks that have an end date associated). • Only Show Cancelled Tasks – To include only cancelled tasks (tasks that have a category of status). Checked Select this check box to include this task category in the Patient Tasks report. 150 Clinical Documentation User’s Guide Patient Tasks Report Generating Patient Tasks Report The Patient Tasks report in the Patient component allows you to preview/print patient tasks for a particular patient. The Patient Tasks report in the Reports component allows you previewing/ printing patient tasks for a group of patients, resources, or branches. 1. Open the Patient component. 2. Select the correct patient. 3. Go to Documents>Patient Tasks. The Patient Tasks window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected tasks. OR Choose the Preview tab to preview the selected tasks onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must close the preview window using the Close button prior to the new criteria being available. Clinical Documentation User’s Guide 151 On‐Call Summary Report On‐Call Summary Report On‐Call Summary Report Window Reports>Clinical>On‐Call Summary The On‐Call Summary report enables you to preview and print a patient’s summary of information that is found in the Patient component. You can choose to print one or two patients per page, and also whether to sort patient code or name. Patient Select Click Select. The Select Patients window appears. Patient Per Page If you want to print: > > One patient per page, click One. Two patients per page, click Two. Patient Sort By Select the corresponding radio button to sort patients by code or name. 152 Clinical Documentation User’s Guide On‐Call Summary Report Generating On‐Call Summary Report 1. Open the Reports component. 2. Go to Clinical>On‐Call Summary. The On‐Call Summary window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 153 Patient Expired ICD9 Report Patient Expired ICD9 Report Patient Expired ICD9 Report Window Reports>Clinical>Patient Expired ICD9 The Patient Expired ICD9 report enables you to see which patients have invalidated ICD9 codes associated with them, so that you can change the invalid codes to the correct codes. The report includes patient name and ID, current status, the invalid diagnosis code and the code's description. You can choose to include all patients or only active patients on the report. The Patient Expired ICD9 report is sorted by diagnosis code, then by patient name. You must print a separate report for each Business Unit. Use the Define tab to choose what information to include on the report. Use the Preview tab to view a sample report on the screen. Patient Expired ICD9 Report All/Active If you want to include: > > 154 All patients in the current Business Unit, click All. Only active patients in the current Business Unit, click Active. Clinical Documentation User’s Guide Patient Expired ICD9 Report Generating Patient Expired ICD9 Report 1. Open the Reports component. 2. Go to Clinical>Patient Expired ICD9. The Patient Expired ICD9 window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 155 Chapter 3 ‐ Care Planning In This Chapter In this chapter, you can find information about clinical problems associated with a patient that require intervention by a health care provider. It includes guidelines on how to identify problems, assign them to patients, enter goals and interventions for problems, chart the progress of problem solutions, generate reports, and much more. This chapter includes the following sections: • • • • • • • • • 156 Care Plan Report Patient Documents – Care Plan Problems Problem Charting Charting History Charting History Report Patient Documents – Charting History Active Patients by Problems Report Active Problems by Discipline Report Clinical Documentation User’s Guide Care Plan Report Care Plan Report Care Plan Report – Generated Reports>Clinical>Care Plan Patient>Documents>Care Plan Orders>Demand Documents>Care Plan With the Care Plan report, you can preview and print team care plans for an individual patient or several selected patients as of a certain date. You can include a particular discipline or all disciplines to the generated report. Start dates for all goals and interventions can be added to this document. You can set up the system to print each new problem on a separate page and sequence the report by teams. Also, the ability to view adverse events information on the care plan document is present. You can see the latest patient’s falls, infections, and medication evaluation data if needed. If necessary, you can include treatment history on care plans, and you need to specify how far back the history should go. In addition, you can see all changes since a specified date underlined on the printed documents. All these parameters can be available if you make appropriate selection on the Define tab. You can also view and print care plans from Field Mode. Information On The Care Plan Report Field Description Agency Information Agency This field displays the name and address of the agency. This information is stored in Administration>Configuration>Business Units. Telephone This field displays telephone of the agency. This information is stored in Administration>Configuration>Business Units. General Patient’s Information Patient This field displays the patient’s ID, name and address. This information is stored in Patient>General>Basic. Team This field displays the team the patient belongs to. This information is stored in Patient>General>Admissions & Status. Clinical Documentation User’s Guide 157 Care Plan Report Field Description Admit This field displays the date of patient’s admission. This information is stored in Patient>General>Admissions & Status. Telephone This field displays the patient’s telephone number. This information is stored in Patient>General>Basic. Insurance This field displays the name of insurance payer. This information is stored in Patient>General>Payer. Insurance Date This field displays the insurance warranty period start date. The second date represents the admission close date if during the insurance warranty period some admissions were closed. Sex This field displays the patient’s sex. This information is stored in Patient>General>Basic. DOB This field displays the patient’s date of birth. This information is stored in Patient>General>Basic. Age This field displays the patient’s age. This information is stored in Patient>General>Basic. Caregiver This field specifies the patient’s caregiver. This information is stored in Patient>General>Admissions & Status. General Clinical Information Directives DME/Supplies This field displays the supply items for the patient. This information is stored in Patient>Clinical>General Clinical. Safety Measures This field displays the patient’s safety precautions. This information is stored in Patient>Clinical>General Clinical. Nutrition This field displays the patient’s nutrition requirements. This information is stored in Patient>Clinical>General Clinical. Allergies This field displays the patient's recorded allergies. This information is stored in Patient>Clinical>General Clinical. Functional Limitation This section displays the patient’s functional limitations. This information is stored in Patient>Clinical>General Clinical. Activities Permitted This field displays the activities permitted for the patient. This information is stored in Patient>Clinical>General Clinical. Mental Status This field displays the patient’s mental or emotional condition. This information is stored in Patient>Clinical>General Clinical. Other 158 This section displays advanced directives concerning the patient. This information is stored in Patient>Clinical>General Clinical. This field displays the additional patient’s information which is not specified by any of the determined fields. This information is stored in Patient>Clinical>General Clinical. Clinical Documentation User’s Guide Care Plan Report Field Description Prognosis This field displays the patient’s prognosis. This information is stored in Patient>Clinical>General Clinical. Diagnosis Information ICD9 This field displays the ICD9 code. This information is stored in Patient>General>Diagnosis. Diagnosis This field displays the diagnosis description. This information is stored in Patient>General>Diagnosis. Special This field displays the special diagnosis indicators. This information is stored in Patient>General>Diagnosis. Start Date This field displays the date this diagnosis became effective for the patient. If the date is followed by the word (Primary), it indicates the patient’s primary diagnosis. This information is stored in Patient>General>Diagnosis. Doctors Information MD#1, MD#2, etc. This field displays the patient’s doctor title and name. This information is stored in Patient>General>Admissions & Status. MD CTI Displays first and last name of the physician certifying terminal illness. The MD CTI is entered in Patient>General>Admissions & Status. Work This field displays the patient’s doctor telephone number. This information is stored in Patient>General>Admissions & Status. Fax This field displays the patient’s doctor fax number. This information is stored in Patient>General>Admissions & Status. Problems, Goals, and Interventions Information Problem This field displays the code and the title of the patient’s problem. This information is stored in Patient>Clinical>Problems. Goals/Expected Outcomes + Potential This field displays the description and dates of expected outcomes and potential results of the treatment. This information is stored in Patient>Clinical>Problems. Interventions This field displays all interventions associated with the selected goal and problem. This information is stored in Patient>Clinical>Problems. Narrative This field displays additional information concerning the appropriate problem. This information is stored in Patient>Clinical>Problems. Clinical Documentation User’s Guide 159 Care Plan Report Field Description Projected Visits Information Projected Visits This section enables you to view projected visits for certain certification period and for each applicable discipline. The discipline can be selected in the Discipline field of the Define tab. This information is stored in Patient>Clinical>Projected Visits. For certification date beginning This field displays the certification period beginning date. This information is stored in Patient>Clinical>Projected Visits. Medications Information Medications This section displays the patient’s active medications. Highlighted medication indicates inactive part of medication group as of reporting period date. This information is stored in Patient>Clinical>Medications. Description/Dose/ Frequency/Route This field displays the information concerning description, dose, frequency and route for each of the patient's medications. This information is stored in Patient>Clinical>Medications. Non‐Covered This field indicates the medications which are not covered by hospice agencies. This information is stored in Patient>Clinical>Medications. Start Date This field displays the medication start date. This information is stored in Patient>Clinical>Medications. Start Hold This field displays start hold date. This information is stored in Patient>Clinical>Medications. Refill Information This field displays medication refill information. This information is stored in Patient>Clinical>Medications. Medication Evaluation Information Medication Evaluations This section displays date of the most recent evaluation of the medications. This information is stored in Patient>Clinical>Medications. Evaluation Date This field displays the date of the medication evaluation. Drug Interactions This field displays Yes if drug interactions were present for the evaluated medications. Comments to the drug interactions are printed next to Yes, if applicable. If no drug interactions were present, this field displays No. Significant Side Effects Displays Yes if significant side effects were present for the evaluated medications. Comments to the significant side effects are printed next to Yes, if applicable. If no significant side effects were present, this field displays No. 160 Clinical Documentation User’s Guide Care Plan Report Field Description Duplicate Drug Therapy Displays Yes if duplicate drug therapy was present for the evaluated medications. Comments to the duplicate drug therapy are printed next to Yes, if applicable. If no duplicate drug therapy was present, this field displays No. Ineffective Drug Therapy Displays Yes if ineffective drug therapy was present for the evaluated medications. Comments to the ineffective drug therapy are printed next to Yes, if applicable. If no ineffective drug therapy was present, this field displays No. Drug Reactions Displays Yes if drug reactions were present for the evaluated medications. Comments to the drug reactions are printed below the caption, if applicable. Omissions Displays Yes if omissions were present for the evaluated medications. Comments to the omissions are printed below the caption, if applicable. Dosage Errors Displays Yes if dosage errors were present for the evaluated medications. Comments to the dosage errors are printed below the caption, if applicable. Non Compliance Displays Yes if noncompliance was present for the evaluated medications. Comments to the noncompliance are printed below the caption, if applicable. Comments This field displays additional medication evaluation comments. Clinical Notes Information Clinical Update/ Progress Notes This section enables you to view clinical notes according to defined discipline starting from certification period beginning date. This information is stored in Patient>Clinical>Clinical Notes. Falls Information Falls This section displays information on the falls adverse events that occurred with a patient. This information is stored in Patient>Clinical>Adverse Events>Falls. Fall Date The date when the fall occurred. If the fall date is not known, the date the fall is documented will be displayed followed by the asterisk (*) indicating the exact date is unknown. Injuries This field displays description of injuries caused by a fall. If the patient had no documented injuries, the <None apparent> value is displayed. Observed by Clinician This field indicates whether the clinician observed the fall. Reported By This field indicates person who reported the fall. Patient This field displays Yes if a patient reported a fall personally. Clinical Documentation User’s Guide 161 Care Plan Report Field Description PCG This field displays Yes if the patient’s primary caregiver reported a fall. Other This field displays information about the person who reported a fall. Physician Notified The name of the notified physician. Notified By This field displays name of the person who notified the physician about a fall. Notification Date/ Time This field displays date and time of the fall notification. Comments This field displays additional comments to the fall. Infections Information Infections This section displays information on the patient’s infections. This information is stored in Patient>Clinical>Adverse Events>Infections. Start Date This field displays the start date of the infection. End Date This field displays the end date of the infection, it is shown only when the infection has ended. Infection System This field displays the name of the body system where an infection is located. Comments This field displays additional comments to the infection. Signatures and Legend Signatures This section enables you to view signatures, discipline title and date of the signature. The signature and dates should be written by hand. Patient Treatment History This section enables you to view the patient’s treatment history since the date specified in Show Historical Data Since field of the Define tab. It can display Problem, Projected Visits, Medications and Clinical Update/Progress Notes sub‐sections which are of time period defined by Show Historical Data Since field and active admission start date. Underlined items have This field displays the date beginning from which the added or been added or modified items are underlined. The date is set in the Highlight modified since <date> Changes Since field of the Define tab. 162 Clinical Documentation User’s Guide Care Plan Report Example Of The Care Plan Report Clinical Documentation User’s Guide 163 Care Plan Report 164 Clinical Documentation User’s Guide Care Plan Report Clinical Documentation User’s Guide 165 Care Plan Report Care Plan Window Reports>Clinical>Care Plan Patient>Documents>Care Plan Orders>Demand Documents>Care Plan Using the Care Plan window, you can preview and print team care plans for the selected patients or an individual patient as of a certain date. You can define the time range and set specific options on the Define tab you want to see the corresponding information on the generated report. To learn more about data displayed on the generated care plan report, see the Care Plan Report – Generated section. The Care Plan window contains the following tabs: > Define Tab > Preview tab You can print care plans from the following components: > Generating Care Plan from Patient Component > Generating Care Plan from Reports Component > Generating Demand Care Plan from Orders Component Care Plan Report ‐ Define Tab Use the Define tab to specify the information you want to include in the report. You can also use the Preview tab to view a sample report onscreen. Care Plan Report – Define Tab 166 Clinical Documentation User’s Guide Care Plan Report Care Plan Report Window ‐ Define Tab Fields As of Date Enter the date to include all care plans as of a certain date in the report or select the date from the drop‐down calendar. Discipline Select the discipline you want to include in the generated report from this drop‐down list. Select All Disciplines to generate report for all disciplines. Show Start Date for Goals and Interventions Select this check box to include the start date in the descriptions of all goals and interventions in this document. The start day appears in parentheses at the beginning of the description. If the start date is within the previous nine months, the year is omitted. Highlight Changes Since Select this check box to highlight all changes since the certain date in this document and choose this date from the drop‐down calendar. Highlighting does not apply to adverse events information. Show Historical Data Since Select this check box to include historical data (treatment history) since the certain date to this document and choose this date from the drop‐down calendar. Final Care Plan (Discharge/Death) Select this check box if this is a final care plan form of the patient due to discharge or death. New Page Per Problem Select this check box to print each problem on a separate page. Sequence by Team Select this check box to print the report in order by team. This check box is available only when you run the report from the Reports or Orders components. Clinical Documentation User’s Guide 167 Care Plan Report Show Adverse Events Select this check box to include patient’s adverse events to the care plan document. Adverse events displayed on this report are falls, infections, and medication evaluation. Show CTI Physician’s information Select this check box to display CTI physician’s first name, last name, address, work and fax phone numbers on the report. MD CTI is entered in Patient>General>Admissions & Status. Patients Click Patients to choose the patients you want to run the report for. This field is shown only when you run the report from the Reports or Orders components. If you are trying to generate report from Patient>Documents, care plan for the selected patient will be automatically printed. Generating Care Plan from Patient Component The Care Plan document in the Patient component allows you to preview, print, and save care plans for a particular patient. 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Care Plan. The Care Plan window appears with the Define tab active. 4. To include care plans as of a certain date, enter the needed date in the As of Date field or select it from the drop‐down calendar. Note Help is available for each field in this window by pressing F1 while in the field. 5. Complete the fields in the Options section as appropriate (for more information on fields, see also Care Plan Report ‐ Define Tab). 6. Click the Preview tab to view an onscreen preview of the report based on the parameters you entered. Note If you change the criteria on the Define tab after preview, those changes do not take effect the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 168 Clinical Documentation User’s Guide Care Plan Report 7. Click Print to print the care plan document. 8. Click to save the care plan document in the Excel, Acrobat, or ASCII format as appropriate. Generating Demand Care Plan from Orders Component The Care Plan document in the Orders component allows you to preview, print, and save demand care plans for a group of patients or a particular patient. 1. Open the Orders component. 2. From the menu bar, select Demand Documents>Care Plan. The Care Plan window appears with the Define tab active. 3. To include care plans as of a certain date, enter the needed date in the As of Date field or select the date from the drop‐down calendar. Note Help is available for each field in this window by pressing F1 while in the field. 4. Select the patients for which you want to generate care plan document by clicking the Patients button and selecting the needed patients from the Select Patient dialog. 5. Complete the fields in the Options section as appropriate (for more information on fields, see also Care Plan Report ‐ Define Tab). 6. Click the Preview tab to view an onscreen preview of the report based on the parameters you entered. Note If you change the criteria on the Define tab after preview, those changes do not take effect the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 7. Click Print to print the care plan document. 8. Click to save the care plan document in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide 169 Care Plan Report Generating Care Plan from Reports Component The Care Plan document in the Reports component allows you to preview, print, and save demand care plans for a group of patients or a particular patient. 1. Open the Reports component. 2. From the menu bar, select Clinical>Care Plan. The Care Plan window appears with the Define tab active. 3. To include care plans as of a certain date, enter the needed date in the As of Date field or select the date from the drop‐down calendar. Note Help is available for each field in this window by pressing F1 while in the field. 4. Select the patients for which you want to generate care plan document by clicking the Patients button and selecting the needed patients from the Select Patient dialog. 5. Complete the fields in the Options section as appropriate (for more information on fields, see also Care Plan Report ‐ Define Tab). 6. Click the Preview tab to view an onscreen preview of the report based on the parameters you entered. Note If you change the criteria on the Define tab after preview, those changes do not take effect the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 7. Click Print to print the care plan document. 8. Click 170 to save the care plan document in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide Patient Documents – Care Plan Patient Documents – Care Plan Care Plan Report Patient>Documents>Care Plan Using the Care Plan report, you can preview and print team care plans for an individual patient as of a certain date. For more information on this report, see Care Plan Report. Clinical Documentation User’s Guide 171 Problems Problems Problems Overview Problems are patient conditions that require intervention by a health care provider. In Allscripts Homecare, you can define a set of specific clinical problems to be associated with patients. A patient must have at least one associated problem with an assigned goal or intervention in order to generate a clinical order. On the 485, this information appears in boxes 2 and 22. Problems also appear on the team care plan and are used in problem charting and visit history areas in the Patient component. When a hospice patient passes away, clinical items are added to the bereavement plan of care. The system generates an open‐ended certification that begins on the patient’s day of death. All prior clinical items are terminated. Supplemental orders are generated only on the patient’s day of death. Problems Window Patient>Clinical>Problems With the Problems window, you can identify specific problems for a patient. After selecting a problem for a patient, you can attach goals and interventions to it. Goals identify the outcome you would like to see for the problem, and interventions – the task to complete in order to progress towards the patient’s goals. In the left section of the window, you can sort problems by ID or name. If the problem reason is defined, it is shown next to the problem name. You can select goals and interventions for the patient's specific diagnosis using Profiles. For general information on problems, see Problems Overview. Goals, interventions, and the corresponding order generation options are defined in Administration>Clinical>Problems. In this window, problems are divided into four groups: Group Active Problems that are currently associated with the patient. Inactive Problems that were previously associated with the patient and then discontinued. Not Used 172 Definition Problems that are available in the application. Clinical Documentation User’s Guide Problems Group Definition Under Consideration Problems that were associated with the patient during the assessment completion (see Defining Problems for the Patient). After you define goals or interventions for such problems, they go to the Active group. You can drag the problem from Under Consideration to Not Used. When trying to close the Problems dialog, and some problems in the Under Consideration group are present, the message appears asking you whether to move them to Not Used. Alternate Physician on Clinical Item Entry Windows If a clinical item is entered with a start date equal to the certification start date and an alternative physician has been entered, only a supplemental order is generated for the alternative physician. Problems Window Profiles Using the Profile button, you can build a care plan for a patient with a profile defined for patient’s diagnosis. A profile is a defined group of problems (goals and interventions) that are associated with a diagnosis. Profiles may be used to ensure consistency in patient care for patients with the same diagnosis. Modifiers and additional patient‐appropriate problems, goals and interventions should be added to customize the patient’s care plan. Profiles are defined in Administration>Clinical>Profiles and can be assigned based on patients that have the diagnosis as their primary or can be used regardless of where the diagnosis falls in prioritization in Administration>Business Units>Settings>Clinical Miscellaneous. Clinical Documentation User’s Guide 173 Problems Assigning Problems to a Patient 1. In the Patient component, select a patient. 2. Go to Clinical>Problems. 3. On the left panel, click + next to Not Used to display a list of available problems. 4. Select the problem you want to assign to the patient. 5. If needed, indicate the cause of the patient’s problem in the Reason field. 6. If you want to view a certain discipline that completed existing interventions, select it in the Disciplines drop‐down list. 7. If you want to view only active goals and interventions, select the Current radio button. 8. If you want to view the problems information in one line, select the One‐line display radio button. 9. If you want to use the profiles defined for diagnoses, click the Profile button. For more information, see Profiles. 10. Enter all appropriate goals (see Entering Goals for a Problem). 11. Enter all appropriate interventions (see Entering Interventions for a Problem). 12. Save your changes. Entering Goals for a Problem 1. Assign a problem to a patient (Assigning Problems to a Patient) or select an active problem for which you want to enter goals. 2. In the Goals Entry section, add a row. The Select goals for problem “[name of the problem]” dialog opens. 3. Select the appropriate goals. The active goals are highlighted in blue and cannot be added again for this patient. 4. Enter the date when you want this goal to become effective. 5. Enter the start physician, and then click OK. 6. Enter the modifier for this patient's rehabilitation or recover goal from this problem. Your agency has determined the goals for which you can enter modifiers in Administration>Clinical>Problems. 7. If you want to allow future dated items to print on physician orders, select the Print on Certification Order check box (if defined in Administration>Configuration>Business Units>Settings>Orders Settings). 8. Save your changes. 174 Clinical Documentation User’s Guide Problems Entering Interventions for a Problem 1. Assign a problem to a patient (Assigning Problems to a Patient) or select an active problem for which you want to enter goals. 2. In the Interventions Entry section, add a row. The Select interventions for problem “[name of the problem]” dialog opens. 3. Select the appropriate interventions. The active interventions are highlighted in blue and cannot be added again for this patient. 4. Enter the date when this intervention becomes active. 5. Specify the start physician. 6. Enter any additional patient‐specific information regarding the intervention in the Modifier field. 7. If you do not want the system to generate a supplemental order for changes made after the certification order is approved or with a start date other than of the certification order, select the No Start Supp check box. 8. Save your changes. Discontinuing Problem for Patient When you discontinue a problem, you discontinue all the goals and interventions associated with the problem and need to enter an outcome for the open goals. The Outcome field is available if defined in Administration>Business Units>Settings>Clinical Miscellaneous. 1. In the Patient component, select a patient. 2. Go to Clinical>Problems. 3. In the left panel, click + next to Active to display problems currently assigned to the patient. 4. Select the problem you want to discontinue. 5. In the End field for each goal and intervention associated with the problem, enter the date when it is discontinued. If you want to discontinue all goals and interventions at once for a problem, click Discontinue and enter the date. You can edit the dates for each item if needed. If you are discontinuing problems due to a re‐admission, this dialog does not include the End Date field. Instead, the discharge date is automatically entered as the end date. 6. Enter the outcomes for each goal. 7. Save your changes. Clinical Documentation User’s Guide 175 Problem Charting Problem Charting Problem Charting Window Patient>Clinical>Problem Charting With the Problem Charting window, you can chart the progress of patient goals and interventions for specific problems. This window is intended for Field Mode users, but is also available in Host Mode. You must complete problem charting before you can upload a patient's information in Field Mode. To document problem charting, you must have a time log active for the patient visit in Transactions>TimeLog. You can view the problems (goals and interventions) associated with the patient in Patient>Clinical>Problems. The information entered in Problem Charting appears in the Charting History window and the Charting History report. Positive and negative variances are used in Problem Charting to complete the statement for goals and interventions showing how they are progressing. Variances are related to the patient, the situation, or the system. Patient‐related variances are all those reasons or responses why a patient can or cannot accomplish a goal or intervention. Examples of positive and negative patient‐related variances include: Positive Negative Improving faster than expected Pt. unconscious Verbalizes understanding Pt. w/limited cognitive ability Return demonstration Medication interference Situation‐related variances refer to the situation surrounding the patient, including the physical surroundings and the primary caregiver. Examples of positive and negative situation‐related variances include: Positive CG returns demo CG not available CG verbalizes understanding CG w/low cognitive ability CG reinforces exercise program 176 Negative Home not clean Clinical Documentation User’s Guide Problem Charting System‐related variances refer to causes related to the things outside the patient's immediate area. Examples of positive and negative system‐related variances include: Positive Negative Meals on Wheels service Equipment not delivered Visit from local clergy Medication not delivered Problem Charting Window Clinical Documentation User’s Guide 177 Problem Charting Documenting Progress for a Patient To document problem charting, you must have a time log active for the patient visit in Transactions>General>TimeLog. 1. In the Patient component, select a patient. 2. Go to Clinical>Problem Charting. 3. Select the service in the upper panel of the Patient component. 4. Verify the correct discipline is selected. By default, this discipline is the discipline of the user who initiated this visit in the TimeLog window. If needed, you can view or document the goals and interventions of other disciplines. 5. Select the problem you want to document in the left section of the window. 6. If you want to select NA (Not Assessed) for all goals and interventions and complete the problem charting, click Finish. 7. For each goal associated with the problem, select one of the following: • Y – If the patient is meeting expected progress. You need to select an appropriate variance. • N – If the patient is not meeting expected progress. You need to select an appropriate variance. • NR – If you did not review this goal during this visit. 8. For each intervention associated with the problem, select one of the following: • Y – If the intervention was addressed this visit. You need to select an appropriate variance. • N – If the intervention was not addressed. You need to select an appropriate variance. • NA – If this intervention is not appropriate for this visit. 9. Click the Notes tab and enter the problem charting notes. 10. Save your changes. 178 Clinical Documentation User’s Guide Charting History Charting History Charting History Window Patient>Clinical>Charting History With the Charting History window, you can view all previous problem charting entered during visits for a patient. However, you cannot enter any problems in this window. You can sort problems by ID and name. You can also view problems for all disciplines or for a selected discipline. This information is helpful for those who are making a patient visit to see what occurred during the patient's last visit. Charting History Window Viewing Patient’s Progress in Charting History 1. In the Patient component, select a patient. 2. Go to Clinical>Charting History. 3. Enter the date range. 4. If needed, specify the discipline for which you want to view interventions. 5. Select the problem for which you want to view the patient’s progress. 6. To view various information about the problem’s goals or interventions, hover over the visit date column to see the visit date, visit code, discipline, and name of the clinician who performed the visit. 7. Select each intervention to view the modifier entered for this intervention. 8. Hover over each intervention response to view its description. 9. View the different visit dates to see what goals and interventions have been completed. Clinical Documentation User’s Guide 179 Charting History Report Charting History Report Charting History Report Window Reports>Clinical>Charting History The Charting History Report enables you to preview and print patient's problems along with their interventions and goals. You can choose to print a specified number of visits or visits within a specified date range a selected Discipline(s). You can also choose to print a problem per page, and an entire problem. You can also print Charting History through Patient>Documents. Charting History Report ID/Description Select the Discipline ID(s) and Description(s). 180 Clinical Documentation User’s Guide Charting History Report Date Range If you want to print the Charting History Report as of a date range, select the Date Range radio button, and enter the From and To Dates. Number of Visits If you want to print the Charting History Report as of a number of visits, select the Number of Visits radio button, and enter the number of recent visits. New page for each problem If you want each problem to print on a separate page, select the check box. If not, clear the check box or leave the box unchecked if it is not checked. Print entire problem If you want to print the entire problem, select the check box. If not, clear the check box or leave the box unchecked if it is not checked. Patient ID Select the Patient ID(s) and Description(s). Add Patients Click to select additional patients to include on this report. The Select Patients window opens. Preview or Print Charting Histories 1. Open the Reports component. 2. Go to Clinical>Charting History. The Charting History window opens with the Define tab visible. 3. Select the disciplines for which you want to print charting histories. 4. Click Next. 5. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. Clinical Documentation User’s Guide 181 Charting History Report 6. Select the patients whose charting histories you want to print. 7. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 8. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. 182 Clinical Documentation User’s Guide Patient Documents – Charting History Patient Documents – Charting History Charting History Window Patient>Documents>Charting History Using the Charting History window, you can preview and print a patient's problems along with the goals and interventions for selected disciplines. You can choose to print by either date range or recent number of visits. You can also print each problem on a separate page, and choose whether or not to print the problem in its entirety. You can include start dates for all goals and interventions on this document. In addition, you can choose to have Allscripts Homecare underline on the printed documents all changes since a specified date. Records with positive variances are displayed as "+V1" and in green. Records with negative variances are displayed as "‐V2" and in red. You can view and print charting histories in Field Mode. You can also print charting histories through Reports>Clinical. Charting History Window Clinical Documentation User’s Guide 183 Patient Documents – Charting History Charting History Window Fields From Specify the begin date to include only problems that occurred within a certain date range. To Specify the end date to include only problems that occurred within a certain date range. Show most recent number of visits To include only problems that occurred during the patient’s most recent visits, specify the number of recent visits you want to include. Highlight changes since Select the check box to highlight (underline) all changes since a certain date on this document. Show Start and End Dates for Goals and Interventions Select the check box to includethe start and end dates in the descriptions of all goals and interventions on this document. The start date appears in parentheses at the beginning of the description. If the start date is within the previous 9 months, the year is omitted. New page per problem Select the check box to print each problem on a separate page. Print entire problem Select the check box to print the entire problem. Discipline list Select the disciplines you want to include on the report. 184 Clinical Documentation User’s Guide Patient Documents – Charting History Printing or Previewing Charting History 1. Open the Patient component. 2. Select the correct patient. 3. Go to Patient>Documents>Charting History. The Charting History window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected charting history. OR Choose the Preview tab to preview the selected charting history onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Charting History is also available in the Reports component. Clinical Documentation User’s Guide 185 Active Patients by Problems Report Active Patients by Problems Report Active Patients by Problems Report Window Reports>Clinical>Active Patients (Problems) The Active Patients by Problems Report enables you preview and print all active patients along with the active problems for each patient. You can choose which assignment types to print, and also whether to print all teams or selected teams. You can also sort the report by: 1)Team, Patient Name, 2)Patient Name, 3)Assignment Name, Patient Name, or 4)Team, Assignment and Patient Name. Active Patients by Problems Report 186 Clinical Documentation User’s Guide Active Patients by Problems Report Active Patients by Problems Report Fields Assignment Type Click and select the Assignment Type. Sort Criteria If you want to sort by > > Team, then patient name, click By team, by patient name. Patient name, click By patient name. Selection Criteria If you want to display: > > All teams, click All. One specific team, click For one team and select the team. Generating Active Patients by Problems Report 1. Open the Reports component. 2. Go to Clinical>Active Patients (Problems). The Active Patients (Problems) window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 187 Active Problems by Discipline Report Active Problems by Discipline Report Active Problems by Discipline Report Window Reports>Clinical>Active Patients by Discipline The Active Problems by Discipline report enables you to preview and print active patients that have active problems defined for the selected discipline as of the day of the report. The report is sorted alphabetically by the patient'slast name. You can use this report to determine that problems/interventions have been entered for all disciplines noted in Projected Visits, or to compare patients and their primary diagnosis to determine if the problems defined address the diagnosis. Generating Active Patients by Discipline Report 1. Open the Reports component. 2. Go to Clinical>Active Patients by Discipline. The Active Patients by Discipline window opens with the Define tab visible. 3. Select the discipline for which you want to print the report. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. 188 Clinical Documentation User’s Guide Chapter 4 ‐ Medications and MAR In This Chapter In this chapter, you can find information about medications prescribed to patients, Medication Administration Record, generating and viewing various reports on patients medications. The chapter consists of the following sections: • • • • • • • • • • • • • Medications Medication Administration Record (MAR) MAR Review Status Report Medication Administration Actual vs. Scheduled Report Medication Evaluation Report Print MAR Documents PRN Medications Administered Report Undocumented Medication Administration Report Medication Descriptions Report Patient Documents – Medication Descriptions Medication Lists Report Patient Documents – Medication Lists Pharmacy Medication List Report Clinical Documentation User’s Guide 189 Medications Medications Medications Window Patient>Clinical>Medications Using the Medications window, you can view medications that a patient is currently taking or was taking in the past. In this window, you can manage the patient’s medication dosing information, enter medication start and end details, place a medication on hold, enter refill information, detail any special instructions that accompany a medication, and evaluate medication according to several criteria. You should enter medications in sequence you want them to appear on the clinical order. You can also use the Up and Down arrows to arrange the medications in the correct order. To ensure the medication administration safety, the columns in the Medications window appear in an order that allows you to better view critical medications information without scrolling within the window. Medication dose, dose units, frequency, route, and any special instructions are entered in a structured manner in the Medications Entry window when you add a medication. In addition, to decrease a risk of medication errors, tabs in the lower section of the window provide consolidated views of medication details that do not require scrolling: > Medications Window – Medication Evaluation Tab > Medications Window – Medication Order Entry Tab > Medications Window – Modification Details Tab > Medications Window – Medication Hold and Resumption Details Tab > Medications Window – Medication Group Details Tab > Medications Window – Hold/Resume History Tab You can put a patient’s medication on hold to be resumed later when the corresponding lab results or the patient’s clinical response to the medication type or dose are received. Hold start dates may be retroactive, but hold start dates before the medication start date are not allowed. When a medication is placed on hold, all non‐editable fields for that medication appear in blue, and the Held value appears in the Medication Status field. The Hold Physician ID, Reason for Hold, and End Hold Date fields remain editable while a medication is on hold. On the field device, however, medications with a Held status remain editable until the field device is synchronized. Once the medication is resumed, the Medications window retains the hold history in the Hold/Resume History tab for your reference. When resuming a held medication, a new record is not generated since the medication is not discontinued when on hold. You can report on all periods the medication was on hold without losing the original order date. If your agency uses Medi‐Span, the Medi‐Span Interaction and Medi‐Span Prior Adverse Reaction Screening functions are available. If your agency does not use Medi‐Span, your application 190 Clinical Documentation User’s Guide Medications administrator manually enters all medications in the Medications window of the Administration component and the Medi‐Span Interaction and Medi‐Span Prior Adverse Reaction Screening functions are not available. All installed Medi‐Span medications are available for selection only if the Use Medi‐Span check box is selected in Administration>Configuration>Business Units>Settings>Medications. When you enter a new medication code, the application checks this code against all Medi‐Span medications and any medications added to the current Business Unit to avoid duplications. When Medi‐Span changes their medication route abbreviations, you can change the codes and descriptions in the list. Your agency can also set up medication kits that include medications used together. Using medication kits, you save your time since you do not need to enter each medication separately. Your application administrator sets up medication kits in the Medication Kits window (Administration>Clinical>Medication Kits). The medications Settings window (Administration>Configuration>Business Units>Settings>Medications) contains the Medication Edit Period setting with a default value of 7 days. In the Medications window (Patient>Clinical>Medications), you can edit patient’s medications based on the medication edit period and your security privileges for locked clinical entries. When you change a medication, the Edit Medication options dialog appears, where you can select to discontinue the medication and make changes in its added copy or edit the selected medication. In the first case, the End Date field is automatically completed for the old medication and a new line is displayed with the C status. If the medication End Date is completed, the medication is considered as discontinued. On the Modification Details tab, you can select an alternate physician and select not to generate the end supplemental. Medication Groups On the Medication Group Details tab, in the lower part of the Medications window, you can enter medication titrations for a patient and the corresponding start and end dates. For example, a physician may prescribe an antibiotic that the patient must take three times a day during the first week and twice a day during the second week. When you enter this medication in the Medications Entry window, select the Medication Group check box. Then, click the Medication Group Details tab and enter the dose, frequency, and start and end dates for each week. This medication group information will be displayed in orders and in all reports that print patient medication data. Alternate Physician on Clinical Item Entry Screens You can enter alternative physicians with any start date. If a clinical item is entered with a start date equal to the certification start date and an alternative physician has been entered, only a supplemental order is generated for the alternative physician. Clinical Documentation User’s Guide 191 Medications For example, if the primary physician orders a medication on 7/1 and then a covering physician needs to stop it and prescribe a new medication on 7/1, the system generates a supplemental order with both an end order for the first medication and a start order for the new medication. Reviewing Medications on Re‐admission Unlike other patient clinical items (such as problems, goals, and interventions), Allscripts Homecare does not automatically ask you to end all active medications when you enter a re‐admission. Clinicians should review the medications during the SOC for a re‐admission and take the appropriate steps if the medication should be ended or changed. If a medication should be changed (change in status, dose, frequency of administration, or route) the clinician should end the existing medication, and enter a new medication line with the appropriate information. Allscripts Homecare generates a supplemental order for the change. Changes to the existing medication's (covered or administered by status) do not require a new medication line to be added. Medications Window 192 Clinical Documentation User’s Guide Medications Medications Window Fields Show All Select this radio button to show all medications. The medications which the patient was taking in the past and those which the patient is currently taking appear in the grid. Show Current Select this radio button to show only those medications which the patient is currently taking. Show/Hide Details The caption of this button changes depending on whether the medication detail tabs are displayed in the window. The possible variants are: • Show Details – Click to show medication details tabs below the Medications grid of the window. • Hide Details – Click to hide medication details tabs. Hold/Resume The caption of this button changes depending on what medication is selected. Possible variants are: • Hold – Click to place the selected medication on hold. • Resume – Click to resume the selected medication. Kits If you want to add a medication kit to this patient, click the Kits button. The Medication Kits Window appears. Complete the fields as appropriate and click OK to add a medication kit for this patient. Medication kits are set up in Administration>Clinical>Medication Kits. Settings Click this button to configure the view of the Medications grid. The Show Fields Dialog dialog appears where you can define fields to be displayed in the grid. Drug/Drug Interactions (Medi‐Span Users) Click the Drug/Drug Int button to check interactions between this patient’s medications. Clinical Documentation User’s Guide 193 Medications The Information dialog appears saying that the medication interaction can be checked only for Medi‐Span medications. Click OK. The Drug/Drug Interactions Dialog window appears. Complete the fields as appropriate and click OK to generate the Drug/Drug Interactions report. PAR Click the PAR button to check for prior adverse reactions to this medication. The Medi‐Span Prior Adverse Reaction Check Window appears where you can define prior reported side effects of the selected medication. Allergies The patient’s recorded allergies. You can enter this information in the General Clinical window (Patient>Clinical>General Clinical). Type The medication type which is defined while entering a new medication. Possible values are: • M – Medi‐Span medication. • N – Common medication (not Medi‐Span). Medication The code of the medication prescribed for the patient. The name of the corresponding medication is displayed in the Medication Name column. You can click to search for existing in the database medications. The Select Medication Dialog window appears. OR You can click to enter a new medication that is not in the database. The New Medication Dialog dialog appears. Complete the fields as appropriate and then click OK. Medication Name The name of the medication prescribed for the patient. 194 Clinical Documentation User’s Guide Medications Dose & Frequency The dosage amount and frequency for the selected medication. To enter dose and frequency for the medication, click in the Dosage & Frequency field in the Medications grid or on the Medication Order Entry tab. The Medication Entry Dialog dialog appears where you can enter dose and frequency for the selected medication. Medication Special Instructions Enter any special instructions that accompany this medication, up to 250 free‐text characters. Route Enter the appropriate route of administration for this medication, or select it from the drop‐down list. N/C Click to mark the selected medication as new or changed for this patient. You can select from the following options: > > N –Mark the medication as new for this patient. C – Mark the medication as changed for this patient. Start Date Enter the date the patient starts taking this medication or select the date from the drop‐down calendar. End Date Enter the date the patient finishes taking this medication or select the date from the drop‐down calendar. Note The end date cannot be earlier than the start date. Status The status of the selected medication. If the medication is put on hold, the Status field displays the Held value. If the medication is not on hold, the status field is blank. The value in this field changes automatically when you hold or resume the medication. Clinical Documentation User’s Guide 195 Medications Modification Details Indicates whether the selected medication was changed after prescribing. Hold and Resumption Details Indicates whether the selected medication was on hold. Group Details Indicates whether the selected medication has group details. History Indicates whether the selected medication was on hold or resumed. If the check box is selected, the medication has hold/resume history. The check box is selected automatically when you put a medication on hold. No Start Supplemental Order Select this check box to suppress the creation of a start supplemental order. In this case, supplemental orders are those changes made after the certification order was approved and those orders entered with a start or end date that falls within the certification period. No End Supplemental Order Select this check box to suppress the creation of an end supplemental order. Medications Window – Medication Evaluation Tab Patient>Clinical>Medications The Medication Evaluation section provides you with the efficient means to evaluate medications prescribed for the patient. You can document an evaluation of medication list for: > > Significant Side Effects > Duplicate Drug Therapy > Ineffective Drug Therapy > 196 Drug Interactions Drug Reactions Clinical Documentation User’s Guide Medications > Omissions > Dosage Errors > Non compliance You can perform the medication evaluation when needed and each evaluation is recorded as separate column in the grid. The most recent evaluation record is located in the left part of the grid. If a new evaluation is added, all exited records are moved to the right direction in the grid. Using this tab, the clinician can easily track the efficacy of the prescribed drug therapy. Thus, the patient treatment can be improved since medications significant side effects, duplications, or ineffective drugs can be quickly identified and reported so that corresponding measures are taken as soon as possible. Medications – Medication Evaluation Evaluate Medications 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. 4. Click to the right of the Medication Evaluation section. The new column is added in the Medication Evaluation grid. 5. Enter the appropriate medication evaluation information (For more information, see Medications Window – Medication Evaluation Tab). 6. Click to save your changes. Clinical Documentation User’s Guide 197 Medications Medications Window – Medication Order Entry Tab Patient>Clinical>Medications>Medication Order Entry This tab provides you with a consolidated view of medication order entry information. You can view or edit such medication entry details as start date, dose, frequency, route, and so on. Any changes you made on this tab are displayed after saving in the Medications grid (if the corresponding field is present on that grid). Medications Window – Medication Order Entry Tab Medications Window – Medication Order Entry Tab Medication The name of the medication selected in the Medications grid of the window. Start Date Enter the date when the patient starts taking this medication. You can also enter this date using the Start Date column in the Medications grid. Start Time (MAR) Enter the start time for medication administration record (MAR). No Start Supplemental Order Select this check box to suppress the creation of a start supplemental order. In this case, supplemental orders are those changes made after the certification order has been approved and those orders entered with a start or end date that falls within the certification period. 198 Clinical Documentation User’s Guide Medications Status The status of the selected medication. If the medication is put on hold, the Status field displays the Held value. If the medication is not on hold, the status field is blank. The value in this field changes automatically when you hold or resume the medication. Covered Select this check box to mark the medication as a covered benefit. Dose & Frequency Displays the dosage amount and frequency for this medication. To enter dose and frequency, click in the Dosage & Frequency filed in the Medications grid or on the Medication Order Entry tab. The Medication Entry Dialog dialog appears where you can enter dose and frequency for the selected medication. Route Enter the appropriate route for this medication, or click drop‐down list. and select it from the New/Change Click to mark the selected medication as new or changed for this patient. You can select from the following options: > > N – Select to mark the medication as new for this patient. C – Select to mark the medication as changed for this patient. Medication Special Instructions Enter any special instructions that accompany this medication, up to 250 free‐text characters. Notes Enter any notes concerning this medication in this field. Clinical Documentation User’s Guide 199 Medications Medications Window – Modification Details Tab Patient>Clinical>Medications>Modification Details This tab provides you with a consolidated view of the medication details. You can view or edit such medication details as start and end physician, order date and time, reasons for change or end of medication, and so on. Any changes you made on this tab are displayed after saving in the Medications grid (if the corresponding field is on that grid). Medications Window – Modification Details Tab Modification Details Tab Fields Start Physician Enter the ID of the physician who started the order for the medication, or click and select it. May Administer Enter the name of the person who may administer the medication for the patient, up to 30 free‐ text characters. You can set the ‘May Administer’ text to be printed on generic orders. To do that, select the Print Admin By info for meds check box in Administration>Configuration>Business Units>Settings>Orders Print Options. Date Order Received Enter the date when the order for this medication was received or select the date from the drop‐ down calendar. Time Order Received Enter the time the order for this medication was received or click 200 and set the time. Clinical Documentation User’s Guide Medications Refill Enter the appropriate refill information for this medication. This field accommodates up to 30 free‐text characters. Reason for Change Enter a reason for the change in medication, up to 100 free‐text characters. No Start Supp Select this check box to suppress the creation of a start supplemental order. In this case, supplemental orders are those changes made after the certification order is approved and those orders entered with a start or end date that falls within the certification period. End Date Enter a date on which the patient should stop taking this medication or select it from the drop‐ down calendar. MAR – Medication End Time Enter the medication end time for this medication or click and set the time. End Physician Enter the ID of the physician who ended the order for the medication or click and select it. No End Supplemental Order Select this check box to suppress creation of an end supplemental order. In this case, supplemental orders are those changes made after the certification order is approved and those orders entered with a start or end date that falls within the certification period. Reason for End Enter a reason for ending this medication, up to 100 free‐text characters. Clinical Documentation User’s Guide 201 Medications Medications Window – Medication Hold and Resumption Details Tab Patient>Clinical>Medications>Medication Hold and Resumption Details This tab provides you with a consolidated view of medication hold and resume information. The tab consists of two sections: > Required fields to place a medication on Hold – Contains fields necessary to complete to put a medication on hold. > Required fields to resume a medication – Contains fields necessary to complete to resume a medication. If you put a medication on hold, the Hold and Resumption Details and History check boxes on the Medications grid are automatically selected after saving. They indicate that selected medication was or is on hold. Medications Window – Medication Hold and Resumption Details Medication Hold and Resumption Details Tab Fields Start Hold Date Enter the start date for holding the medication or click calendar. and select it from the drop‐down The start date for the hold may be prior to current date (retroactive) but not before the start date of the medication. Hold Physician Enter ID of the physician who ordered a hold on the selected medication or click from the drop‐down list. and select it Click Select another physician if the physician you need is not available in the list. The Select Physician window appears where you can search for proper physician. 202 Clinical Documentation User’s Guide Medications End Hold Date Enter the date the hold ends for this medication or select the date from the drop‐down calendar. No Hold Supplemental Select this check box to suppress the creation of a hold supplemental order. Reason for Hold Enter a reason for holding this medication, up to 100 free‐text characters. Resume Medication Date Enter the date the patient resumes this medication. Resume Physician Enter ID of the physician who ordered the selected held medication to be resumed or select the physician from the drop‐down list. Click Select another physician if the physician you need is not available in the list. The Select Physician window appears where you can search for proper physician. No Resume Supplemental Select this check this box to suppress the creation of a resume supplemental order. Reason Medication Resumed Enter a reason for resuming this medication, up to 100 free‐text characters. Clinical Documentation User’s Guide 203 Medications Medications Window – Hold/Resume History Tab Patient>Clinical>Medications>Hold/Resume History This tab provides you with information on each hold and resumption of the selected medication. One record in the grid contains information concerning the hold and resumption dates, time, physician, and reason. If the medication was put on hold and then resumed, all fields in one record are completed. If the same medication is put on hold for the second time, a new record in the grid is added. If the medication has hold/resume history, the History check box in the Medications grid is selected. Medications Window – Hold/Resume History Tab Hold/Resume History Tab Fields Start Hold Date The date when the selected medication was put on hold (mm‐dd‐yyyy). Start Hold Time The time when the selected medication was put on hold. Hold Physician The ID of the physician who ordered a hold on the selected medication. Reason for Hold The reason for holding this medication. 204 Clinical Documentation User’s Guide Medications End Hold Date The date when it is planned to end the medication hold. Resume Medication Date The date when the medication was resumed. Resume Medication Time The time when the medication was resumed. Resume Physician The ID of the physician who ordered to resume the medication. Resume Medication Reason The reason of why the medication was resumed. Medications Window – Medication Group Details Tab Patient>Clinical>Medications>Medication Group Details This tab displays information on medication group details. If the same medication needs to be taken in different dose and frequency depending on the treatment duration, the scheduling records for this medication are called a medication group. Using this tab, you can enter medication dose and frequency, special instructions, start date and time, scheduled end date and time, and actual end date. Medications Window – Medication Group Details Tab Clinical Documentation User’s Guide 205 Medications Medication Group Details Tab Fields Dose & Frequency Enter the dosage amount and frequency for this medication. This field accommodates up to 1,000 free‐text characters. Medication Special Instructions Enter any special instructions for this date range in the medication group, up to 250 free‐text characters. Start Date Enter or select the start date for this date range in the medication group. Start Time Enter or select the medication start time for this medication, if any. Scheduled End Date Enter or select scheduled end date for this date range in the medication group. Scheduled End Time Enter or select scheduled end time for this medication, if any. Actual End Date Enter or select actual end date for this date range in the medication group. Add Row to Medication Group If you want to add a detail line to this medication group, click Add Row. The application adds an empty row for the item at the bottom of the grid. Insert Row in Medication Group If you want to add a detail line to this medication group above the selected grid row, click Insert Row. The application adds an empty row for the item. 206 Clinical Documentation User’s Guide Medications Delete Row from Medication Group If you want to delete the selected medication group detail line, click Delete Row. The application removes the selected row. Enter Medications for a Patient Note Note When you change an existing medication or add a new medication, a supplemental order is generated in the HCFA‐485 form. If the HCFA‐485 form is not created yet, the medication will be included in that form when it is generated. This only applies if the patient's insurance requires HCFA‐485 and is set up to generate it. 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click Add Row to enter a new medication. 5. In the Medication field, click and select the medication you want to add. The Medication Entry Dialog window appears. 6. Complete the fields as appropriate. 7. Click OK. The Medications window appears again. 8. Complete the fields in the grid line as appropriate. Note Help is available for all fields within this window by pressing F1 while in the field. 9. Click to save your changes. Clinical Documentation User’s Guide 207 Medications Edit Medications for a Patient Caution As with all edits, be sure to follow your agency’s policy. 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Select the medication you want to edit. Note Select the Show All radio button to view past and current medications, or select the Show Current radio button to view only the current medications. 5. Edit the fields as appropriate. Note Help is available for all fields within this window by pressing F1 while in the field. 6. Click to save your changes. Note When you change an existing medication or add a new medication, a supplemental order is generated in the HCFA‐485 form. If the HCFA‐485 form is not created yet, the medication will be included in that form when it is generated. This only applies if the patient's insurance requires HCFA‐485 and is set up to generate it. Enter Special Instructions for a New Medication 1. Open the Patient component. 2. Select the proper patient. 3. From menu bar, select Clinical>Medications. The Medications window appears. 4. Click Add Row to enter a new medication. 5. In the Medication field, click and select the medication you want to add. The Medication Entry Dialog window appears. 208 Clinical Documentation User’s Guide Medications 6. Complete the fields as appropriate. 7. Click the Medication Special Instructions button. The Medication Special Instructions field appears. 8. Enter your special instructions for the medication, up to 1000 free‐text characters. 9. Click OK. 10. Complete the rest necessary fields to add the medication. 11. Click to save your changes. Add Special Instructions to Existing Medication 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click the record with the medication you want to enter special instructions for. 5. In the Medication Special Instructions field, click . 6. Enter your special instructions for the medication, up to 1000 free‐text characters. 7. Click OK. 8. Click to save your changes. Enter Medication Groups for a Patient 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click the record with the medication you want to create a medication group for. 5. In the Medication Group Details tab, click . The Medication Entry Dialog window appears. 6. Complete the fields as appropriate. Clinical Documentation User’s Guide 209 Medications 7. Click OK. 8. Enter a start date for this dosage and frequency. 9. Enter an end date for this dosage and frequency. 10. Click or to enter dosage, frequency, and dates for the next date range in the medication group. You can add as many records as necessary. 11. Click to save your changes. Hold Medications for a Patient 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click the record with the medication you want to put on hold. 5. Click Hold. The selected record turns gray and is locked for editing. 6. Click the Medication Hold and Resumption Details tab. 7. In the Hold Physician ID field, click and select the physician who ordered the hold of the medication. Click Select another physician if the physician you need is not available for selection in the list. The Select Physician window appears where you can search for proper physician. 8. In the Reason for Hold field, click up to 100 free‐text characters. and enter the reason the selected medication is put on hold, 9. In the End Hold Date field, enter the date on which the medication hold ends OR Click 10. Click 210 and select it from the drop‐down calendar. to save your changes. Clinical Documentation User’s Guide Medications Resume Held Medications for a Patient 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click the record with the held medication you want to resume. Records with held medications have gray fill. 5. Click Resume. A new row appears with the medication information copied from the held medication record. The row with the hold information remains in the grid for historical purposes with blue fill in the fields indicating that they are locked for editing. 6. Click the Medication Hold and Resumption Details tab. 7. In the Resume Physician ID field, click and select the physician who ordered to resume the medication. Click Select another physician if the physician you want is not available for selection in the list. The Select Physician window appears where you can search for proper physician. 8. In the Reason Medication Resumed field, click resumed, up to 100 free‐text characters. 9. Click and enter the reason the held medication was to save your changes. Delete Medications for a Patient 1. Open the Patient component, and select the proper patient. 2. From the menu bar, select Clinical>Medications. The Medications window appears. Note Help is available for all fields within this window by pressing F1 while in the field. 3. Select the medication you want to delete. 4. Click . Allscripts Homecare removes the medication from the Medications grid. 5. Click to save your changes. Clinical Documentation User’s Guide 211 Medications Discontinue a Medication for a Patient 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Select the medication you want to discontinue. 5. In the End Date field, enter the date on which you are discontinuing the medication. OR Click and select it from the drop‐down calendar. Note Note Help is available for all fields within this window by pressing F1 while in the field. 6. Click to save your changes. 7. Click the Modification Details tab. 8. If the physician ending the medication is other than the primary physician, enter the ID of the physician who ended the medication in the End Physician ID field. 9. Select the No End Supplement check box if you do not want a supplemental order to be created for ending this medication. 10. In the Reason for End text box, enter the reason for discontinuing the medication, up to 100 free‐ text characters. This field is not required. 11. Click 212 to save your changes. Clinical Documentation User’s Guide Medications Medi‐Span Prior Adverse Reaction Check Window Patient>Clinical>Medications The Prior Adverse Reaction check window enables you to see whether a certain medication was reported to cause any side effects. You can select the medication and the specific side effects to be checked. To access the Prior Adverse Reaction check window, click the PAR button in the Medication window. Medi‐Span Prior Adverse Reaction check Dialog Medi‐Span Prior Adverse Reaction Check Window Fields Prior Adverse Reactant Click and select the medication you want to check for side effects. The Select Medication Dialog window appears. Reported Symptoms Select the check box next to the side effect you want to check the medication for. The available side effects are: • Skin Rashes/Hives • Shock/Unconsciousness • Asthma/Shortness of Breath • Nausea/Vomiting/Diarrhea • Anemia/Blood Disorders • Other (undefined) Symptoms Clinical Documentation User’s Guide 213 Medications Check Medication Interactions 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. Note Help is available for all fields within this window by pressing F1 while in the field. 4. Select the medication for which you want to check interactions. 5. Click the Drug/Drug Int button. The Medications Interactions window appears. Check Prior Adverse Reactions to a Medication 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. Note Help is available for all fields within this window by pressing F1 while in the field. 4. Select the medication for which you want to check prior adverse reactions. 5. Click PAR to perform the Medi‐Span prior adverse reaction check. The Prior Adverse Reactions window appears. 214 Clinical Documentation User’s Guide Medications Medication Kits Window Patient>Clinical>Medications The Medication Kits window enables you to select the existing medication kit and apply it to the selected patient. Medication kit is a set of medications predefined for certain illness or diagnosis. If you apply a medication kit for a patient, all the medications assigned to that kit appear in the Medication grid of the Medications Window. Medication Kits Window Medication Kits Window Fields The fields marked with red asterisk are required to assign a medication kit for a patient. Start Date Enter the start date for the selected medication kit or select it from the drop‐down list. Start Physician Enter the physician who ordered to assign the selected medication kit for a patient or select it from the drop‐down calendar. If the needed physician is not in the drop‐down list, click Select another physician and select the correct physician from the Physician dialog. May Administer Enter the name of the person who may administer selected medication kit, up to 30 alphanumeric characters. Description Displays the available for selection medication kits which are set in Administration>Clinical>Medication Kits. Clinical Documentation User’s Guide 215 Medications Add Medication Kits to a Patient 1. Open the Patient component. 2. Select the proper patient. 3. From the menu bar, select Clinical>Medications. The Medications window appears. 4. Click the Kits button. The Medications Kits window appears. 5. Select the appropriate kit and date. 6. Click OK. The Medications window reappears. 7. Click to save your changes. Drug/Drug Interactions Dialog Patient>Clinical>Medications Using the Drug/Drug Interactions window, you can check the interactions between exiting (already assigned to the patient) or between new and existing medications. You can access this window by clicking the Drug/Drug Int button in the Medications window. Drug/Drug Interactions Dialog Drug/Drug Interactions Window Fields Existing Medications Select this radio button to check interaction between existing medications (currently prescribed for the patient.) 216 Clinical Documentation User’s Guide Medications New Medication Select this radio button to check interaction between the new and existing medications. To select a new medication, click in the field below the New Medication radio button and select the medication from the Select Medication dialog. OK Click to start checking the drug interaction and run the Drug/Drug Interactions report. Cancel Click to cancel drug interaction check and exit the Drug/Drug Interactions window. Show Fields Dialog Patient>Clinical>Medications Using this dialog, you can define the view of the Medication grid. You can access this dialog by clicking the Settings button on the Medications Window. The dialog consists of two sections: > Available Fields – Displays the fields which are currently hidden in the Medication grid. To make these fields available in the Medication grid, move them to the Show these fields section using the arrow buttons located between the sections of the dialog. > Show these fields – Displays fields which are currently displayed in the Medications grid. To hide these fields from the Medication grid, move them to the Available Fields section using the arrow buttons located between the sections of the dialog. Click OK to apply your changes or click Cancel to discard them. The Medications grid view changes according to your settings. Show Fields Dialog Clinical Documentation User’s Guide 217 Medications New Medication Dialog Patient>Clinical>Medications Use this dialog to enter a medication, which is not currently in the database. You can access this window by clicking in the Medication field of the Medications Window. New Medication Dialog New Medication Dialog Fields Code Enter the medication code, up to 10 alphanumeric characters. Name Enter the medication name, up to 30 alphanumeric characters. Other Name Enter other name of the medication if any, up to 50 alphanumeric characters. Medication Action Enter the description of medication action. Side Effects Enter side effects of the medication. 218 Clinical Documentation User’s Guide Medications Strength Enter the strength of the medication, up to 25 alphanumeric characters. Route Enter the route of administration for the medication, up to 2 alphanumeric characters. Form Enter the form of the medication, up to 4 alphanumeric characters. OK Click OK to add the new medication with the parameters you defined to the database and to assign it to the currently selected patient. Cancel Click Cancel to discard saving of the new medication. Clinical Documentation User’s Guide 219 Medications Select Medication Dialog Patient>Clinical>Medications Using the Select Medication dialog you can search for the existing in the database medication by the medication name, other name, and action criteria. You can also define the type of the medication (Medi‐Span Only, Non Medi‐Span Only, or Both) to narrow your search. The more criteria you specify, the more accurate the search results you will get. When you click the Search button, the medications that meet your criteria appear in the right section of the dialog. Select Medication Dialog Select Medication Dialog Fields Name Enter the name of the medication you want to search for. Other Name Enter the other name of the medication you want to search for. Action Enter the action of the medication you want to search for. 220 Clinical Documentation User’s Guide Medications Show Define the type of the medication you want to search for. Select one of the following radio buttons: • Medi‐Span Only – Select to search for Medi‐Span medications only. • Non Medi‐Span Only – Select to search for Non Medi‐Span medications only. • Both – Select to search for both, Medi‐Span and Non Medi‐Span medications. OK Click OK to assign the selected medication to the patient. Cancel Click Cancel not to assign the selected medication to the patient and close the Select Medication window. Medication Entry Dialog Patient>Clinical>Medications Using the Medication Entry dialog, you can define dose, dose units, and frequency for the selected medication. You can access this dialog by clicking Medications window. next to the Dose & Frequency field in the Medication Entry Dialog Medication Entry Dialog Windows Dose Enter the dose for this medication, up to 15 alphanumeric characters. Clinical Documentation User’s Guide 221 Medications Dose Units Enter dose units for this medication or select them from the drop‐down calendar. Frequency Enter the frequency for this medication or select it from the drop‐down calendar. OK Click OK to apply entered parameters. Cancel Click Cancel to discard entered parameters. 222 Clinical Documentation User’s Guide Medication Administration Record (MAR) Medication Administration Record (MAR) MAR Window Patient>Clinical>MAR Allscripts Homecare>MAR Using the MAR (Medication Administration Record) window, you can document the administration of all scheduled and PRN (as‐needed) medications to in‐facility hospice patients or homebound patients. You can work with the MAR window in the following modes: • Define ‐ Used to schedule the medications on the MAR. • Document ‐ Used to document the administration of medications. The MAR window consists of two tabs: • MAR Window ‐ Patient Info Tab • MAR Window ‐ Filter Tab MAR ‐ Define Mode Clinical Documentation User’s Guide 223 Medication Administration Record (MAR) MAR ‐ Document Mode MAR Window Fields New Click this button to add a new MAR for the patient. Activate/Deactivate Click this button to activate or deactivate the MAR for the patient. Define MAR/Document MAR Click to switch from Define to Document mode and vice versa. Delete MAR Click this button to remove the current MAR. 224 Clinical Documentation User’s Guide Medication Administration Record (MAR) Add Scheduled Medication Click this button to add a scheduled medication to the patient MAR. Add PRN Medication Click this button to add a PRN medication to the patient MAR. Move Up Click this button to move the selected medication up in the grid. Move Down Click this button to move the selected medication down in the grid. Remove Current Click this button to remove the selected medication from the MAR. View Meds not posted to MAR Click this button to view the list of the patient medications that were not entered in the current MAR. Mark MAR as Reviewed Click this button to mark this MAR as reviewed for accuracy of medications listed, dose, frequency, and route. Mark Selection as Given Click this button to mark this selection as given to the patient including dose, frequency, and route. Patient Signature Click this button to enable the patient to sign the MAR indicating that the listed medications were administered. The Patient’s Signature Capture window appears. Clinical Documentation User’s Guide 225 Medication Administration Record (MAR) MAR Window ‐ Patient Info Tab Use this tab to view the information about the patient for whom you are adding the MAR. MAR ‐ Patient Info Tab MAR Window ‐ Define Tab Fields Code Displays the ID of the patient associated with this MAR entered in Patient>General>Basic. This field is view only. Name Displays the first and last name of the patient associated with this MAR entered in Patient>General>Basic. This field is view only. DOB Displays the date of birth for the patient entered in Patient>General>Basic. This field is view only. Age Displays the current age of the patient entered in Patient>General>Basic. This field is view only. Admission Date Displays the admission date of the patient entered in Patient>General>Admissions&Status. This field is view only. Primary MD Displays the name of the patient primary physician entered in Patient>General>Admissions&Status. This field is view only. 226 Clinical Documentation User’s Guide Medication Administration Record (MAR) Diet Displays the diet requested for the patient, that was entered in Patient>Clinical>General Clinical. This field is view only. Allergies Displays the patient allergies entered in Patient>Clinical>General Clinical. This field is view only. Primary Dx Displays the patient primary diagnosis entered in Patient>General>Diagnosis. This field is view only. Secondary Dx Displays the patient secondary diagnosis entered in Patient>General>Diagnosis. This field is view only. Patient Location (optional) Displays the patient location. Enter the needed value in this field, up to 20 free‐text characters. Room Number (optional) Displays the room number where the patient is treated. Enter the needed value in this field, up to 20 free‐text characters. Reason Displays the reason for the MAR. Enter the needed value in this field or click down arrow to select it from the drop‐down list. Clinical Documentation User’s Guide 227 Medication Administration Record (MAR) MAR Window ‐ Filter Tab Use this tab to define the medications you want to view. MAR ‐ Filter Tab MAR Window ‐ Filter Tab Fields Scheduled Date Select this check box to filter the patient MARs by date. Enter the date by which you want to filter the MARs or click down arrow to select it from the drop‐down calendar. Scheduled Time Select this check box to filter this patient MARs by time. Enter the start and end time in the corresponding fields or click down arrow to select it from the drop‐down list. Show only held medications Select this check box to view only the medications on the MAR that were given to the patient. Show only ended/discontinued medications Select this check box to view only the medications on the MAR that are no longer given to the patient. 228 Clinical Documentation User’s Guide Medication Administration Record (MAR) Medications for Patient Window Use the Medications for Patient window to add scheduled and PRN medications to the patient’s MAR. You can access this window by clicking the Add Scheduled Medication or Add PRN Medication button in the MAR window. Note Note You can add medications to the MAR only if you are in Define mode. Medications for Patient Window Medications for Patient Window Fields Add Click this button to add the selected medication to the MAR. Close Click this button to close the Medications for Patient dialog and return to MAR window. Select All Click this button to select all the medications in the grid. Clear All Click this button to clear all the medications in the grid. Clinical Documentation User’s Guide 229 Medication Administration Record (MAR) Name Displays names of the medications that are available for selection. Start Date Displays the date when the patient should begin taking the drugs. End Date Displays the date when the patient should finish taking the drugs. Dose&Frequency Displays the dose and frequency of the medicine that should be taken. Route Displays the routes for the medications. Filter Displays the filter by which the information for the patient medication list is selected. Enter a character or combination of characters to filter the information on the patient medication list. The wildcard character (%) is permitted. Customize Click this button to create a custom filter for the patient medication list. The Filter builder dialog appears. 230 Clinical Documentation User’s Guide Medication Administration Record (MAR) Add Medication to MAR Window With this window, you can add a MAR for the medication automatically without accessing it directly. Add Medication to MAR Window Add Medication to MAR Window Fields Add as Define what type of medication you are assigning to the MAR using this section. You can choose from the following options: > > PRN ‐ Select this check box to indicate the medication as PRN. Schedule ‐ Select this check box to indicate the medication as scheduled. Post to MAR Duration Use this section to define the period of time the medication should be scheduled for. You can choose one of the following options: > > Day ‐ Select this radio button to schedule the medication for one day. The date field below the Date radio button becomes active. Enter the date for the scheduled medication there or click down arrow and select it from the drop‐down calendar. Range ‐ Select this radio button to schedule the medication for more than one day. The date fields below the Range radio button become active. Enter the begin and end dates in the corresponding fields or click down arrows and select them from the drop‐down calendars. Clinical Documentation User’s Guide 231 Medication Administration Record (MAR) Frequency Define the frequency for the medication using this section. You can set the following options: > > Predefined ‐ Click down arrow to select the predefined frequency for the medication if necessary. The frequencies are entered in Administration>Clinical>Medication Frequencies. Custom Frequency ‐ Click this button to define the settings for the frequency. The Frequency window appears. Define Frequency Window Use the Define Frequency window to enter the frequency for the scheduled medications that are to be administered. You can access the Define Frequency window by clicking the Add button in Medications for Patient window. Define Frequency Window Define Frequency Window Fields Post to MAR Duration Use this section to define the period of time for scheduling the medication. You can choose one of the following options: > 232 Day ‐ Select this radio button to schedule the medication for one day. The date field below the Date radio button becomes active. Enter the date for the scheduled medication there or click down arrow and select it from the drop‐down calendar. Clinical Documentation User’s Guide Medication Administration Record (MAR) > Range ‐ Select this radio button to schedule the medication for more than one day. The date fields below the Range radio button become active. Enter the begin and end dates in the corresponding fields or click down arrows and select them from the drop‐down calendars. Frequency With this section, you can define the frequency for the medication. You can set the following options: > > Predefined ‐ Click down arrow to select the predefined frequency for the medication if necessary. The frequencies are entered in Administration>Clinical>Medication Frequencies. Custom Frequency ‐ Click this button to define the settings for the frequency. Define Range Window Use this window to enter the range for the PRN medications that are to be administered. You can access the Define Frequency window by clicking the Add button in Medications for Patient window. Define Frequency Window Define Frequency window fields Post to MAR Duration With this field, you can define the period of time for scheduling the medication. You can choose one of the following options: > Day ‐ Select this radio button to schedule the medication for one day. The date field below the Date radio button becomes active. Enter the date for the medication there or click down arrow and select it from the drop‐down calendar. Clinical Documentation User’s Guide 233 Medication Administration Record (MAR) > Range ‐ Select this radio button to schedule the medication for more than one day. The date fields below the Range radio button become active. Enter the begin and end dates in the corresponding fields or click down arrows and select them from the drop‐down calendars. New/Edit Entry Window Patient>Clinical>MAR The New Entry window appears when you double‐click the Date/Time grid for the scheduled medications of the MAR window in Document mode. Use it to indicate whether the scheduled medication was given to the patient and enter the actual time for this. If it was not given to the patient, you must enter the reason for this in the Notes field. With the Edit Entry window, you can make changes to the information on the MAR entry you previously entered. Note Note You can edit only the records entered by yourself. Edit Entry Window Given Select this radio button if the medication was given to the patient. Not Given Select this radio button if the medication was not given to the patient. 234 Clinical Documentation User’s Guide Medication Administration Record (MAR) Actual Time Enter the time when the medication was given to the patient or click down arrow and select it from the drop‐down calendar. Now Click this button to fill the Actual Time field with the current time set on your computer. Notes Enter the information associated with the medication administration in this field, up to 100 characters. This field is obligatory if the Not Given radio button is selected. New PRN Entry Window Patient>Clinical>MAR The New PRN Entry window appears when you double‐click the Date/Time grid for the PRN medications of the MAR window in Document mode. Use it to document the administration of PRN medications that are subscribed for specific illness or condition based on patient signs or symptoms. You can also document patient response to the medication in this window. New PRN Entry Window Clinical Documentation User’s Guide 235 Medication Administration Record (MAR) New PRN Entry Window Fields Administer Date Enter the date the PRN medication was administered or select it from the drop‐down list. Time Enter the time the PRN medication was administered or use to set the needed number. Now Click this button to fill the Time field with the current time set on your computer. Route Enter the route by which this PRN medication was administered or select it from the drop‐down list. Site Enter the body site the PRN medication was administered through, up to 52 free‐text characters. Reason Enter the reason for administering this PRN medication, up to 100 free‐text characters. Response Date Enter the date of documenting the patient response to the PRN medication or select it from the drop‐down calendar. Time Enter the time of documenting the patient response to the PRN medication by typing it or use to set the needed number. Now Click this button to fill the Time field with the current time displayed on your computer. 236 Clinical Documentation User’s Guide Medication Administration Record (MAR) Symptoms Relieved Select if the patient symptoms were relieved after taking the PRN medication. Symptoms Improved Select if the patient symptoms were improved after taking the PRN medication. No Relief Select if the patient symptoms did not change after taking the PRN medication. Free text notes Select this radio button to enter additional details about the patient response to the PRN medication, up to 50 free‐text characters. Patient’s Signature Capture Window This window opens when you click Signature in the MAR window. Use this window to append patient’s signature as a bitmap image to MAR medications that are documented. Note Note If you change a documented medication after a signature was appended, the system removes the signature. Patient’s Signature Window Clinical Documentation User’s Guide 237 Medication Administration Record (MAR) Patient’s Signature Capture Window Fields Medications without Signature Select this radio button to view all the MAR medications that were not signed by the patient. Medications with Signature Select this radio button to view all the MAR medications that were signed by the patient. Medication Displays the names of medications assigned to thepatient. Entry Time Displays the time when the entry was administered. Administered By Displays the name of the physician who entered the information in the MAR. Arrow Click to select the signature and move it on the screen. Draw Click , and holding your left mouse button, drag the pointer to draw a signature. Erase Click , and holding your left mouse button, drag the pointer to erase a signature. Clear Click 238 to clear the signature in the signature area. Clinical Documentation User’s Guide Medication Administration Record (MAR) Create New MAR 1. Open the Patient component. 2. Select the patient for whom you want to create a new MAR. 3. From the menu bar, select Clinical>MAR. 4. If the patient does not have MAR defined yet, the Confirm dialog appears asking you whether you want to create a new MAR. Click Yes. OR If the patient has a MAR record already, the MAR window appears in Define mode. To define a new MAR, click New. 5. The MAR window appears in Define mode. Enter the values in the fields as needed. 6. Click to save the changes. Activate MAR 1. Open the Patient component. 2. Select the patient for whom you want to activate the MAR. 3. From the menu bar, select Clinical>MAR. 4. Create a new MAR and save your changes or select an inactive MAR. 5. The MAR window appears in Define mode. Click Activate. 6. The Confirm dialog appears asking you if you want to activate the current MAR. Click Yes. 7. The Specify MAR Activation Date window appears. 8. Enter the date to activate the MAR or click and select it from the drop‐down calendar. 9. Click OK. 10. Click to save the changes. Clinical Documentation User’s Guide 239 Medication Administration Record (MAR) Deactivate MAR 1. Open the Patient component. 2. Select the patient for whom you want to deactivate the MAR. 3. From the menu bar, select Clinical>MAR. 4. Select an active MAR you want to deactivate. 5. The MAR window appears in Define mode. Click Deactivate. 6. The Confirm dialog appears asking you whether you want to deactivate the current MAR. Click Yes. Note If you deactivate the MAR, it cannot be activated again. 7. Click to save the changes. Mark MAR as Reviewed 1. Open the Patient component. 2. Select the patient whose MAR you want to mark as reviewed. 3. From the menu bar, select Clinical>MAR. 4. The MAR window appears in Define mode. Click Mark MAR as Reviewed. 5. The Confirm dialog appears indicating that the MAR was reviewed. 6. Click OK. The review date and time and the reviewer’s initials appear in the Last MAR review date field at the bottom of the window. 7. Click to save the changes. Adding Scheduled Medication to MAR 1. Open the Patient component. 2. Select the patient for whom you want to add scheduled medication to the MAR. 3. From the menu bar, select Clinical>MAR. 4. Create a new MAR or open the existing one. 240 Clinical Documentation User’s Guide Medication Administration Record (MAR) The MAR window appears in Define mode. 5. Click Add Scheduled Medication. The Medications for Patient window appears. 6. Highlight the medication that you want to schedule in the grid. 7. Click Add to add the scheduled medication to the MAR. The Define Frequency window appears. 8. Enter the values in the fields as needed. 9. Click OK to close the Define Frequency dialog and go back to the Medications for Patient window. 10. Click Close to close the Medications for Patient window. The medication appears in the Scheduled Orders grids. 11. Click to save the changes. Add PRN medication to MAR 1. Open thePatient component. 2. Select the patient for whom you want to add PRN medication to the MAR. 3. From the menu bar, select Clinical>MAR. 4. Create a new MAR or open the existing one. The MAR window appears in Define mode. 5. Click Add PRN Medication. The Patient Medications dialog appears. 6. Highlight the medication that you want to administer in the grid. 7. Click Add to add the PRN medication to MAR. The Define Range window appears. 8. Enter the values in the fields as needed. 9. Click OK to close the Define Ranges dialog and go back to the Medications for Patient window. 10. Click Close to close the Medications for Patient window. The medication appears in the PRN grids in the lower part of the window. 11. Click to save the changes. Clinical Documentation User’s Guide 241 Medication Administration Record (MAR) Update Active MAR with New Medications 1. Open the Patient component. 2. Select the patient for whom you want to update the active MAR with new medications. 3. From the menu bar, select Clinical>Medications. 4. The Medications window appears. Enter the new medication ordered for the patient in the Medication column. 5. Enter the values in other columns as appropriate. 6. Save your changes. 7. If the patient has an active MAR, a dialog box appears asking whether you want to add the medication you just entered to the patient’s active MAR. Click Yes. The Add Medication to MAR window appears. 8. Enter the values in the fields as appropriate. 9. Click OK. The medication appears on the patient’s active MAR. Note If the patient’s MAR was open while you were adding the new medication, exit the MAR window and open it again to see the new medication on the MAR. Change Medication Administration Time on MAR 1. Open the Patient component. 2. Select the patient with an active MAR for whom you want to change medication administration time. 3. From menu bar, select Clinical>MAR. 4. The MAR window appears. Click Define MAR if the MAR is not in Define mode yet. 5. Double‐click the medication for which you want to change administration time. The Medication Frequencies window appears. 6. Double‐click the frequency you want to edit. The Define Frequency window appears. 7. In the Frequency field, click to select a new predefined frequency with new administration time or click Custom frequency to define the administration time manually. 242 Clinical Documentation User’s Guide Medication Administration Record (MAR) 8. Click OK to confirm the new administration time. 9. Click to save the changes. Document Administration of Scheduled Medications on MAR 1. Open the Patient component. 2. Select the patient for whom you want to document the administration of the scheduled medications on the MAR. 3. From the menu bar, select Clinical>MAR. 4. The MAR window appears. Click Document MAR if the MAR is not in Document mode yet. 5. Double‐click the medication in the Scheduled Orders grid. 6. The New Entry window appears. Enter the needed values in the fields. 7. Click OK to save the changes. The initials of the clinician administering the medication appear on the medication line in the date and time you selected. 8. Click to save the changes. Edit MAR Entries 1. Open the Patient component. 2. Select the patient with an active MAR for whom you want to edit the MAR entry. 3. From the menu bar, select Clinical>MAR. 4. The MAR window appears. Click Document MAR if the MAR is not in Document mode yet. 5. Double‐click an existing medication administration entry from the grid. OR Right‐click the entry and select Edit. The Edit Entry window opens. 6. Change the values in the fields as appropriate. 7. Click OK. 8. Click to save the changes. Clinical Documentation User’s Guide 243 Medication Administration Record (MAR) Document Administration of PRN Medications on MAR 1. Open the Patient component. 2. Select the patient for whom you want to document the administration of PRN medications on MAR. 3. From menu bar, select Clinical>MAR. 4. The MAR window appears. Click Document MAR if the MAR is not in Document mode yet. 5. Double‐click the medications the PRN grid. The PRN New Entry window appears. 6. Enter the necessary values in the Administer Date, Time, Route, Site, and Reason fields as appropriate. 7. Click OK. 8. Click to save the changes. Document Response for PRN Medication on MAR Note Note You can document a response even if you did not administered the medication. 1. Open the Patient component. 2. Select the patient for whom you want to document the response for PRN medications on MAR. 3. From menu bar, select Clinical>MAR. 4. The MAR window appears. Click Document MAR if the MAR is not in Document mode yet. 5. Double‐click the medications the PRN grid. The PRN New Entry window appears. 6. Enter the necessary values in the Response Date and Time fields and select one of the radio buttons below depending on the changes in the patient condition. 7. Click OK. 8. Click 244 to save the changes. Clinical Documentation User’s Guide Medication Administration Record (MAR) Append Patient’s Signature to MAR Medication 1. Open the Patient component. 2. Select the patient for whom you want to append the signature to the MAR medication. 3. From the menu bar, select Clinical>MAR. 4. The MAR window appears. Click Document MAR if the MAR is not in Document mode yet. 5. Click Signature. The Patient’s Signature Capture dialog appears. 6. Select the medications you want to append the patient’s signature to. 7. Click 8. Click , and holding the left mouse button, drag the cursor to sign. to save the changes. Clinical Documentation User’s Guide 245 MAR Review Status Report MAR Review Status Report MAR Review Status Window Patient>Documents>MAR>MAR Review Status, Reports>Clinical>MAR>MAR Review Status Using the MAR Review Status window, you can preview and print a report that shows all patients with an active admission status who have an active MAR that has not been marked as reviewed in the last 24 hours or more. MAR Review Status Window Fields MAR Review Status Window Fields Resource Type Select the check boxes next to the resource types you want to include in this report. Staff Types Click to select the staff types you want to include in this report. Clear All Click to deselect all items in the grid that are currently selected. 246 Clinical Documentation User’s Guide MAR Review Status Report Select Click to select the patients to include in this report. Export to ASCII file Select this check box to export the data from this report to an ASCII file. Generating a MAR Review Status Report 1. Go to Patient>Documents>MAR>MAR Review Status. OR Go to Reports>Clinical>MAR>MAR Review Status. The MAR Review Status window opens with the Define tab active. 2. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 3. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 4. Click Print to print the report. Clinical Documentation User’s Guide 247 Medication Administration Actual vs.Scheduled Report Medication Administration Actual vs. Scheduled Report Medication Administration Actual vs. Scheduled Report Generated The Medications Administration Actual vs. Scheduled report displays the information about the patients that meet the following criteria: • Have an active admission status and active MAR (Medical Administration Record). • Have changes in the scheduled medication administration time during the specified date range. The information on the report is sorted by patient last name. Information on the Medication Administration Actual vs. Scheduled Report Field Name Actual Time when the medication was actually taken. Scheduled Time the medication was scheduled for. Medication Name of the medication. Staff Name Name of the physician who gave the medication to the patient. Logging Change Time when the information was entered by the physician. Reason for Change Reason why the time for medication was changed. Patient 248 Description Patient ID and first and last names. Clinical Documentation User’s Guide Medication Administration Actual vs. Scheduled Report Example of the Medication Administration Actual vs. Scheduled Report Medication Administration Actual vs. Scheduled Report Generated Medication Administration Actual vs. Scheduled Window Patient>Documents>MAR>Medication Administration Actual vs. Scheduled Reports>Clinical>MAR>Medication Administration Actual vs. Scheduled MAR>Documentation>Medication Administration Actual vs. Scheduled With the Medications Administration Actual vs. Scheduled window, you can preview and print information on the patients with an active admission status and MAR and have the scheduled medication administration time changed during the specified date range. Two tabs are available in this window: > Medication Administration Actual vs. Scheduled ‐ Define Tab > Preview tab Clinical Documentation User’s Guide 249 Medication Administration Actual vs. Scheduled Report Medication Administration Actual vs. Scheduled ‐ Define Tab Use the Define tab to choose the information that you want to include in the report. You can also use the Preview tab to view a sample report onscreen. Medication Administration Actual vs. Scheduled ‐ Define Tab Medication Administration Actual vs. Scheduled – Define Tab Fields Date Range Select the time period the report should be generated for. > > Begin Date ‐ Enter the date you want the application to use as the first date for this reporting period or click down arrow and select it from the drop‐down calendar. End Date ‐ Enter the date you want the application to use as the last day for this reporting period or click down arrow and select it from the drop‐down calendar. Resource Types Use this section to choose the resource types that you want to be in the report. > > > 250 Include ‐ Indicates whether the corresponding resource type will be included in the report. By default, all check boxes are clear, so you need to select the check boxes opposite the resource types you want to be in the report. Code ‐ Displays the codes of the resource types that are available for selection. Description ‐ Displays the description of the resource types that are available for selection. Clinical Documentation User’s Guide Medication Administration Actual vs. Scheduled Report Manage the information using the following buttons: > Click Staff Types to choose the appropriate resource types for the report. The Resource Types window opens. Select the check boxes opposite the resource types you want to be in the report. Click OK. Show only records exceeding medication administration allowed range (X minutes) Select this check box if you want the records that are outside of allowed administration range to be included in the report. X is set in Administration>Configuration>Business Units>Settings>Medications. Generating Medication Administration Actual vs. Scheduled Report 1. Open the Medication Administration Actual vs. Scheduled report. You can open the Medication Administration Actual vs. Scheduled report from the following components: Reports>Clinical>MAR>Medication Administration Actual vs. Scheduled, Patient>Documents>MAR>Medication Administration Actual vs. Scheduled, or MAR>Documents>Medication Administration Actual vs. Scheduled. 2. The Medications Administration Actual vs. Scheduled window appears with the Define tab active. Enter the values in the fields as appropriate. 3. Select the Preview tab to view the report onscreen. 4. Click Print to print the report. Note If you change the criteria on the Define tab after preview, those changes do not take effect the next time you preview the report. You should click Close on the Preview tab and then click the Preview tab again. Clinical Documentation User’s Guide 251 Medication Evaluation Report Medication Evaluation Report Medication Evaluation Report – Generated Patient>Documents>Medication Evaluation The Medication Evaluation report displays information on the evaluation of medications prescribed for an individual patient. This report includes information about the patient for whom medications were evaluated, occurrence of different side effects, drug interactions and reactions, ineffective or duplicate drug therapy, dosage errors, omissions of the evaluated medications, and additional comments. The report is based on information entered in the Medication Evaluation section in Patient>Clinical>Medications. Information on the Medication Evaluation Report Field Name Patient Code Code of the patient for whom medication evaluation was performed. The codes are assigned to patients in Patient>General>Basic. Patient Name First and last names of the patient for whom medication evaluation was performed. SOC Date The patient's admission date. This date is obtained from the current admission date in Patient>General>Admissions & Status. Evaluation Date The date of medication evaluation. Drug Interactions Displays Yes if drug interactions were present for the evaluated medications. Comments to the drug interactions are printed below the caption, if applicable. Significant Side Effects Displays Yes if significant side effects were present for the evaluated medications. Comments to the significant side effects are printed below the caption, if applicable. Duplicate Drug Therapy Displays Yes if duplicate drug therapy was present for the evaluated medications. Comments to the duplicate drug therapy are printed below the caption, if applicable. Ineffective Drug Therapy Displays Yes if ineffective drug therapy was present for the evaluated medications. Comments to the ineffective drug therapy are printed below the caption, if applicable. Drug Reactions 252 Description Displays Yes if drug reactions were present for the evaluated medications. Comments to the drug reactions are printed below the caption, if applicable. Clinical Documentation User’s Guide Medication Evaluation Report Field Name Description Omissions Displays Yes if omissions were present for the evaluated medications. Comments to the omissions are printed below the caption, if applicable. Dosage Errors Displays Yes if dosage errors were present for the evaluated medications. Comments to the dosage errors are printed below the caption, if applicable. Non Compliance Displays Yes if noncompliance was present for the evaluated medications. Comments to the noncompliance are printed below the caption, if applicable. Comments Additional comments related to the documented medication evaluation. Example of the Medication Evaluation Report Clinical Documentation User’s Guide 253 Medication Evaluation Report Medication Evaluation Window Patient>Documents>Medication Evaluation Using the Medication Evaluation window, you can preview and print information on the evaluation of medications for a patient within the defined date range. To learn more about the generated Medication Evaluation report, see the Medication Evaluation Report – Generated section. The Medication Evaluation window contains the following tabs: > Define Tab > Preview tab With the help of this window you can generate the report. Medication Evaluation Report – Define Tab Use the Define tab to specify the information you want to include in the report. You can also use the Preview tab to view a sample report onscreen. Medication Evaluation Report – Define Tab Medication Evaluation Report – Define Tab Fields Date Range Select the time range the report should be generated for. > > 254 Begin Date – Enter the start date. End Date – Enter the end date. Clinical Documentation User’s Guide Medication Evaluation Report Generating Medication Evaluation Report 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Medication Evaluation. The Medication Evaluation window appears with the Define tab active. 4. Select the time period the report should be generated for in the Date Range section. Note Help is available for each field in this window by pressing F1 while in the field. 5. Click the Preview tab to view an onscreen preview of the report based on the parameters you entered. Note If you change the criteria on the Define tab after preview, those changes do not take effect until the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 6. Click Print to print the report. 7. Click to save the report in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide 255 Print MAR Documents Print MAR Documents Print MAR Window Patient>Documents>MAR>Print MAR, Reports>Clinical>MAR>Print MAR Using the Print MAR window, you can preview and print a blank MAR to be filled in manually, or MARs for a selected patient within a specified date range. You can specify whether to exclude medications on hold from the printed MAR, or whether to include all current medications. Scheduled medications are included on this report including if they have been administered (date, time, initials), or if they are due to be administered (time). You can also access this report through Reports>Clinical>MAR>Print MAR. Print MAR Window Print MAR Window Fields Begin Date Specify the date you want the system to use as the beginning date for this report. End Date Specify the date you want the system to use as the end date for this report. 256 Clinical Documentation User’s Guide Print MAR Documents Blank Select Blank to print a blank MAR form to be filled in manually. Patients Select the patients to print MARs for a selected patient during the specified date range, and click the Patients button to select the patients to include in the report. Include Medications Click to select whether to include all medications excluding medications on hold, or current medications including medications on hold. Generating MAR 1. Go to Patient>Documents>MAR>Print MAR. OR Go to Reports>Clinical>MAR>Print MAR. The Print MAR window opens with the Define tab visible. 2. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 3. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 4. Click Print to print the report. Clinical Documentation User’s Guide 257 PRN Medications Administered Report PRN Medications Administered Report PRN Medications Administered With and Without Response Window Patient>Documents>MAR>PRN Medications Administered With and Without Response, Reports>Clinical>MAR>PRN Medications Administered With and Without Response Using the PRN Medications Administered With and Without Response window, you can preview and print a report that shows all MARs within a specified date range where PRN medications were administered, and whether those PRN medications had a response recorded. This report can be sorted by patient last name or by administering staff member’s last name. PRN Medications Administered With and Without Response Window PRN Medications Administered With and Without Response Window Fields Begin Date Specify the date you want the system to use as the beginning date for this report. End Date Specify the date you want the system to use as the end date for this report. Sort Options Select By Patient to sort the report by patient last name. Select By Staff to sort by administering staff member’s last name. 258 Clinical Documentation User’s Guide PRN Medications Administered Report Select Click All Patients or Specific Patients to include in this report. Generating a PRN Medications Administered With and Without Response Recorded Report 1. Go to Patient>Documents>MAR>PRN Medications Administered With and Without Response Recorded. OR Go to Reports>Clinical>MAR>PRN Medications Administered With and Without Response Recorded. The PRN Medications Administered With and Without Response Recorded window opens with the Define tab visible. 2. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 3. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 4. Click Print to print the report. Clinical Documentation User’s Guide 259 Undocumented Medication Administration Report Undocumented Medication Administration Report Undocumented Medication Administration Window Patient>Documents>MAR>Undocumented Medication Administration, Reports>Clinical>MAR>Undocumented Medication Administration Using the Undocumented Medication Administration window, you can preview and print a report that shows all patients with an active admission status who have an active MAR where a scheduled medication has not been documented against and the scheduled date for administration has passed. Undocumented Medication Administration Window Undocumented Medication Administration Window Fields Begin Date Specify the date you want the system to use as the beginning date for this report. End Date Specify the date you want the system to use as the end date for this report. Select Click to select the patients to include in this report. 260 Clinical Documentation User’s Guide Undocumented Medication Administration Report Export to ASCII file Select this check box to export the datafrom this report to an ASCII file. Generating Undocumented Medication Administration Report 1. Go to Patient>Documents>MAR>Undocumented Medication Administration. OR Go to Reports>Clinical>MAR>Undocumented Medication Administration. The Undocumented Medication Administration window opens with the Define tab visible. 2. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 3. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 4. Click Print to print the report. Clinical Documentation User’s Guide 261 Medication Descriptions Report Medication Descriptions Report Medication Descriptions Report Window Reports>Clinical>Medication Descriptions The Medication Descriptions window enables you to preview and print instructions, side effect information, and cautions for each medication that a patient is taking. You can select the patients for whom you want to print medication descriptions. You can also choose to print only medications that the patients were taking as of a certain date. You can print the descriptions in order by team. You can also print medication descriptions for individual patients through Patient>Documents and through the Orders component. Medication Descriptions Report 262 Clinical Documentation User’s Guide Medication Descriptions Report Generating Medication Descriptions 1. Open the Reports component. 2. Go to Clinical>Medication Descriptions. The Medication Descriptions window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 263 Patient Documents – Medication Descriptions Patient Documents – Medication Descriptions Medication Descriptions Window Patient>Documents>Medication Descriptions Using the Medication Descriptions window, you can preview and print instructions, side effect information, and cautions for each medication that a patient is taking. You can choose to print only medications that the patient was taking as of a certain date. If your agency has installed Medi‐Span, then the description for each medication comes directly from Medi‐Span. If your agency has chosen to manually enter each medication in the Administration component, then the medication descriptions come from that information. If you are using Medi‐ Span and have entered medication actions and side effects into your medication data definition, the report also includes that information. If you have selected the Load Spanish Teaching Sheets option in Administration>Configuration>Business Units>Settings>Medi‐Span tab, you have the option to print the Medication Descriptions document in English or Spanish. You can also print medication descriptions for a selected group of patients through the Demand Documents option of the Orders component and in Reports>Clinical. You can view and print medication descriptions in Field Mode. Medication Descriptions Window As of Date Specify the date to include on the report only medications that patients were taking as of that date. Page Break Select the Page Break check box to include a page break between each medication description. 264 Clinical Documentation User’s Guide Patient Documents – Medication Descriptions Language Click English to view or print the Medication Descriptions document in English. Click Spanish to view or print the Medication Descriptions document in Spanish. Generating Medication Descriptions Report The Medication Descriptions document in the Patient component allows you to preview/print the medication descriptions for a particular patient. The Medication Descriptions document in the Orders component allows you to preview/print the medication descriptions for a group of patients or a particular patient. 1. Open the Patient component and select the correct patient. 2. Go to Documents>Medication Descriptions. The Medication Descriptions window opens. 3. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 4. Click Print to print the selected medication descriptions. 5. Choose the Preview tab to preview the selected medication descriptions onscreen. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. . Clinical Documentation User’s Guide 265 Medication Lists Report Medication Lists Report Medication Lists Report Window Reports>Clinical>Medication Lists The Medication Lists window enables you to preview and print a list of all medications that the selected patients are taking. You can choose to print only medications that the patients were taking as of a certain date and exclude discontinued medications. You can also print the list in order by team and for a specific branch. You can also print medication lists for individual patients through Patient>Documents and the Orders component. Medications can be entered in two windows: The Medications entry window or the Clinical Notes window in Patient>Clinical. The Medication List prints all medications that were recorded for the patient, regardless of where they were entered. Medication Lists Window Branch Do you want to include a specific branch as of reporting service date, click and select it. If you select a branch, the branch description appears as a subheading on the report and high‐ level grouping is by branch. 266 Clinical Documentation User’s Guide Medication Lists Report Generating Medication Lists Report 1. Open the Reports component. 2. Go to Clinical>Medication Lists. The Medication Lists window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 267 Patient Documents – Medication Lists Patient Documents – Medication Lists Medication Lists Window Patient>Documents>Medication Lists Using the Medication Lists window, you can preview and print a list of all medications that a patient is taking. You can choose to print only medications that the patient was taking as of a certain date and exclude discontinued medications. The report includes patient name, ID, primary payer, primary diagnosis, team, medication descriptions, dosage/frequency, whether the medication is covered or non‐covered, and when the patient began and stopped taking the medication. You can also print medication lists for a selected group of patients in Orders>Demand Documents and in Reports>Clinical. Medications can be entered in two ways in the application: The Medications entry window in Patient>Clinical or the Clinical Notes window also located in Patient>Clinical. The Medication List prints all medications that have been recorded for the patient, regardless of where they were entered. You can view and print medication lists in Field Mode. Medication Lists Window Medication Lists Window Fields As of Date Specify the date to include on the report only medications that patients were taking as of that date. 268 Clinical Documentation User’s Guide Patient Documents – Medication Lists Exclude discontinued meds Select this check box to include only medications that the patients are currently taking. Print or Preview Medication Lists The Medication Lists document in the Patient component allows you to preview/print the medication lists for a particular patient. The Medication Lists document in the Orders component allows you to preview/print the medication lists for a group of patients or a particular patient. 1. Open the Patient component. 2. Select the correct patient. 3. Go to Documents>Medication Lists. The Medication Lists window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected medication lists. OR Choose the Preview tab to preview the selected medication lists onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Medication lists are also available in the Orders and Reports components. Clinical Documentation User’s Guide 269 Pharmacy Medication List Report Pharmacy Medication List Report Pharmacy Medication List Report Window Reports>Clinical>Pharmacy Medication List The Pharmacy Medication List report enables you to print information for pharmacy notification. It prints one page per patient per medication for all a patient's medications. You can print the report for individual patients, patients on a Patient List, prospective patients, patients in the latest orders run, all active patients, or all active patients on a selected team. You can also run this report for a specific branch. The report includes patient information such as ID, name, address, admit and termination date. It also shows resource information and the description, dose, frequency, route, and start date for each of the patient's medications. If more than one pharmacy is assigned to a patient, a separate page prints for each. Pharmacy Medication List Report As of Date Click and choose the date on which you want to take a "snapshot" of patients' medication information. 270 Clinical Documentation User’s Guide Pharmacy Medication List Report Assignment Click and choose the assignment type for which you want to print this Pharmacy Medication List Report. To print medication information for pharmacies, choose Pharmacy as the assignment. Sequence Click and choose the sort order you want to use for this Pharmacy Medication List Report. Mode If you want to print the report for: > > > > > > All active patients, click All Active Patients. All active patients on a certain team, click All Active Patients for One Team. All patients in the latest orders run, click All Patients in Latest Orders Run. Selected patients, click Individual Patients. Patients on a Patient List, click Use "Select Patients" List. All prospective patients, click Choose All Prospective Patients. Include discontinued meds If you want to include discontinued medications on the report, select the check box. If not, clear the check box or leave the box unchecked if it is not checked. Branch If you want to include a specific branch as of report range end date, click and select it. Note If you select a branch, the branch description appears as a subheading on the report and high‐level grouping is by branch. Clinical Documentation User’s Guide 271 Pharmacy Medication List Report Generating Pharmacy Medication List 1. Open the Reports component. 2. Go to Clinical>Pharmacy Medication List. The Pharmacy Medication List window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. 272 Clinical Documentation User’s Guide Chapter 5 ‐ Orders In This Chapter In this chapter, you can find information about creating, managing and processing different kinds of orders, rejecting orders, and also generating various reports that provide information on orders. The chapter consists of the following sections: • • • • • • • Creating Orders Processing Orders Managing Returned Orders Active Orders Report Orders Signature Report View Orders Viewing Order Reports Clinical Documentation User’s Guide 273 Creating Orders Creating Orders About Orders Orders contain instructions for the care of the patient by the Home Health or Hospice agency and must be signed by a physician or other as determined by Federal and State law. Once an order is created, it can be added to an Order Run. Then it can be printed, corrected, approved, reprinted, and sent to the physician. Electronic orders do not need to be printed and are sent directly to Physician Portal for electronic signature. Orders can also be rejected on Physician Portal or when updating the status of signed orders. They may be managed and tracked through a number of reports. Creating Orders The initial certification order must be created before a supplemental order can be generated. 1. In the Patient component, select the appropriate patient. 2. Complete the following clinical entries in Patient>Clinical that generate orders: • General Clinical (only for certification orders) • Medications • Projected Visits • Problems (goals and interventions) Note: The goals and interventions generate an order only when specified in the Orders field in Administration>Clinical>Problems. • Clinical Notes of the “O” use code (for orders) only if cannot be added through the autogenerated options 3. Save your changes. 4. Go to Patient>Documents>View Orders and preview the order. If any errors are found, change the appropriate clinical items and review the order again. 274 Clinical Documentation User’s Guide Creating Orders Order Statuses In the Allscripts Homecare application, orders can have different statuses that show what processing stage they are in: Status Definition R (Generated) Order is generated in the system as soon as clinical items for the order are entered. L (Linked) Order becomes linked when you add it to an Order Run. P (Printed) Order is printed when you print it from an Order Run. Order is on hold when you try to print paper or approve electronic orders, but the physician is not PECOS enrolled. C (Corrected) Order is corrected if you make non‐clinical changes and then click Force a Correction in an Order Run, or if the order was printed and clinical changes are made. There is a short processing delay. X (Rejected) Order is rejected via the Process Signed Orders functionality or Physician Portal. Rejected orders are inactive and noneditable. A (Approved) Order is approved when you approve it in an Order Run. Clinical Documentation User’s Guide 275 Creating Orders Creating Corrected Orders Generally, clinical entries (medications, projected visits, goals and interventions, clinical notes, and other items) can be edited before an order has been approved and sent to the physician. The way you create a corrected order depends on its status. For more information on statuses, see Order Statuses. Status To correct R (Generated) L (Linked) Make your corrections and all changes are available when you preview the order again. P (Printed) Make your corrections, select the corresponding printed orders and click Force a Correction in the Order Run to reflect your changes. The order status changes from ”P” (printed) to “C” (corrected). Corrected orders for paper signature need to be reprinted before approval. X (Rejected) Rejected orders are inactive and non‐editable. The system generates a new order with the identical clinical information. Rejected orders are corrected through reprocessing by the general workflow. A (Approved) Once an order has been approved (“A”), any clinical changes appear on a supplemental order. If there are some changes in general clinical (from Patient>Clinical>General Clinical), non‐clinical information and clinical note of the “E” use code (encounter), use Printing Corrected Orders to reflect the changes. To print a copy of the order for MD#2 and MD#3, you can use Reprinting Orders. Managing Open Orders The following reports help manage open orders: > > Open Orders Report shows what orders have been printed, reviewed by the agency, sent to the physician but not returned yet. > 276 Orders Alert Report displays any patients who do not have initial certification order generated and the patients who need recertification orders. Orders Audit Report shows the status of orders and the physician’s signature status. Clinical Documentation User’s Guide Processing Orders Processing Orders Processing Orders Workflow Orders>General>Order Run 1. Defining an Order Run or Selecting an Order Run to Process. 2. Printing Orders. Note: Printing orders is not a required step for the Physician Portal users, so they can approve orders with linked and corrected statuses. 3. Approving Orders. Order Run Window Defining an Order Run Defining an Order Run is a two‐step process: naming it and selecting the orders for this Order Run. 1. Go to Orders>General>Order Run. 2. Verify that the Open Run option is selected. 3. Click to add a new run. 4. Type the name of the Order Run and click OK. Note: Naming the Order Run is strictly a way to identify the run. It does not prevent other users from selecting the Order Run. Your agency should determine a standard naming convention for Order Runs so they are easy to identify. Clinical Documentation User’s Guide 277 Processing Orders 5. In the Select Order Run window, double‐click the Order Run you just named. The window for the selected Order Run opens with the Define tab active. 6. Click and select orders for the run in the Select Orders dialog. Only orders not yet assigned are available for selection. You can select either all or specific patients and then select the check boxes next to the orders you want to include in the Order Run. Use Expand All to see the orders of the selected patients and Select All to select all orders for all patients. Also, you can select orders by class, team, branch, or order type. 7. Click OK. Orders’ status becomes “L” (linked). 8. You may print the orders and review on paper, or review them on screen. Corrections can be made until an order is approved. Selecting an Order Run to Process 1. Go to Orders>General>Order Run. 2. Click the Open Run radio button. You can change only open Order Runs that contain some unapproved orders. You can add or remove only not printed orders. 3. Double‐click the Order Run you want to process. You can add new orders, preview, print, and approve orders. You can click Select Orders to select orders in bulk: paper, electronic, printed and so on. Approving an order means that it is ready to be mailed to the MD, or it is available for electronic signature on Physicians Portal. Once all orders in the Order Run have been approved, that Order Run automatically becomes closed. 278 Clinical Documentation User’s Guide Processing Orders Printing Orders You can print orders within the Order Run. By printing an order, its status changes to printed (“P”) allowing you to approve the orders for paper signature, or “H” meaning that the order is on hold because the physician is not PECOS enrolled (due to settings in Administration>Financial>Insurance Codes). If you print approved or rejected orders, their statuses do not change. For the Physician Portal orders, which are grouped under the Electronic Signature section, approving is allowed without printing. To print orders: 1. Go to Orders>General>Order Run. 2. Select the orders you want to print. You can select the MD#2 or MD#3 check boxes to print duplicate copies of the order for other physicians. The system prints the physician’s name in the appropriate areas on the order instead of the primary physician’s name. 3. Click Preview. 4. Click . The status of the order becomes “P”. An orders register is printed after orders. If the status changes to “H”, it means that the order is on hold because the physician is not PECOS enrolled. When the physician becomes enrolled, then the status automatically changes to “P”. Before the orders are approved, you can change and reprint orders as many times as you want using the Force a Correction button. Approving Orders For non Physician Portal users, an order cannot be approved unless its status is printed (“P”). By approving an order, its status changes to approved (“A”). When the order has been signed with some changes made on Physician Portal, you can preview and print it in the Order Run to which this order was linked. To approve orders: 1. Go to Orders>General>Order Run. 2. Double‐click the Order Run containing the orders you want to approve. 3. Select the orders you want to approve. Clinical Documentation User’s Guide 279 Processing Orders Printing of orders for paper signature is a necessary step prior to their approval. The Physician Portal orders, which are grouped under the Electronic Signature section, can be approved without printing. 4. Click Approve. The Approval window reappears with the Save button available. The window displays all orders ready for approval, so you can select more orders if needed. 5. Click Save. The orders appear highlighted in green with the approved status (“A”). The Physician Portal orders are available for review and signature on the portal. After an order is approved and contained in a closed run, you can reprint it but the system only reproduces the last stored image at the time of approval. If the status changes to “H”, it means that the order is on hold because the physician is not PECOS enrolled. When the physician becomes enrolled, then the status of portal orders changes to “P”, so you need to approve these orders again. Printing Corrected Orders With the Print Corrected Orders functionality, you can correct previously printed and approved orders when there has been a change to the patient’s non‐clinical information or the information in Patient>Clinical>General Clinical and update the order with the clinical note with the “E” use code (encounter). To print corrected orders: 1. Go to Orders>General>Print Corrected Orders. 2. Select the appropriate patient. The patient’s orders appear in the grid. The Physician Portal orders appear in the Electronic Signature section. 3. Include the orders you want to print. 4. Click the Preview tab. 5. Click . The paper size for printing orders must be set to Letter. 280 Clinical Documentation User’s Guide Processing Orders Reprinting Orders Orders>General>Reprint Orders With the Reprint Orders window, you can reprint new copies of previously approved orders and print copies for MD#2 and MD#3. Reprinting orders does not change orders tracking in any way. You can reprint orders by patient, physician, or Order Run. Reprint Orders Window Reprinting Orders by Patient or Physician 1. Go to Orders>General>Reprint Orders. 2. Select the Patient or Physician radio button. 3. Select the appropriate patient or physician. If you are using Physician Portal, the orders appear in the Electronic Signature section. 4. Select the appropriate orders to reprint. 5. Click the Preview tab. 6. Click Print. The paper size for printing orders must be set to Letter. 7. Click Close. Clinical Documentation User’s Guide 281 Processing Orders Reprinting Orders by Order Run 1. Go to Orders>General>Reprint Orders. 2. Select the Order Run radio button. 3. Click Select Run. 4. Select either the Open Run or Closed Run radio button as appropriate. The Select Order Run dialog opens. 5. Select the Order Run that you want to reprint. You can select the Only My Own Run check box to display only the runs you created in the selection grid. If you are using Physician Portal, the orders appear in the Electronic Signature section. 6. Click OK. 7. Select the appropriate orders to reprint. 8. Click the Preview tab. 9. Click Print. The paper size for printing orders must be set to Letter. 10. Click Close. Tracking Orders After the orders have been approved and sent to the physicians, you need to track their status by generating the following reports: > > Orders Audit Report shows the status of the orders and the physician’s signature status. > 282 Open Orders Report shows what orders that have been printed, reviewed, and sent to the physician but have not been returned yet. Orders Alert Report shows what patients need initial certification or recertification orders. Clinical Documentation User’s Guide Managing Returned Orders Managing Returned Orders Processing Signed Orders Transactions>General>Process Signed Orders When physicians have signed their orders, you need to record the receipt of these orders in the Process Signed Orders window. This window displays either all or only open orders for a particular physician. Also, you can see the date and time when the order was printed, the date of the order, order type (certification or supplemental), whether it was signed electronically or signature captured, the date when the order was received, patient name, and any notes relating to the order. After you receive an order with a physician’s signature, you need to apply the appropriate status to this order, specify the date when the order is received, add any necessary notes for that order, and for the initial certification orders, indicate whether the encounter note is present. Also, you can reject an order if you received it from a physician stating it is not correct. For more information, see Updating the Status of Signed Orders. Process Signed Orders Window Clinical Documentation User’s Guide 283 Managing Returned Orders Updating the Status of Signed Orders 1. Go to Transactions>General>Process Signed Orders. 2. Select the physician for whom you want to record the receipt of signed orders and, if needed, modify the date range. By default, the Process Signed Orders window opens displaying all open orders (with the “P” and “M” statuses). To see all orders, select the All radio button. 3. Select the appropriate status for the order: Note: The default status is pending (“P”) once the order is approved in the Order Run. • P (Pending) – To indicate that the order has not been returned signed yet. • A (Signed) – To indicate that the order has been obtained with a physician’s signature. • If the order was signed on paper, you should manually change the status to signed, and the Received field will populate with the current date that can be edited. • If the order has been signed electronically on Physician Portal, it automatically appears with the “A” status and the E check box selected (electronically signed). • M (Signed with changes) – To indicate that the order has been signed by the physician but some changes are required. It is an agency’s responsibility to review the Orders Audit report and correct all the orders with the “M” status to “C”. • C (Signed, changes applied) – To indicate that the order with the “M” status has been corrected. If a physician signs an order with some notes added on Physician Portal, it automatically appears with the “C” status and the E check box selected. You can preview and print these orders in the Order Run to which they were linked. • X (Rejected) – To reject the order. For more information, see Rejecting Orders. 4. If you are processing the initial certification order, select the N check box to indicate the presence of the encounter note. If encounter notes were added on Physician Portal or in the Clinical Notes window, this check box is automatically selected. 5. If necessary, enter any other notes for the order in the Notes section at the lower part of the window. Notes are entered for the currently selected order in the grid. After saving, the added notes appear in the Notes column for the corresponding order. 6. Save your changes. 284 Clinical Documentation User’s Guide Managing Returned Orders Rejecting Orders When you reject an order, the system generates a new order with the identical clinical information of the rejected order. You have to correct clinical items and then process the order again. If an order has been rejected by mistake, go to the Order Run and link the system‐generated copy of this order again. To reject an order: 1. Select the order you want to reject in the Process Signed Orders window. You can reject only the orders with the status “P”. 2. In the Status field, select X. 3. In the Rejection Reason field, select the reason. Important: You cannot undo the rejection once you save your changes. 4. Save your changes. The rejected orders disappear from the grid. Accelerated Posting of Signed Orders With the Accelerated Post Signed Orders window, you can rapidly mark returned physician orders as signed. You can quickly update the status of signed orders by entering the order ID or scanning the bar code. Only those physician orders that do not require changes should be scanned. Orders with changes are handled manually through the Process Signed Orders window. Requirements and Setup If you use the accelerated posting of orders, you need a configured bar code scanner in compliance with Allscripts Homecare hardware requirements attached to the computer on which you run the Accelerated Posting Signed Orders function. To use accelerated orders posting in Allscripts Homecare: • Allscripts should enable the software license for the accelerated orders posting in Administration>Configuration>Business Unit>Licensing. • A corresponding privilege must be granted in Administration>Configuration>Operators>Privileges. • The scanner should be installed following the manufacturer’s instructions. Clinical Documentation User’s Guide 285 Managing Returned Orders Validating the Bar Code Scanner Test the bar code scanner following manufacturer instructions or by opening your choice of word processing programs and scanning in any product with a bar code. The number identified on the product will appear in the document. To perform accelerated orders processing: 1. Go to Transactions>General>Accelerate Post Signed Orders. 2. Enter the order ID number (appears at the bottom right on the order form) or scan the order using a barcode scanner. The grid displays the order ID, medical record number, patient name, certification period (start of care), physician name, and the status of the order. > If you rescan or reenter an order that has already been scanned or entered, the system ignores it. > If you scan or enter an already accepted order, you will see Signed in the Status column. > If you scan or enter an order that does not exist in the system, you will see Order Not Found in the Status column. 3. Click Add to add the order to the list of orders to be processed. While the orders remain in the grid, you can review and verify them. 4. Click Save. The orders are processed as signed. Accelerated Post Signed Orders Window 286 Clinical Documentation User’s Guide Active Orders Report Active Orders Report Active Orders Report – Generated Patient>Documents>Active Orders The Active Orders report displays all active orders for an individual patient in one consolidated view. It consists of all physician orders documented in Allscripts Homecare that are active as of the specified date and time. The Active Orders report contains the information on diagnoses, projected visits, interventions, clinical notes, general clinical orders, and medications including Hold medications which are the inactive part of the group. The report collects the selected information from Patient>General and Patient>Clinical. Note: If a user is in Field Mode, the Active Orders report will not include orders entered in Host Mode after the last synchronization was made. Information on the Active Orders Report Field Name Description Patient Name First and last name of the selected patient. Patient Code Selected patient’s code. Primary Physician First and last name of the patient’s primary physician. Start of Care Date Beginning date when patient started receiving care. Diagnoses Diagnoses and diagnoses codes, including the primary diagnosis of the patient as of the current date. The information is collected from Patient>General>Diagnosis. Start Date Beginning date for the diagnosed. End Date End date of each diagnosis. Medications Medications, dose, frequency, and route of intake prescribed for the patient. The information is collected from Patient>Clinical>Medications. Medications – Start Date Beginning date of the prescribed medication. Medications – End Date The end date of the prescribed medication. Medications – Ordering Physician First and last name of the ordering physician. Clinical Documentation User’s Guide 287 Active Orders Report Field Name Description Projected Visits Information on the frequency of planned visits. The details include: Low Number of Visits per Period, High Number of Visits per Period, Period, Duration, Number of Visits as Needed (PRN), and PRN Reason. The information is collected from Patient>Clinical>Projected Visits. Projected Visits – Start Date Beginning date of the projected visits. Projected Visits – End End date of the projected visits. Date Projected Visits – Ordering Physician Interventions Intervention descriptions and modifiers. The information is collected from Patient>Clinical>Problems. Interventions – Start Date Beginning date of the defined intervention. Interventions – End Date End date of the defined intervention. Interventions – Ordering Physician First and last name of the physician's written orders. Clinical Notes Discipline and clinical notes entered by the start physician. The information is collected from Patient>Clinical>Clinical Notes. Clinical Notes – Start Date Effective date when the clinical note was entered by the physician. Clinical Notes – End Date End date of the clinical note. Clinical Notes – Ordering Physician First and last name of the ordering physician. General Clinical 288 First and last name of the ordering physician. Patients’ information on diet, allergies, DME, safety, functional limits, activities permitted, mental status, advance directives, and prognosis, entered in Patient>Clinical>General Clinical. Clinical Documentation User’s Guide Active Orders Report Example of the Active Orders Report Active Orders Report Generating Active Orders Report 1. In the Patient component, select the appropriate patient. 2. Go to Documents>Active Orders. The Active Orders window opens with the Preview tab open. 3. If needed, print or save the report using the Preview toolbar. Clinical Documentation User’s Guide 289 Orders Signature Report Orders Signature Report Orders Signature Report Window Reports>Clinical>Orders Signature With the Orders Signature report, you can view the physician's signature for those prospective patients who have the signed orders. Pre‐admissions must be activated on the Business Units level to access the Pre‐Admission order process. This process allows orders generation, printing, and signature prior to the actual admission date. The pre‐admission orders can be signed in the Orders Management window in both Field and Host modes. Information on the Orders Signature Report Field Name Patient Patient’s ID, first and last names for whom the order was signed. This information is stored in Patient>General>Basic. Physician Code, first and last names of the physician who signed the order. Operator Resource name assigned to the operator. Order Date Date when the order was created for a patient. Order Type Type of the order. Signed Date 290 Description Date when the order was signed. Clinical Documentation User’s Guide Orders Signature Report Example of the Orders Signature Report Orders Signature Report – Define Tab Use the Define tab to specify information you want to include in the report. You can also use the Preview tab to view a sample report onscreen. The Define tab consists of the following sections where you can select parameters for generating the report. Data Range In the Begin Date and End Date fields, select the time range the report should be generated for. Patient > All Patients – Select to generate the report for all patients who have the pre‐admission orders signed. > Specific Patients – Select to specify one or more patients who have the pre‐admission orders signed. You can search and add the needed patients in the Select Patients dialog. The quantity of the selected patients will be displayed next to the Select button. Clinical Documentation User’s Guide 291 Orders Signature Report Physician > All Physicians – Select to generate the report for all physicians who have signed the pre‐admission orders. > Specific Physicians – Select to specify one or more physicians who have signed the pre‐admission orders by searching and adding the needed physicians in the Physician dialog. The quantity of the selected physicians will be displayed next to the Select button. Generating the Orders Signature Report 1. Go to Reports>Clinical>Orders Signature. The Orders Signature window opens with the Define tab active. 2. In the Date Range section, select the time period the report should be generated for. 3. Select the appropriate options in the Patient and Physician sections (for more information on these fields, see Orders Signature Report – Define Tab). 4. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 292 Clinical Documentation User’s Guide View Orders View Orders View Orders Window Patient>Documents>View Orders With the View Orders window, you can only preview orders for the selected patient. You can choose to view orders for the following: > The next certification period > All queued supplemental orders > All pre‐admissions orders > All previously printed orders If an agency selects to print the name of the resource associated with the order(s) on supplemental orders, then the resource names appear on the order previews as the second line of each clinical item on the orders. For more information on how to view orders for a patient, see Previewing Orders View Orders Window Clinical Documentation User’s Guide 293 View Orders Previewing Orders 1. In the Patient component, select the needed patient. 2. Go to Documents>View Orders. 3. On the Define tab, select what to you want to view: • Click Next Certification Period to view the orders from the next certification period. • Click Queued Supplemental Orders to view queued supplemental orders. • Click Previously Printed Orders to view orders that have already been printed. 4. If you selected to view previously printed orders, select the check boxes next to the orders you want to view from the list that appears. Orders that were signed on Physician Portal appear with the E check box selected. 5. Click the Preview tab to preview the selected orders onscreen. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 294 Clinical Documentation User’s Guide Viewing Order Reports Viewing Order Reports Open Orders Report With the Open Orders report, you can view open orders as of the current date. Open orders are the orders that have been printed, reviewed by your agency, sent to the physician but have not been returned yet. 1. Go to Reports>Clinical>Open Orders. 2. On the Define tab, select the patients for whom you want to see open orders: all patients, specific patients or patients from a specific team. You can include a note entered in the Process Signed Orders window if needed. 3. Specify the orders delivery method. 4. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 5. If needed, print the report. Orders Alert Report With the Orders Alert report, you can see what patients need initial certification or recertification orders in a specified period. It shows what orders are deferred along with specifying the reason. You can print the team care plans for the specified team. Also, you can select to include patients that already have generated orders. The recertification period is defined in Administration>Configuration>Business Units>Settings>Orders Settings and Administration>Financial>Insurance Codes. To generate the Orders Alert report: 1. Go to Reports>Clinical>Orders Alert. 2. On the Define tab, complete the report criteria fields: enter the date range and select the sorting. Optionally, you can select to print team care plans and include patients who have generated orders. 3. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 4. If needed, print the report. Clinical Documentation User’s Guide 295 Viewing Order Reports Orders Audit Report The Orders Audit report allows agencies to manage their orders. It shows the order’s status and indicates whether it has been signed by the physician. This report lists the same data as the orders register in Order Runs. To generate the Orders Audit report: 1. Go to Reports>Clinical>Orders Audit. 2. Select the date range for the report. 3. You can select the order statuses that you want to view. If you select to view rejected orders, the report shows who rejected the order, the reason, and date of rejection. For more information on statuses, see Creating Corrected Orders. 4. You can select the order type you want to view. 5. In the Optional Selection Criteria section, you can select physician signed status instead of order statuses. Physician signed statuses are pulled from the Process Signed Orders window except for the Not Sent status, which is given to all unapproved orders. You can also select branch, team, patient class, and specify particular physicians. 6. Specify the individual Order Run if needed. 7. You can include the notes entered in the Process Signed Orders window in the report. 8. You can specify whether to view orders for paper signature or electronic signature (for Physician Portal). 9. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 10. If needed, print the report. 296 Clinical Documentation User’s Guide Chapter 6 ‐ Certification of Terminal Illness In This Chapter This chapter describes the process of creating, processing and printing Certification of Terminal Illness documents. The information is divided into the following sections: • • • • • Certification of Terminal Illness Patient Documents – Certification of Terminal Illness Process Signed CTIs CTI Status Encounter Date Report Clinical Documentation User’s Guide 297 Certification of Terminal Illness Certification of Terminal Illness About Certification of Terminal Illness (CTI) Certification of Terminal Illness (CTI) is a document certifying that a patient is considered terminally ill with a life expectancy of six months or less if the illness runs its normal course. CTIs are needed for each benefit period (90, 90, and ongoing 60‐day periods) and the Hospice Medical Director or Hospice Physician must certify the terminal illness. In Allscripts Homecare, three different CTI forms are generated for the hospice periods of care: A (first 90 days), B (second 90 days), and C (60 days). CTIs will not be generated unless they are defined in the Hospice Benefit Information Window and the CTI MD is specified in the Admissions & Status Window. For prospective patients, the CTI A form is generated without any dates. To view the generated CTIs, go to Certification of Terminal Illness Window (Patient) or Certification of Terminal Illness Window (Orders). CTIs need brief narrative statements, which can be entered using the clinical note with the use code “B”. Form C needs a clinical encounter note, which can be added using the clinical note “H” (according to regulations, encounter is required no sooner than 30 days prior to the third benefit period and every subsequent recertification). To track the receipt of signed CTIs, use the Process Signed CTIs Window. To track the statuses and clinical encounters, use the CTI Status Report and the Encounter Date Report. Certification of Terminal Illness Window (Orders) Orders>Demand Documents>Certification of Terminal Illness With the Certification of Terminal Illness window, you can preview and print generated CTI documents for the selected patients. By printing a CTI, you make it available for further processing. Also, you can reprint (see Reprinting CTIs) or inactivate (see Inactivating CTIs) CTIs if necessary, and edit benefit periods if you have been granted additional corresponding privileges. For each selected patient, you can see the status of all CTI forms, CTI physician, CTI dates, date of printing, and the date of approval or rejection if the form was processed in Transactions>General>Process CTIs. If there are any changes to the printed CTI, it should be manually reprinted. For more information, see Printing CTIs from Orders Component. 298 Clinical Documentation User’s Guide Certification of Terminal Illness Certification of Terminal Illness Window Printing CTIs from Orders Component By printing a CTI, you change its status to Pending and make it available for signature and processing. 1. Go to Orders>Demand Documents>Certification of Terminal Illness. 2. On the Define tab, click Select Patients and add the patients for whom you need to print CTIs. All the generated CTI forms for the selected patients are listed. For the CTI physicians using Physician Portal, the documents are displayed in the Electronic Signature section. 3. If needed, view the CTIs from inactive admissions by selecting the Show Prior Admissions check box, the inactivated and rejected CTIs by selecting the Show Inactive/Rejected CTIs check box. 4. Select the CTIs you want to print for further signature (applies to the New status only). 5. If needed, edit the benefit period. 6. To preview the CTIs, click the Preview tab. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 7. If the CTIs are ready for signature, change their status to Pending: • For paper signature, print the CTIs using the Preview toolbar. • For electronic signature, click Set Pending, and then click Save. CTIs appear on Physician Portal for review and signature. Clinical Documentation User’s Guide 299 Certification of Terminal Illness Reprinting CTIs Reprinting is used for updating printed CTIs if there were some changes to the patient information, CTI physician, or if a new note has been added (brief narrative statements or encounter notes). 1. To reprint CTIs: • For multiple patients – go to Orders>Demand Documents>Certification of Terminal Illness and select the patients for whom you need to reprint CTIs. • For the individual patient – select this patient in the Patient component and go to Documents>Certification of Terminal Illness. 2. On the Define tab, click Reprint. The list of previously printed (Pending) CTIs appears. 3. Select the CTIs you want to update. 4. Click Save. The CTIs are updated. 5. To see the changes, click the Preview tab. Inactivating CTIs Inactivation is used when printed or signed CTIs are no longer valid. Inactivated CTI documents are retained in the system for historical purposes and the new ones are generated instead. If the CTI benefit period changes, the document is inactivated automatically. 1. To inactivate CTIs: • For multiple patients – go to Orders>Demand Documents>Certification of Terminal Illness and select the needed patients. • For the individual patient – select this patient in the Patient component and go to Documents>Certification of Terminal Illness. 2. On the Define tab, click Inactivate. The list of Pending and Signed CTIs appear. 3. Select the CTI you want to inactivate. 4. Click Save. The CTIs are inactivated. 5. To view all inactive CTIs, select the Show Inactive Documents check box. 300 Clinical Documentation User’s Guide Patient Documents – Certification of Terminal Illness Patient Documents – Certification of Terminal Illness Certification of Terminal Illness Window (Patient) Patient>Documents>Certification of Terminal Illness With the Certification of Terminal Illness window, you can preview and print generated CTI forms for the patient selected in the Patient component. For more information on this window, see Certification of Terminal Illness Window (Orders), where you can print CTIs for multiple patients. For more information on the CTI documents and theirgeneration, see About Certification of Terminal Illness (CTI). Printing CTIs from Patient Component By printing a CTI, you change its status to Pending and make it available for signature and processing. 1. In the Patient component, select the needed patient. 2. Go to Documents>Certification of Terminal Illness. All the generated CTI forms for the patient are listed. For the CTI physicians that use Physician Portal, the documents are displayed in the Electronic Signature section. 3. If needed, view the CTIs from inactive admissions by selecting the Show Prior Admissions check box, the inactivated and rejected CTIs by selecting the Show Inactive/Rejected CTIs check box. 4. Select the CTI forms you want to print for further signature (applies to the New status only). 5. If needed, edit the benefit period. 6. Click the Preview tab. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 7. If the CTIs are ready for signature, change their status to Pending: • For paper signature, print the CTIs using the Preview toolbar. • For electronic signature, click Set Pending, and then click Save. The CTIs appear on Physician Portal for review and signature. Clinical Documentation User’s Guide 301 Process Signed CTIs Process Signed CTIs Process Signed CTIs Window Transactions>General>Process Signed CTIs With the Process Signed CTIs window, you can record the receipt of signed CTI forms for the selected CTI physician in the specified period. For the Physician Portal users, all the signed CTIs appear automatically with the Signed status and the E check box selected. If necessary, you can reject CTIs and specify the reason. For each CTI form, you can view the CTI date, date of printing, status, and date of signature (if any). For more information, see Processing Signed CTIs. To track the statuses for CTIs, use the CTI Status Report. 302 Clinical Documentation User’s Guide Process Signed CTIs Processing Signed CTIs If you received the CTI document with the CTI physician’s signature, you need to mark its status as Signed. 1. Go to Transactions>General>Process Signed CTIs. 2. Select the CTI physician for whom you want to process the CTI and, if needed, change the default date range. By default, the Process Signed CTIs window opens displaying all the pending CTIs. To view the signed documents, select the Show Signed check box. To view inactivated CTIs, select the Show Inactive check box. 3. Select the appropriate status for the CTI: • Signed – To indicate that the CTI has been signed. For the Physician Portal users, all the signed CTIs automatically appear with the Signed status and the E check box selected. • Rejected – To reject the CTI. When rejecting, specify the reason. The system generates a new document with the identical clinical information, but the rejected CTI is retained for historical purposes. Correct the clinical items and then process the CTI again. The rejected CTIs appear in Orders>Demand Documents>Certification of Terminal Illness and Patient>Documents>Certification of Terminal Illness. 4. Save your changes. Clinical Documentation User’s Guide 303 CTI Status CTI Status CTI Status Report Using the CTI Status report, you can view status for Certifications of Terminal Illness (CTI) for the specified date range. The generated report shows the CTI type, the date when the CTI chain started to generate, CTI date, and benefit period’s start and end dates. For rejected CTIs, you can view the date, rejection reason, and operator who rejected the document. To generate the CTI Status report: To access this report, you must be granted a corresponding privilege by the Allscripts Homecare administrator. 1. Go to Reports>Clinical>CTI Status. 2. On the Define tab, specify the patients for whom you want to see CTI status (either all or specific patients). 3. If needed, change the default date range for the report. 4. If needed, include notes entered in the Process Signed CTIs window. 5. Specify what statuses you want to view in the report: New, Pending, Signed, Inactive, and Rejected. 6. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 7. If needed, print or save the report in the necessary format using the Preview toolbar. 304 Clinical Documentation User’s Guide Encounter Date Report Encounter Date Report Encounter Date Report Report>General>Encounter Date Report Using the Encounter Date Report, you can track what patients need clinical face‐to‐face encounters based on the dates entered on the Encounter Information tab in the Admissions & Status window. When searching for encounter dates, report also considers the date range for which encounter meetings are required. According to regulations, encounters for Home Health patients must occur up to 90 days prior to the initial start of care or within 30 days after the start of care. For Hospice patients, encounter is required no sooner than 30 days prior to the third benefit period and every subsequent recertification. For each initial certification order, you can view patient name and code, admission date, start of care date (SOC), and encounter type and date (scheduled or performed). On the generated report, for each CTI, you can view patient name and code, admission date, CTI’s date and days (for the first C form, it will be 180, for example), and encounter date and type (scheduled or performed). To generate the Encounter Date Report: To access this report, you must be granted a corresponding privilege by the Allscripts Homecare administrator. 1. Go to Reports>General>Encounter Date Report. 2. On the Define tab, change the default date range for the report as necessary. 3. In the Mode drop‐down list, select the patient class (Hospice or Home Health). 4. Specify the patients you want to include: all, specific patients, or patients from a team. 5. Click the Preview tab to generate the report. If you change the criteria on the Define tab after preview, you should close and then open the Preview tab again to reflect your changes. 6. If needed, print or save the report in the necessary format using the Preview toolbar. Clinical Documentation User’s Guide 305 Chapter 7 ‐ Time Log In This Chapter In this chapter, you can find the detailed description of the TimeLog and Batch Timelog windows by referring to the following sections: • • 306 TimeLog Batch Timelog Clinical Documentation User’s Guide TimeLog TimeLog About the TimeLog The TimeLog acts like a timesheet for your day. Use the TimeLog to record the time you spend with a patient and the time you spend documenting the visit. In addition, you can record travel mileage and cash spent on tolls, parking, and so on. The TimeLog shows you what percentage of the assessment and variances you have completed for the visit, so you can easily see what you still need to do. You can also enter supplies dispensed on a visit. Finally, you can verify a visit directly from the TimeLog. About Entering Bereavement Services When you select an inactive patient with a “deceased” termination status code, you can select a service code of Non billable or Bereavement type. Bereavement‐type service codes appear for all patients regardless of whether billing rates are defined or not. Allscripts Homecare calculates all revenue fields and cost fields the same as for any billable service. You can enter Bereavement services from the day of death forward; you cannot enter them prior to the day of death. About Entering Visits Prior to Admission If you enter a visit for a patient prior to admission and then change the admit date to be that of the visit date, the visit will still appear as a preadmission visit on the Productivity Report until you run either Recalculate Service Amounts or Recalculate Staff Service. When you enter a service, its amounts are calculated based on the rates effective at the moment the service is entered. To ensure that the service picks up the correct rates when the service type changes (based on an admit date change, for example) and that the correct amounts are reflected on the Productivity Report, you must run either Recalculate Service Amounts or Recalculate Staff Service to refresh the patient status after changing the admit date (or termination date). These functions refresh the patient status and service amounts. About Verifying Visits When you complete documentation for a patient and then enter a new patient on the TimeLog, Allscripts Homecare asks you if the patient should be verified. Always follow your agency's policy on verifying visits. If you are allowed to verify visits, click Yes on the prompting dialog. The Verified check box on the TimeLog for the visit will be selected automatically after the verification. If you are not allowed to verify visits, click No. The authorized person in your agency's office will verify the visit. Clinical Documentation User’s Guide 307 TimeLog About Resolving Visits in Host Mode In the TimeLog window in Host Mode, the Unresolved? button is always enabled. When you are working in Host Mode and have a resource selected, Allscripts Homecare searches for any unresolved visits. If the resource has no unresolved visits, the following message appears: There are no unresolved past visits for this Resource. If the resource has only one unresolved visit, the information about it appears in the window. If the resource has multiple unresolved visits, the visit with the earliest date will be displayed. After you resolve the visit and click the Unresolved? button, the unresolved visit with the next date appears. The visits appear until you resolve all the unresolved visits. In Field Mode, the button is enabled only if there are unresolved visits for the resource. User Defaults Several user settings for the screen are stored in the database as a part of user preferences. The following options are preserved: One‐line, Duration, Scheduled, In Process, Verified, and Unmade. The Odometer Start default to 0 unless there are already readings entered for the selected Resource on the given Day. In this case, the very last value entered by the user for this resource or day is taken as a default. The default resets to 0 anytime the user switches a resource or a day. TimeLog Window Transactions>General>TimeLog With the TimeLog window, also known as Staff Services Entry, you can enter visits and supplies provided to patients. You can also enter nonvisit related staff activities. The TimeLog window enables your agency to enter direct and indirect visit start and end times, travel start and end times, and mileage start and end odometer readings. The TimeLog window provides a convenient tools panel on the top of the Service grid. It consists of three sections. The first section are the filters for Scheduled, In Process, Verified, and Unmade visits used to filter the services by their status. Use these buttons to display or hide corresponding service types on the screen. The second section are the options buttons for One‐Line display, Duration instead of Start Time and End Time display, and Real Time display. The third section is the Action section and each of the buttons does the update to a service or a group of services: Remove Signature, Unresolved, Clear Scheduled Times, and Verify All. You can also use the Batches button to edit TimeLog batch number. 308 Clinical Documentation User’s Guide TimeLog When you enter visits that are covered under an authorization in TimeLog, you must associate each visit with its authorization by selecting the correct pay source so that each visit appear on the correct claim associated with the correct authorization. You can also enter visits as PRN to distinguish them from regular visits. The TimeLog window provides a service record indicator, which helps visually quickly to recognize the currently selected record and monitor the record status. The record indicator is placed on the left of the each service row. • – Indicates that the record is currently having pointer on. • – Indicates that the record is modified. • – Indicates that the record has been inserted. The bottom of the TimeLog window is divided into two areas. The left side area shows information on Assessments and Notes attached to visit. The Assessments field shows any assessments associated with the selected visit or service. Right‐click the Assessment field, and then select Open Assessment Screen or click next to the corresponding assessment record to open the Assessments window in the Patient component. The Notes field shows any notes associated with the selected visit or service. You can also add your notes to this fields or edit notes attached. The right side area contains a page control with Supplies, Costs and Revenue, Negotiation, and Pay Costs tabs. The Supplies tab of the TimeLog window tracks any supplies that the resource dispensed to the patient. The TimeLog window also records a running total of costs and revenue for time, travel, and supplies on the Costs and Revenue tab. The negotiation fields and the gross margin percentage (as defined in Payroll>Settings>Gross Margin) appear on the Negotiation tab. For pay cost calculation details, click the Pay Cost tab. This tab contains pay rate details and calculated values, including for holidays, weekends, differential hours, and overtime. The fields on this tab are read only. If you enter, update, or insert a new service for a patient, whose patient class is set (as of the visit date) to use OASIS Due alerts, and if your agency is using the OASIS Due alerts function, the TimeLog displays a warning message if the patient has an OASIS alerts due within the specified time frame. The message informs you about what kind of OASIS assessment is due and on what date it is due. It is shown at a time the user selects or changes the patient or when the record is posted. For the given patient, the warning is shown only once. You can also sort visits and save the chosen sequence so that it appears the next time you view the TimeLog for the same date and resource. You can sort either by column (by clicking the appropriate column heading) or by sequence using the standard Move Up and Move Down arrows. The TimeLog window also includes the standard Add Row, Insert Row, and Delete Row buttons on both Services and Supply grids. Use these buttons to add, insert, or delete rows in a specified position within each Clinical Documentation User’s Guide 309 TimeLog grid. Both Services and Supplies grids have their own set of these arrows and buttons found to the right of each grid. When closing TimeLog following a grid reordering, the application prompts you to save the new order (and any other changes that were made). When you save and exit the window, Allscripts Homecare stores the order in which the visits were displayed and uses that same order the next time you view the TimeLog window for the same date and resource. Therefore, it is possible for each date‐resource combination to use a different sort order in the window. Although both Verify Scheduled Events and TimeLog can be used to verify visits, TimeLog is more appropriate for clinicians with clinical documentation requirements and should always be used by Field Mode users. Verify Scheduled Events is intended primarily for managed personnel such as Home Health Aides, who submit day sheets on paper. When scheduling therapy visits, you may receive a message notifying that the visit should be performed by a qualified therapist. For more information see Scheduling Therapy Visits. TimeLog Window TimeLog Window Fields For Enter the resource for whom you are entering service or visit information. OR Click 310 and select the resource. Clinical Documentation User’s Guide TimeLog Date Enter the date on which this information applies. OR Click and select it from the drop‐down calendar. Previous Week Click if you want to use the date one week prior to today's date as the entry date. Next Week Click if you want to use the date one week after today's date as the entry date. Previous Day Click to use yesterday's date as the entry date. Next Day Click to use tomorrow's date as the entry date. Today Click to use today's date as the entry date. Scheduled Click Scheduled if you want the application to display scheduled visits in the TimeLog window. Click this button again to hide scheduled visits. In Process Click In Process if you want the application to display in process visits on the screen. Click this button again to hide in process visits. Verified (Show Verified Visits) Click Verified if you want the application to display verified visits on the screen. Click this button again to hide verified visits. Clinical Documentation User’s Guide 311 TimeLog Unmade (Show Unmade Visits) Click Unmade if you want the application to display unmade visits on the screen. Click this button again to hide unmade visits. One‐line Click One‐line if you want to view this time log entry information on one line only. Click this button again to view the information on multiple lines. Duration Click Duration if you want to enter durations manually. Click this button again if you want Allscripts Homecare to calculate durations. Real Time Click Real Time if you want to use real time. If you click this button, the application enters the current time whenever you complete a time‐related field. You will most likely use this field in Field Mode when you start a TimeLog at the actual time of visit. Click this button again if you do not want to use real time. For example, if you are documenting a visit after the fact, do not use real time. Remove Signature Click this button to remove the signature assigned to the selected service. The dialog will appear asking you to confirm signature deletion. After the signature is deleted, the check box in the SC field is cleared. The button is active only if the selected service has a signature assigned. Unresolved Click the Unresolved? button to go to the first date with unresolved services. This button is always enabled in Host Mode. In Field Mode, the button is enabled only if there are unresolved visits for the resource. If the resource has no unresolved visits, the following message appears: There are no unresolved past visits for this Resource. If the resource has only one unresolved visit, the application jumps to that date. If the resource has multiple unresolved visits, the application jumps to the earliest date. After you resolve the visit and click the Unresolved? button again, the application jumps to the unresolved visit with the next date until you resolve all visits. 312 Clinical Documentation User’s Guide TimeLog Clear Scheduled Times Click Clear Scheduled Times to erase all scheduled times. The dialog appears asking you to select whether to clear current visit or all scheduled visits. Verify All Click Verify All to verify all unresolved services. The Verified check box for each of the verified service is automatically selected. Batches Click Batches to open the Edit Batch Numbers window. You can assign batch numbers, remove assigned batch numbers, or create new batch numbers for the transaction that are within the TimeLog window. RT (Resource Type) Enter the resource type of the resource for whom you are entering time log information. OR Click and select it. Code Enter the type of service for which you are entering time log information. OR Click and select it. Clinical documentation is not required for activity service codes. In addition, Time and Mileage entry is optional for activity service codes. PtID Enter the patient for whom you provided the visit or services you are recording. OR Click and select the patient. The patients that are available depend on your user access and on the download option you chose during your last synchronization. To open the patient’s record in the Patient component, click . Clinical Documentation User’s Guide 313 TimeLog Name Displays the name of the patient for whom the visit or service is provided. Authorization Status This column displays the authorization status of the service or visit provided for the patient. This information is stored in Patient>Services>Authorizations. – Status authorized. – Status pending (after the authorization request was sent to the payer for its approval). – Status not authorized. Branch Depending on the settings in Administration>Configuration>Business Units>Settings>Administration, this field can contain either branch name which was defined for the resource in Resource>General>Roles or the patient’s branch name defined in Patient>General>Admissions & Status. The field is not available if there are no settings or service is created for contractor resources. You can select another branch from the Select Branch dialog is needed. This dialog contains only active branches. Pri (Primary Payer) Displays the primary payer for the selected patient. This information is stored in Patient>General>Payers. IC (Insurance Code) Enter the insurance associated with this service. OR Click and select it. Caution If you are entering a visit for a patient with multiple authorizations and duplicate pay sources, be sure you choose the correct insurance code. 314 Clinical Documentation User’s Guide TimeLog A (Show Authorization Information) Move the mouse pointer over to view the payer authorization information of the service in the hint. The authorization is assigned in Patient>General>Authorizations. For more information on the Select Authorization hint refer to TimeLog Window – Authorizations Hint, on page 320. NPI Click down arrow and then select group or individual NPI (National Provider Identifier) number for the resource that provides services. The drop‐down list contains individual and group NPI numbers that are assigned in the Roles window (Resource>Roles). The field is available only if Require Clinical NPI field value for the selected resource type is set to Yes or Optional in the Administration>General>Resource Types window. CPT Code Enter the CPT (Current Procedural Terminology) code associated with this service. OR Click and select it. This field is available only if the Use CPT Codes field value for the selected resource type is set to Yes or Optional in the Administration>General>Resource Types window. All the CPT codes are stored in Administration>General>CPT Codes. Mod (Modifier) Enter the modifier associated with the selected CPT code. This field is available if the following conditions are met: • The Use CPT Codes field value for the selected resource type is set to Yes or Optional in the Administration>General>Resource Types window. • The Modifier Required field value for the selected CPT code is set to Yes or Optional in the Administration>General>CPT Codes window. Cash If you are allowed to charge the agency for such costs as parkway and bridge tolls, enter the amount. This field is available only if the Petty Cash check box for the corresponding resource type is selected in the Administration>General>Resource Types window. Clinical Documentation User’s Guide 315 TimeLog S (Scheduling Note Attached) If there is a scheduling note attached to this visit, the selected check box appears in this field. PC% (Variances Percentage) This field displays the percentage complete of the variances associated with the visit. Note Select this check box if you want to add a note related to this service. PRN Select this check box if this visit is a PRN visit. Clear this check box if it is not a PRN visit. Ver (Verified) Select this check box if you want to verify this service. Clear this check box to leave this service unverified. SC (Signature Capture) If this check box is selected, a signature has been captured for the patient visit. If this check box is not selected, a signature is not captured for the visit. AS (Apply Signature) Click to apply a patient signature to this visit. The Patient Signature Capture Wizard launches. VS (View Signature) Click to retrieve the patient signature for this visit. The Retrieve Signature window opens. P (Jump to this patient) Click to view this patient's information in the Patient component. By jumping to the patient in the Patient component, you automatically link the visit with the assessment and other clinical items you typically complete during a visit. If you do not jump, you must manually link each of these itemsto the visit. 316 Clinical Documentation User’s Guide TimeLog Travel (Travel Time Start) (Optional) Enter the start time for travel time. OR Click and select it. If you are required to enter start and end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). This field is optional for activity service codes. End (Travel Time End) (Optional) Enter the end time for travel time. OR Click and select it. If you are required to enter start/end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). This field is optional for activity service codes. Duration (Travel Time Duration) (Optional) Enter the duration for travel time. OR Click and select it. This field is optional for activity service codes. Direct (Direct Time Start) (Optional) Enter the start time for direct time. OR Click and select it. If you are required to enter start and end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). If the staff service code you are using is defined with direct time as optional, you can verify or upload the service without entering a value in the field. You can also enter 0 (zero). If the service code is defined as nonbillable or as telephone call, you can also select Do Not Record. Clinical Documentation User’s Guide 317 TimeLog End (Direct Time End) (Optional) Enter the end time for direct time. OR Click and select it. If you are required to enter start and end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). This field is optional for activity service codes. Duration (Direct Time Duration) (Optional) Enter the duration for direct time. OR Click and select it. This field is optional for activity service codes. Indirect (Indirect Time Start) (Optional) Enter the start time for indirect time. OR Click and select it. Indirect time is time related to a patient visit that you do not actually spend with the patient. One common example of indirect time is the time you spend documenting the visit after the visit has ended—at the end of your shift, for example. If you are required to enter start and end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). This field is optional for activity service codes. End (Indirect Time End) (Optional) Enter the end time for indirect time. OR Click and select it. If you are required to enter start and end times, you must complete this field before you can complete or upload the visit. If the field is not appropriate for you, enter 0 (zero). This field is optional for activity service codes. 318 Clinical Documentation User’s Guide TimeLog Duration (Indirect Time Duration) (Optional) Enter the duration for indirect time. OR This field is optional for activity service codes. Odometer (Odometer Start) Enter the odometer mileage reading at the beginning of the trip. This field is optional for activity service codes. End (Odometer End) Enter the odometer mileage reading at the end of the trip. This field is optional for activity service codes. Miles (Optional) Enter the total miles traveled. OR Click and select it. This field is optional for activity service codes. Unmade (Unmade Reason) Click and select the reason of why the service or visit was not made from the drop‐down list. You can not enter the reason which is not in the list. To add the reason to the list go to Administration>General>Unmade Visit Reasons. Move Up Click to move the selected visit or supply up in the list (depending on whether you are in the Visits or Supplies grid). Move Down Click to move the selected visit or supply up in the list (depending on whether you are in the Visits or Supplies grid). Clinical Documentation User’s Guide 319 TimeLog Assessment Information • Assessment – Displays the description of the assessment. • Percentage Completed – Displays the percentage complete of the assessment associated with the visit. If you completed the assessment, this field should read “100%.” Depending on your user settings, you might not be able to upload a visit during Synchronization unless the assessment, Problem Charting, and Clinical Note are 100% complete. Click assessment in the Patient component if needed. to jump to the TimeLog Window – Authorizations Hint This hint appears when you focus the mouse on the ellipsis button of the A (Select Authorization) column in the TimeLog window. Using this hint, you can view the payer authorization information. Also, the system automatically assigns the authorization to the service. The authorization is assigned in Patient>General>Authorizations. The authorization details that appear in the hint are based on the patient, role, service code, and insurance (primary or secondary) parameters. When you select Save, the system assigns the authorization to the service. The result is displayed as the icon on the Authorization Status column depending on the authorization status of the service or visit (the information on the status of services is stored in Patient>General>Authorization). Authorizations settings depend on the Allow Exceed Authorizations selected in Administration>Configuration>Operators>Privileges>Scheduler. For example, two visits are allowed for the authorization and set in Patient>General>Authorization, and there is no privilege for the Allow Exceed Authorizations set. If we enter the third visits in TimeLog, exceeding the quantity of visits allowed, the error message will appear and the user will not be able to save the changes. 320 Clinical Documentation User’s Guide TimeLog In the same case, if there are two visits allowed and three visits are intended to be scheduled, but an Allow Exceed Authorizations privilege is set in Administration>Configuration>Operators>Privileges>Scheduler, the user will see the warning message. Still the changes will be saved. TimeLog Window Supplies Tab The Supplies tab of the TimeLog window tracks any supplies that the resource dispensed to the patient. The selection options in this window are based on the information entered in the Supplies window (Administration>General>Supplies). TimeLog window Supplies Tab Clinical Documentation User’s Guide 321 TimeLog TimeLog Window Supplies Tab Fields Code Enter the Supply code for the supply associated with this visit or click Select Supply dialog. and select it from the The list of available supplies is stored in Administration>General>Supplies. Description This field shows a description for the Supply code selected. The field is not editable. Qty (Quantity) Enter the number of the selected supplies or click until the correct number appears. Lot Number Enter the Lot number for the selected supply in this field if required. If the information in this field is required for the supply selected, a warning message The “NDC Lot Number” is required for this supply appears when saving or choosing another visit without filling this field. This field is available only if the Require Lot# check box for the corresponding supply is selected in the Administration>General>Supplies window. 322 Clinical Documentation User’s Guide TimeLog TimeLog Window Costs and Revenue Tab The TimeLog window records a running total of costs and revenue for time, travel, and supplies on the Costs and Revenue tab. The information on this tab is based on the settings in Administration>Financial> Billing Rates and Administration>Financial>Staff Cost Rates. Based on the security settings in Administration>Configuration>Operators, a user may be prevented from seeing an information on the Cost and Revenue tab. Instead, the No Information Available message is displayed. TimeLog Window – Costs and Revenue Tab TimeLog Window Negotiation Tab The negotiation fields and the gross margin percentage (as defined in Payroll>Settings>Gross Margin) appear on the Negotiation tab. Based on the security settings in Administration>Configuration>Operators, a user may be prevented from seeing an information on the Negotiation tab. Instead, the No Information Available message is displayed, or the tab appears as read‐only. TimeLog Window – Negotiation Tab Clinical Documentation User’s Guide 323 TimeLog TimeLog Window Negotiation Tab Fields Bill Rate/Basis Enter the bill rate that was negotiated for the scheduled service or event. Click to select the basis by which the bill rate will be applied: by the hour or by the visit. You define billing rates in the Billing Rates window of the Administration component (Administration>Financial>Billing Rates). Pay Rate Adjustment Enter the amount above or below the base pay rate to adjust the resource's pay rate for this event or click and select the rate adjustment amount. Net Amount The net of the total billing is displayed in this field. Pay Cost Total This field contains the calculated pay cost based on the pay rate, pay rate adjustment, and additional amounts (holiday, weekend, overtime, and differential hours). Defined Gross Margin% This field contains the gross margin percentage defined in Payroll>Settings>Gross Margin. Calculated Gross Margin% This field contains the gross margin percentage calculated after edits made to the pay, bill rates, and their basis. If the bill and pay rates are changed after negotiation, the Gross Margin is recalculated. GPM Difference This field contains the difference between the defined and calculated gross margins. Reset Click Reset to reset the values of the Pay Rate Adjustment and Bill Rate/Basis fields to their defaults. 324 Clinical Documentation User’s Guide TimeLog TimeLog Window Pay Cost Tab For pay cost calculation details, click the Pay Cost tab. This tab contains pay rate details and calculated values, including for holidays, weekends, differential hours, and overtime. The fields on this tab are read only. The information on this tab is set in Payroll>Settings. Based on the security settings in Administration>Configuration>Operators, a user may be prevented from seeing an information on the Pay Cost tab. Instead, No Information Available message is displayed. TimeLog Window – Pay Cost Tab Start a TimeLog If your agency has specific policies for how you should complete the TimeLog, be sure to follow those policies. These steps are only a general outline of how the TimeLog is typically completed. 1. Go to Transactions>General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 2. Enter the date, visit code, patient ID, and CPT code as appropriate. 3. Complete the Start and End fields for travel time and the Start field for direct time and indirect time as appropriate. 4. Enter the odometer start and end readings and the total number of miles traveled as appropriate. 5. Complete the Cash field as appropriate. 6. If this visit is a PRN visit, select the PRN check box. 7. Click next to the patient’s name to jump to the patient in the Patient component. Allscripts Homecare automatically saves the TimeLog when you jump to the patient. Clinical Documentation User’s Guide 325 TimeLog Complete a TimeLog 1. After completing all patient documentation, return to the TimeLog. If you attached a clinical note to the visit, the Note check box is selected for this visit. 2. Enter time and mileage according to your agency’s requirements. The TimeLog displays different fields for recording your time depending on what your agency has set up for you. 3. Verify that the visit code is a billable code. 4. Click Save to save the TimeLog. The visit should now be complete and ready to upload during Synchronization. When scheduling therapy visits, you may receive a message notifying that the visit should be performed by a qualified therapist. For more information see Scheduling Therapy Visits. Record Indirect Time Related to a Patient Visit Indirect time is time related to a patient visit that you do not actually spend with the patient. One common example of indirect time is the time you spend documenting the visit after the visit has ended—at the end of your shift, for example. 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the visit for which you want to enter indirect time. 4. In the Indirect Time Start and End fields, enter appropriate times. OR Enter the total indirect time spent in the Indirect Time Duration field. 5. Click Save to save the TimeLog. 326 Clinical Documentation User’s Guide TimeLog Enter Visits Provided to a Patient 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Enter the date, visit code, patient ID, and CPT code as appropriate. 4. Complete the Start and End fields for travel time and the Start field for direct time and indirect time as appropriate. 5. Enter the odometer start and end readings and the total number of miles traveled as appropriate. 6. Complete the Cash field as appropriate. 7. If this visit is a PRN visit, select the PRN check box. 8. Click next to the patient’s name to jump to the patient in the Patient component. Allscripts Homecare automatically saves the TimeLog when you jump to the patient. Enter Supplies for a Patient (TimeLog) 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the visit for which you want to enter supplies. 4. Click the Supplies tab in the lower half of the window. 5. Enter the appropriate supply code. OR Click to select it. 6. In the Qty field, enter the quantity of the supply provided. 7. Click to save the TimeLog. Clinical Documentation User’s Guide 327 TimeLog Enter Times, Durations, Travel, and Mileage Related to a Visit or Other Service 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the appropriate visit or service. 4. Complete the Start and End fields for travel time and the Start field for direct time and indirect time as appropriate. 5. Enter the odometer start and end readings and the total number of miles traveled as appropriate. 6. Click Save to save the TimeLog. Indicate a PRN Visit in TimeLog 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the appropriate visit. 4. Select the PRN check box. 5. Click Save to save the TimeLog. 328 Clinical Documentation User’s Guide TimeLog Capture a Patient Signature for a Visit 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the appropriate visit. 4. Click in the Apply Signature column. The Patient Signature Wizard appears. 5. Complete the Patient Signature Wizard as indicated. 6. The TimeLog window appears again with the Signature Capture check box selected. This indicates that the patient signature has been captured. 7. Click Save. Clear Scheduled Times Window Transactions>General>TimeLog>Clear Scheduled Times With the Clear Scheduled Times window, you can clear all the scheduled times for visits associated with a service. You can clear just the scheduled time for the current visit or you can clear the scheduled times for all the scheduled visits associated with a service. This function is useful if a change in either a patient’s or resource’s availability requires that visits be rescheduled. Clear Scheduled Times will empty all times and durations: Direct, Indirect, and Travel. When the first option is selected the visit currently in focus will be affected, but only if the visit is Scheduled or In Progress. If the second option is selected, then all scheduled visits will be affected. Clear Scheduled Times Window Clinical Documentation User’s Guide 329 TimeLog Clear Scheduled Times Window Fields For Current/For all Scheduled visits Select one of the following options: > > For the current visit – To clear scheduled times for the current visit. For all scheduled visits – To clear scheduled times for all scheduled visits for this service. Clear All Scheduled Times for a Visit 1. Open the Transactions component. 2. Go to General>TimeLog. The TimeLog window appears. Note Online help is available for each field in this window by pressing F1 while in the field. 3. Select the appropriate visit. 4. Click Clear Scheduled Times. The Clear Scheduled Times window appears. 5. Select one of the following options: • For the current visit – To clear scheduled times for the current visit. • For all scheduled visits – To clear scheduled times for all scheduled visits for this service. 6. Click OK. The scheduled times are cleared. 330 Clinical Documentation User’s Guide Batch Timelog Batch Timelog About Batch Timelog The Batch Timelog allows for increased flexibility in the entry of Timelog transaction and enables mass processing of entries into the Timelog window. The mass processing option, which is a separate window, allows a singe user to select multiple batches that can be process in one submission. All transactions are processed across the selected batches and any errors will be report at the end of processing. You can also use the Batch Timelog window either to process single entries or all entries in a specific batch. In addition to mass process, you can establish control totals for a batch to ensure the transactions enter in the batch equal the value determine for the batch outside of Allscripts Homecare. For example, each resource’s transaction for the week so equal 40 hours of time. The increased flexibility comes in the way of allow entries to be added to Batch Timelog across resources and date of services, which are currently header details for Timelog entry. So from the Batch Timelog window, you can enter records for two different resources and two different dates into the same batch and process together. When scheduling therapy visits, you may receive a message notifying that the visit should be performed by a qualified therapist. For more information see Scheduling Therapy Visits. Setting Up Batch Timelog The set‐up of Batch Timelog requires that security privileges be assigned to all operators that require access to the windows, which includes the Batch Timelog and the Batch Timelog Processing. Each window has a separate privilege. In addition to granting access to the windows, there are specific privileges that control the operator’s actions on these windows and the TimeLog window. The “May Assign Batches” privilege allows a user to assign a batch number to existing Timelog transactions on the TimeLog window. The “May Process Other User Batches” privilege allows a user to processes batches created by another operator. TimeLog Window Batch TimeLog is accessed from the TimeLog window by clicking Batches. The Edit Batch Numbers window opens from which you can assign batch numbers, remove assigned batch numbers, or create new batch numbers for the transactions within the TimeLog window when you click Batches. For details on the specific fields on the TimeLog window, please refer to TimeLog Window. Clinical Documentation User’s Guide 331 Batch Timelog Timelog Window Batch Timelog Window Transactions>General>TimeLog>Batch TimeLog The Batch Timelog window allows you to process Timelog batches for the transactions active in the TimeLog window when you clicked Batches. You can enter records across date of service and resource at one time while processing these records together into TimeLog via a new submission process. Batch Timelog Window 332 Clinical Documentation User’s Guide Batch Timelog The following are the fields specific to the Batch Timelog window. Batch Number Displays the batch number assigned to the selected transaction. You can click to search for the existing batch numbers in the Select Batch Number dialog or you can click to create a new batch number in the Batch Number Creation dialog. Status The field provides the current status of the batch number displayed within the window. The statuses are Working, Ready, Pending, or Complete. • Working means the batch has not been release for processing by the operator that is using it. • Ready means the operator has released the batch for processing. • Pending means the batch has at least one transaction in error. • Complete means that all transaction assigned to the batch have been processed into Timelog. One‐Line Click One‐line if you want to view this time log entry information on one line only. Click this button again to view the information on multiple lines. Show Process Messages Click Show Process Messages to change show any processing message below the records that are pending within a batch. Edit Batch Click Edit Batch to open the Edit Batch window where you can change the names assigned to a batch or to change the control totals for the batch. Ready For Processing Click Ready for Processing to change the batch status to Ready status from Working status. If the batch is in Ready status, clicking Show Process Messages moves the batch to a Working status. Process Options Click Process Options to open the Process Options window which allows you to assign the your processing options for the batch. Clinical Documentation User’s Guide 333 Batch Timelog Process Entry Click Process Entry to process only the selected (highlighted) line item. Process All Click Process All to process all rows of information. Total The total number of visits currently in the batch appears in this field. If the control totals are used for the batch, the control total for visits will appear next to the current batch total in parenthesis. Duration The total time in hours and minutes currently in the batch appears in this field. If the control totals are used for the batch, the control total for time will appear next to the current batch total in parenthesis. Pending The total number of transactions that have errors within a batch appears in this field. Processed Total number of transactions processed from this batch into TimeLog appears in this field. Edit Batch Numbers Window The Edit Batch Numbers window allows you to change the names assigned to a batch or to change the control totals for the batch. Edit Batch Numbers Window 334 Clinical Documentation User’s Guide Batch Timelog Edit Batch Numbers Window Fields RT (Resource Type) The role or resource type appear in this field for the transactions as listed in the TimeLog window when you click Batches. Code (Service Code) The service code appear in this field for the transactions as listed in the TimeLog window when you click Batches. PtID (Patient ID) The Patient ID appears in this field for the transactions as listed in the TimeLog window when you click Batches. Name The patient name appears in this field for the transactions as listed in the TimeLog window when you click Batches. Batch Number The batch number appears in this field for the transactions as listed in the TimeLog window when you click Batches. This field can be edited to allow the assignment of a batch number either the button for searching for existing batches, the or the can be used to create a new batch number, can be used to remove the batch number for the listed transaction. Clinical Documentation User’s Guide 335 Batch Timelog Select Batch Number Window The Select Batch Number window allows you to search for a batch number using various constraints. Select Batch Number Window Select Batch Number Window Fields Date From Enter the starting batch date for the search. Date To Enter the ending batch date for the search. Seq. # From Enter the starting batch sequence number for the search. Seq. # To Enter the ending batch sequence number for the search. Operator Click Operator to display the Operator Look‐up window for the selection of operators that entered batch in the search. 336 Clinical Documentation User’s Guide Batch Timelog Search Click Search to execute the search function for the parameters defined within the window. Clear Click Clear to remove all constraints entered and start over. Set As Default Click Set as Default to store your search criteria so it can be used each time you perform a search from this window. Batch Number This column displays the assigned batch number for the returned record. Batch Name This column displays the assigned batch name for the returned record. Batch Status This column displays the current status of the batch record returned. Records This column displays the total number of record associated to the batch number returned in the search. Clinical Documentation User’s Guide 337 Batch Timelog Batch Number Creation Window The Batch Number Creation window allows you to enter details to create a new batch number, including date, operator, name, visits, and hours. Batch Number Creation Window Batch Number Creation Window Fields Date Select or enter the date for the batch number. The current date defaults but you can change it using the drop‐down arrow. Operator Select the operator name for the operator ID to use with the batch number. The current operator defaults but can be changed. Name Enter the name for the batch. Visits Enter the number of visits, which appears in the Batch Timelog window. This value is optional and can be changed to ensure batches can be balanced with external values. Hours Enter the total time control value, which appears in the Batch Timelog window. This value is optional and can be changed to ensure batches can be balanced with external values. 338 Clinical Documentation User’s Guide Batch Timelog Edit Batch Window The Edit Batch window allows you to change the name, number of visits, and total hours for the selected batch. You cannot change the date or the operator stored with the batch. Edit Batch Window Edit Batch Window Fields Date The date assigned to the batch number appears in this field and cannot be edited within this window. Operator The operator assigned to the batch number appears here and cannot be edited from this window. Name Edit the name associated to the batch, if desired. Visits Edit the visit control total value, which appears on the Batch Timelog window. This value is optional and can be changed to ensure batches can be balanced with external values. Hours Edit the time control total value, which appears on the Batch Timelog window. This value is optional and can be changed to ensure batches can be balanced with external values. Clinical Documentation User’s Guide 339 Batch Timelog Batch Timelog Process Options Window The Batch Timelog Process Options window allows you to select the options for processing Batch Timelog records. Batch Timelog Process Options Window Batch Timelog Process Options Window Verify Entries during Process Select the Verify Entries During Process check box to process entries into Timelog as verified entries. Override Authorization Warning Select the Override Authorization Warning check box to override the warning message for exceeding the patient authorization requirement. This option is only active if the operator has the appropriate security privileges. Override Project Visits Warning Select the Override Project Visits Warning check box to override the warning message for exceed patient’s projected visits. This option is only active if the operator has the appropriate security privileges. Preprocess Entries Select Process Entries to process entries into TimeLog without updating TimeLog. This option allows you to determine if any transaction has an error message that must be resolved before it can be processed into Timelog. 340 Clinical Documentation User’s Guide Batch Timelog Process Entries Select Process Entries to process entries directly in Timelog. Batch Timelog Processing Window Transactions>General>Batch Timelog Processing In this window, you have the ability post batch TimeLog transactions into the TimeLog window. You can process multiple batches at ensheathe batches selected must be a Ready or Pending status to be available in this window. To process batches that contain records that meet the criteria defined, enter the desired information in the Transaction Criteria group box. The entire batch is included for processing not just the transactions that meet the criteria defined. Batch Timelog Processing Window Batch Timelog Processing Window – Batch Criteria Date From Enter or select the starting batch date for the batch criteria search. Date To Enter or select the ending batch date for the batch criteria search. Clinical Documentation User’s Guide 341 Batch Timelog Seq. # From Enter or select the starting batch sequence number for the batch criteria search. Seq. # To Enter or select the ending batch sequence number for the batch criteria search. Operators: Select... Click Select... to open the Operator Look‐up window and select operators for the batch criteria search. Transaction Criteria Date From Enter or select the starting batch date for the transaction criteria search. Date To Enter or select the ending batch date for the transaction criteria search. Patients: Select... Click Select... to open the Patient Look‐up window and select patients that exist in transactions included in a batch for the transaction criteria search. Resources: Select... Click Select... to open the Resource Look‐up window to select resources that exist in transaction included in a batch for the transaction criteria search. Create a Batch Number for Batch Timelog 1. Go to Transactions> General> Batch Timelog. 2. Click . 3. Enter the name of the batch date, batch operator, and batch name. 4. If control totals are desired, enters the value for Visits and/or Time. 5. Click OK. 342 Clinical Documentation User’s Guide Batch Timelog Enter a Transaction in Batch Timelog Window 1. Go to Transactions> General> Batch Timelog. 2. Select existing batch number or create a batch number. 3. Enter details for transaction. 4. Save the batch. Delete a Transaction in the Batch Timelog Window 1. Go to Transactions> General> Batch Timelog. 2. Enter or select an existing batch number. 3. Select the transaction to delete from the grid, then click . 4. Save the batch. Update Batch Number Control Totals 1. Go to Transactions> General> Batch Timelog. 2. Enter or select an existing batch number. 3. Click Edit Batch to display the Edit Batch Number window 4. Change the Visits and/or Time fields as needed. 5. Click OK. Process a Single Entry in Batch Timelog Window 1. Go to Transactions> General> Batch Timelog. 2. Enter or select an existing batch number. 3. Click Ready to Process to change the batch status to Ready. 4. Select specific record. 5. Click Process Entry to process selected transaction. Clinical Documentation User’s Guide 343 Batch Timelog Process All Entries in Batch Timelog Window 1. Access the Transactions component. 2. Select Transactions> General> Batch Timelog from the outlook menu or the ribbon menu. 3. Enter or select an existing batch number. 4. Click Ready to Process to change the batch status to Ready. 5. Click Process All to process entries Process Batches Using Batch Timelog Processing Window 1. Access the Transactions component. 2. Select Transactions> General> Batch Timelog Processing from the outlook menu or the ribbon menu. 3. Define selection criteria for the batches to process on the Batch Selection Options window then click Next. 4. Select specific batches for processing on the Batch Selection window then click Next. The Batch Selection Confirmation window appears for the selected batches. 5. Verify the correct batches are selected, then click Next if the correct batches are selected. Click Back to correct the selection. 6. Define the processing options on the Processing Option window then click Process. The Processing Status window will appear as the selected batches are processed. Once processing is complete, the Process Complete window will appear • If the batch status is marked complete, all records have been moved from this batch to TimeLog. • If the batch status is marked pending, there is a least one record in error in the batch. This batch should be accessed in the Transactions>General>Batch Timelog window and corrected. 7. Click Process Message to display any error messages. Based on the error message, the transaction or other supporting set‐up should be adjusted to process transaction into Timelog. 344 Clinical Documentation User’s Guide Chapter 8 ‐ Field Mode In This Chapter This chapter describes using the application in Field Mode (while the workstation is disconnected from the server). The overview, usage, administration and synchronization processes, and My Day component are described in the following sections: • • • • • Field Mode Overview Field Mode Use Field Mode Administration Synchronizing Field Mode with Host Mode My Day Clinical Documentation User’s Guide 345 Field Mode Overview Field Mode Overview What Is Field Mode? You can use the Allscripts Homecare application on a computer directly connected to the server (Host Mode) or on a device that is not connected to the server (Field Mode). Most Field Mode devices are laptop computers. In most organizations, operators use Field Mode according to the following procedure: 1. Each morning, an operator using a Field Mode device (laptop) connects to the server and downloads any information needed for the day's work. 2. In the afternoon, the user uploads to the server the results of the work done on the laptop during that day. 3. Later, according to the settings, the laptop performs an automatic synchronization so the operator can have access to any data entered after the previous synchronization. The process of downloading new information from the server and uploading the results of the day’s work to the server is called Full Synchronization. When a user receives a request in the middle of the day to visit a new patient whose information is not on the laptop, the user can select to only download the information for that patient without doing a full synchronization. This process is called Quick Synchronization. After a Full Synchronization, the Allscripts Homecare application can do one of the following: > Go into sleep mode and synchronize again at a defined time. > Return to Field Mode. > Stay connected to Host Mode. After Quick Synchronization, a user can only continue working in Field Mode. When uploading information to the server, the application displays a list of items to be uploaded. Users can select any item displayed and go directly to the entry window of that item to make changes if needed. The user must also electronically “sign” the items certifying that all recorded data completely and accurately reflects the patients' condition and activities performed. Two types of Full Synchronization are available: complete and partial. > 346 Before complete synchronization, certain information must be 100% complete to be uploaded to the server. This information includes Assessments, Problem Charting, and daily TimeLog entries. If these items are incomplete, they are automatically put on hold. That is, these items remain on the Field Mode device until they are complete. Clinical Documentation User’s Guide Field Mode Overview Each time a user selects to upload information to the server, the application displays a warning about the incomplete items. You can also set certain service‐related data as required to synchronize on the Required to Synchronize tab of the Service Codes/Staff window (Administration>General>Service Codes/Staff). In this case, during synchronization the system will check the visit with corresponding service for these data. If the required data is absent, the visit will be put on hold and not uploaded to the server. Only after all required data is entered, the visit can be synchronized. Users can also select to place certain complete items on hold and not upload them during complete synchronization. Items on hold are editable in Field Mode and are read only in Host Mode. > With partial synchronization, a user can upload incomplete items to the server, unless they are manually put on hold. Uploaded incomplete items are editable in Host Mode. After synchronization, no changes can be made to the clinical entries in Field Mode. Only users with sufficient privileges can change the information in Host Mode. My Day for Field Mode Users My Day is a workflow solution designed to help a busy clinician using Field Mode manage daily work effectively. Using My Day, the clinical staff can view a list of patients that are assigned to them, patients’ OASIS assessments or recertifications due, the assessments reserved for editing, visits scheduled for the clinician, and assigned tasks. The information displayed in My Day in Field Mode is based on the data obtained during the last synchronization of the Field Mode device. In Field Mode, you can access My Day by selecting Allscripts Homecare>My Day. Clinical Monitoring Option for Field Mode Users With the Clinical Monitoring option, you can add, edit, or view specific clinical data as discrete elements using the View Clinical Data window and the Add/Edit Clinical Data window (Patient>Clinical>Clinical Monitoring). Clinical Documentation User’s Guide 347 Field Mode Use Field Mode Use What Functions Are Not Available in Field Mode? All the application functions are available in Field Mode, except for the following: > In the Patient component: Authorizations, Negotiated Rates, and Collections. > In the Resource component: Donations and Reports. > In the Transactions component: Donations. > In the Schedule component: Modifying other resources’ schedules. In Field Mode, you have limited access to the Payers window (Patient>General>Payers). The Pay Control Date field in the lower grid of the Payers window is read only. You cannot add new or edit an existing pay control date. However, you can add a new pay source for the patient in the Pay Source Insurance Code field of the upper window grid, but you cannot edit existing and add new pay sources in the lower grid. Only pay sources that are in the application database can be added in Field Mode. In the Admission & Status window (Patient>General>Admissions & Status), only specially defined Field Mode status codes are available. In the Transactions component, only Contract Invoices, Supplies, and Time Log are available. The following components are not available in Field Mode: Administration, Report, Query, Interface, Claims, Pay Rate Calculator, and Server Monitor. Admission and Discharge Clinicians can admit and discharge patients in Field Mode using special Field Mode status codes. With these codes, you can enter clinical information for an admitted patient, such as billable visits, care plan information, assessments, and other. However, no pay source entry is required or permitted in Field Mode. If the Allow pre‐admission orders check box is selected for your Business Unit (Administration>Business Units>Settings>Orders Settings), you can add the pre‐admission patient in Field Mode indicating the pre‐admission date in the Anticipated Admission Date field (Patient>General>Admission & Status). If a payer is assigned to the pre‐admission patient, you can then generate, print, and sign patient orders. The application does not process claims with Field Mode status codes. A special Field Status Review function is available in Host Mode (Claims>Process>Field Status Review). It lists patients with the Field Mode status codes. Administrative staff uses this function to view and change the status entries. Each Field Mode status code must be replaced with the equivalent standard Host Mode status code in 348 Clinical Documentation User’s Guide Field Mode Use the Admissions & Status window. The claim can be processed as soon as the pay source information is entered and the status code is changed. Patient Numbers In Field Mode, patient code is entered in the New Patient window which appears when you click the New button on the Patient component toolbar. If the Generate New Patient Codes check box is not selected for your Business Unit (Administration>Configuration>Business Units>Settings>Patient Code), you enter a patient code manually. If another patient was assigned this code, the application tells you to change it during synchronization. With the Generate New Patient Codes check box selected, you do not have to change the patient code during synchronization, because the application assigns the patient an available code automatically as in Host Mode. Printing in Field Mode The Field Mode device does not have all information necessary to generate a complete report, so the Reports and Query components are not available in Field Mode. However, you can view or print a number of patient related documents available in Field Mode (Patient>Documents). Purge Cached Patients In Field Mode, you can purge cached patients (Allscripts Homecare>Purge Cached Patients). With this feature, you can manually initiate cleanup of your patient data cache to keep optimum laptop performance. You can use this feature in addition to your regular cache purge scheduled in the Perform Patient Purge every field on the Field Mode tab (Allscripts Homecare>Settings>Field Mode). Set Up Connection to the Server in Field Mode 1. Go to Allscripts Homecare>Settings. 2. Click the Field Mode tab. 3. Complete the fields as appropriate. 4. Click Apply to save the changes and remain in this window. OR Click OK to save the changes and close this window. Clinical Documentation User’s Guide 349 Field Mode Use Override the Login Name When Logging in Field Mode 1. Log in to Field Mode. The Welcome to Allscripts Homecare Field Mode! window appears. 2. If the Name field is not editable, right‐click in the Password field and select Supervisor Override. 3. Enter the appropriate name and password in the Name and Password fields. 4. Select the Synchronize Now check box to synchronize at once if needed. 5. Click OK to enter Field Mode. Admit a Patient in Field Mode Note Note Help is available for individual windows and fields mentioned in the following steps. 1. Open the Patient component. 2. Click on the toolbar. The New Patient dialog window appears. 3. Enter the new patient information and click OK. 4. Select General>Admissions & Status. If your agency defined a prospective status code, the application automatically creates a line in the Admission & Status grid with that code by default. If no prospective status code is defined, create the line manually. Note Only status codes defined in Host Mode as Field Use Only (Administration>General>Patient Status Codes) are available in this Field Mode window. 5. When all information is complete, click Save All. The information is now ready for upload. Note You cannot make any billable services in Field Mode until you go to Host Mode, replace the Field Use Only patient status code with the equivalent Host Mode status code, and add payer information. 350 Clinical Documentation User’s Guide Field Mode Use Perform a Patient Visit in Field Mode Note Note Help is available for individual windows and fields mentioned in the following steps. 1. Log in to Field Mode. Note Synchronize to download the new server information entered since your last synchronization if needed. 2. Select Transactions>General>TimeLog. 3. In the Code field, enter the service code for the selected resource. 4. In the PtID field, enter the patient ID. If the service code disappears from the Code field, the patient was not admitted yet. 5. Enter the start time in the corresponding fields if required. 6. Click P next to the PtID column to open the Patient component. 7. In the Patient component, complete clinical documentation if required (Assessments, Clinical Notes, and Problem Charting). 8. Select Transactions>General>TimeLog. 9. Complete the time and mileage fields if required. 10. Click the Verified button to verify the visit if needed. 11. Click Save to save the visit information. Note The visit should be completed to be uploaded to the server during complete synchronization. However, with partial synchronization, you can leave the visit incomplete. Uploaded incomplete visit is editable in Host Mode. 12. Connect the telephone cable to the Field Mode unit and synchronize if needed. For more details, see Perform Full Synchronization. Clinical Documentation User’s Guide 351 Field Mode Use Manually Purge Cached Patients 1. Select Allscripts Homecare>Purge Cached Patients from the menu bar. The Cached Patients Purge Complete message appears. 2. Click OK. 352 Clinical Documentation User’s Guide Field Mode Administration Field Mode Administration Field Mode System Administrators Allscripts Homecare recommends appointing a person to be the Field Mode system administrator. You can turn to this person with your questions on Field Mode, including establishing network connections and synchronizing data. The Field Mode system administrator is also responsible for printing the Synchronization Register report, troubleshooting failed synchronizations, and conflict management problems. Having a Field Mode system administrator ensures that your Field Mode policies are uniform and clear. Who “Owns” a Field Mode Device? More than one operator can use a single Field Mode device. For example, two operators who work on different shifts can share a laptop. However, operator A must upload and synchronize the work done on the laptop before operator B uses this laptop. Your agency owns a certain number of Field Mode licenses. You can designate as many Field Mode devices as many licenses you have. Use the Workstations window (Administration>Configuration>Workstations) to designate Field Mode devices. How Long Does a Field Mode Device Save Data? In the Field Mode Settings window (Administration>Configuration>Business Units>Settings>Field Mode), you can define how long Field Mode devices save information. The application does not automatically delete information when it is uploaded, but saves it for the time you specify in this window. In addition, you can define how far in advance of a scheduled visit a patient's record is downloaded to a Field Mode device. This function is called Scheduling Lookahead. You can also specify the number of weeks to retain historical data on the Field Mode devices by completing the corresponding fields of the Field Mode Settings window (Administration>Configuration>Business Units>Settings>Field Mode). In addition, you can designate whether to synchronize prospective patients to the Field Mode device, and if they are synchronized, how many weeks to retain them on the Field Mode unit. If you select the Include Deceased Patients in the Above Criteria check box, deceased patients will be downloaded to your Field Mode device based on the defined criteria during the next synchronization. Defining these parameters, you can set limits to the number of existing patients you want to download from the server to your Field Mode device during synchronization. Clinical Documentation User’s Guide 353 Field Mode Administration Synchronization Setup You can define the type of synchronization performed in Field Mode. There are two types of synchronization available: complete and partial. To let particular records be uploaded to the server during complete synchronization, Allscripts Homecare requires 100% completion of these records. If not completed, they are automatically put on hold and cannot be uploaded to the server. However, these records are read only in Host Mode. With partial synchronization, you can upload incomplete records to the server, unless you manually put them on hold. Uploaded incomplete items are editable in Host Mode. You can specify the type of synchronization by selecting the appropriate radio button in the Synchronization section of the Field Mode Settings window (Administration>Configuration>Business Units>Settings>Field Mode). Patient List Management Each operator is associated with one or more Business Units (Administration>Configuration>Operators). For each Business Unit, you can define the Patient Access Mode and specify that the application should automatically download active patients to the laptop if they have a visit scheduled with the operator within the Scheduling Lookahead period. This function ensures that Field Mode users have all the needed information on their laptops. Patient List You can set up each Field Mode user so that the application downloads only certain patients to the laptop during synchronization. You can select to download all patients in the user’s Business Unit, only patients on the user’s team, or onlypatients specifically assigned to the user. (If you select to download only patients on the user's team, the application also downloads patients assigned to the user even if those patients are not on the user’s team.) In the Access Mode column (Administration>Configuration>Operators>Basic>Patient Access), you can define the patients to be downloaded. During synchronization, a Field Mode user can select to download all patients or just a subset of patients allowed for downloading. 354 Clinical Documentation User’s Guide Field Mode Administration Scheduling Software Updates Your agency should update software after all clinicians using the Field Mode devices uploaded the results of their day’s work. Consider the following items when defining the time for the software updates: > At what time should all ordinary shift clinicians upload their day's work? > Will clinicians use sleep mode and if so, what time is set for each clinician’s automatic synchronization? Ensure these time points are after all uploads and after the nightly system backup. > If clinicians do not use sleep mode, they must synchronize again before the working day (or as scheduled by the clinician’s agency) to apply any software updates and keep all information up‐ to‐date. It can take up to an hour to load a software update via dial‐up modem. To avoid affecting the clinicians work, it is better to schedule the update for the period each clinician's laptop is in sleep mode. Field Use Only Status Codes The Field Use Only status codes are defined in the Patient Status Codes window (Administration>General>Patient Status Codes). Field Mode Setup Checklist 1. Ensure that sufficient number of licenses is provided for your organization to use your workstation as a Field Mode device. (Administration>Configuration>Workstations>Field Mode Units) If not, contact a member of the Allscripts Homecare Technical Support team. 2. Define the operator Field Mode privileges. (Administration>Configuration>Operators>Privileges>Allscripts Homecare) 3. For the Field Mode user within the selected Business Unit, define the patient access mode. (Administration>Configuration>Operators>Basic>Patient Access>Access Mode) 4. For the Field Mode user within the selected Business Unit, define if the operator can enter new patient admissions and statuses within the selected Business Unit. (Administration>Configuration>Operators>Basic>Patient Access>Clinical) 5. For the Field Mode user within the selected Business Unit, ensure the resource is assigned to the selected Business Unit. (Administration>Configuration>Operators>Basic>Patient Access>Resource) Clinical Documentation User’s Guide 355 Field Mode Administration 6. Define the type of synchronization, how long historical data, synchronization logs, and audit trails remain on field workstations, and how far ahead the application looks for scheduled visits when downloading patients to the Field Mode units. (Administration>Configuration>Business Units>Basic>Settings>Field Mode) 7. Define the Field Use Only patient status codes. (Administration>General>Patient Status Codes) 8. Define what clinical documentation is required for each Field Mode resource type if needed. (Administration>General>Service Codes/Staff) 9. Set up time and mileage entry requirements for each Field Mode resource type if needed. (Administration>General>Service Codes/Staff) 10. For each Field Mode user, define the branches if needed. (Administration>Configuration>Business Units>Branches) It matters during the synchronization when selecting to download data for the patients in the user’s branch. 11. Define your workstation as a Field Mode device (Field Unit). (Administration>Configuration>Workstations) Define How Many Field Mode Units are Licensed for an Organization Note Note Licensing within the Allscripts Homecare application can be performed only by a member of the Allscripts Homecare Technical Support team. 1. Open the Administration component. 2. From the menu bar, select Configuration>Organizations>Basic. The Organizations window appears. 3. Click Licensing. The Enter Allscripts Healthcare Systems Secondary Password dialog appears. 4. Enter the Allscripts Healthcare secondary password. The Licensing window appears with the General tab active. 5. In the Field Mode Workstations field, enter the number of the licensed Field Mode workstations. 6. Click OK and then 356 to save the changes. Clinical Documentation User’s Guide Field Mode Administration Enable a User to Work in Field Mode Only 1. Open the Administration component. 2. From the menu bar, select Configuration>Operators. The Operators window appears with the Basic tab active. 3. In the left window pane, select the operator whose settings you want to edit. 4. Click the Privileges tab. 5. Select the Allow check box next to the Can Work in Field Mode field. 6. Click to save the changes. Enable a User to Work in Field Mode and Host Mode 1. Open the Administration component. 2. From the menu bar, select Configuration>Operators. The Operators window appears. 3. In the left window pane, select the operator whose settings you want to edit. 4. Click the Privileges tab. 5. Select the Allow check boxes next to the Can Work in Field Mode field and the Can Work also in Host Mode field. 6. Click to save the changes. Clinical Documentation User’s Guide 357 Field Mode Administration Set up a Field Mode Device for Initial Synchronization Print these instructions before you begin the setup. You might not be able to access the help during the setup process. Note Note Some of these instructions include configuring options within the Windows operating system, outside the application. This document does not provide details on those options. Refer to your Windows documentation for more information. Before you begin: 1. Ensure that the laptop's application client can access the server in Host Mode. 2. Ensure that your laptop's Internet or VPN connections are installed and configured correctly. 3. Select Adminstration>Configuration>Workstations. 4. In the Field Mode Units section, verify the number of licensed Field Mode units. If this number is insufficient, contact a member of the Allscripts Homecare Technical Support team. 5. On the Windows desktop, right‐click the My Computer icon and select Properties. The System Properties window appears. 6. Select the Computer Name tab and read your laptop (workstation) full name in the Full computer name field. Configuring the Field Mode device: 1. Connect to the server using the Allscripts System Administration name and password. Use Ethernet connection. 2. Select Administration>Configuration>Workstation. 3. Select the check box next to the workstation you want to define as a Field Mode device (laptop). 4. Click or select File>Save Workstations to save the changes. 5. Select Administration>Configuration>Operators>Basic. 6. In the left window pane, select the operator you want to configure. 7. Click in the Access Mode field of the Patient Access grid, and select All patients in the Business Unit from the drop‐down list. 8. Select the Clinical check box. 358 Clinical Documentation User’s Guide FieldMode Administration 9. For the Field Mode user within the selected Business Unit, ensure the resource is assigned to the selected Business Unit in the Resource column. 10. Click to save the changes. 11. Click the Privileges tab. 12. On the Allscripts Homecare tab, select the Allow check boxes next to the Can work in Field Mode and Can work also in Host Mode fields. 13. Choose File>Save Operators or click to save the changes. Note After the initial synchronization, you can adjust the Field Mode settings in Host Mode. 14. Select File>Logout Operator <Operator Name> to log out. 15. Log in to the application using the operator name and password the Allscripts System Administrator provided for you. 16. Click on the Allscripts Homecare toolbar to disconnect your laptop from the server. The laptop performs the initial synchronization and configuration procedure. After the initial configuration and synchronization: As soon as you see the Synchronize and QuickSynch buttons on the Allscripts Homecare toolbar, your laptop is in Field Mode. 1. To configure the connection to server, select Allscripts Homecare>Settings. The Preferences window appears. 2. Click the Field Mode tab and select the appropriate option in the Connecting to Allscripts Homecare Server section. 3. Click OK to apply changes and close the Preferences window. 4. Click to synchronize. The Allscripts Homecare Field Mode Data Synchronization dialog box appears. 5. In the After Synchronizing section, select the Stay connected in Host Mode radio button. 6. In the Download Data for section, select All Patients in my Business Unit(s). 7. Clear the Show Forms Download Dialog check box. 8. Click the Synchronize Now button. Your laptop returns to Host Mode. Clinical Documentation User’s Guide 359 Field Mode Administration Adjust the operator's patient access and operator privileges as appropriate: 1. Select Administration>Configuration>Operators. 2. In the left window pane, select the operator you want to configure. 3. Click in the Access Mode field of the Patient Access grid and select the appropriate option. 4. Click the Privileges tab. 5. On the Allscripts Homecare tab, select or clear the Allow check boxes next to the Can work in Field Mode and Can work also in Host Mode fields to grant or deny the corresponding privileges. 6. Select File>Save Operators or click Save. 7. On the Allscripts Homecare toolbar, click to disconnect your laptop from server. The Field Mode data download dialog window appears. 8. In the Download data for section, select the group of patients whose data you want to download to your laptop. 9. If you have the custom forms licensed, select the Show forms download dialog check box to see the licensed forms download dialog. If not, skip to step 11. 10. If the Select form(s) that should be available in Field Mode dialog window appears, select the forms using the Use check box or clicking Select All and click OK. As soon as you see the Synchronize and QuickSynch buttons on the Allscripts Homecare toolbar, your laptop is in Field Mode. 11. To return to Host Mode, click dialog box appears. . The Allscripts Homecare Field Mode Data Synchronization 12. In the After Synchronizing section, select the Stay connected in Host Mode radio button. 13. Click the Synchronize Now button. Your laptop returns to Host Mode. Setup a Field Mode user: 1. Verify if settings for the following privileges are correct: Can Work in Field Mode, Can Work also in Host Mode, and Can Use PDA. (Administration>Configuration>Operators>Privileges>Operator Privileges) 2. Define what patients are available to a user in Host or Field Mode and what information is updated during synchronization. (Administration>Configuration>Operators>Basic>Access Mode) 360 Clinical Documentation User’s Guide Field Mode Administration 3. Define for which branch of the organization user will exchange data during synchronization. (Administration>Configuration>Branches) 4. Define status codes which can be assigned to patients in Field Mode. Make sure the Field Use Only check box is selected for these status codes. (Administration>General>Patient Status Codes) 5. Verify the documentation required to upload the visit data during complete synchronization. (Administration>General>Service Codes/Staff>Required to Synchronize) Note With partial synchronization, you can upload incomplete items (set as required) to the server and edit them in Host Mode, unless they are manually put on hold. 6. Set the Field Mode visit time and mileage entry requirements for the appropriate resource type. (Administration>General>Service Codes/Staff>Required to Synchronize) 7. Ensure the communication protocol is set up and installed on the laptop. 8. Ensure the application is installed on the laptop before you test the connection. 9. Ensure the connection works before the laptop shifts to Field Mode. 10. In Host Mode, select Administration>Configuration>Workstations. 11. Select the needed laptop name in the left window grid and define it as a Field Unit. A Disconnect field unit from server button appears in the Allscripts Homecare toolbar. 12. Click the Disconnect field unit from server button to disconnect from the server and begin the initial synchronization. After the disconnect, the laptop is in Field Mode. The only way the user can enter Host Mode is through synchronization. When completing this step, be sure you are signed in to the application as the user who will actually use the laptop. Note Help is available for individual windows and fields mentioned in the steps. Define How Long the Application Retains Historical Data on Field Mode Units 1. Open the Administration component. 2. From the menu bar, select Configuration>Business Units. The Business Units window appears. 3. From the list of Business Units, select the Business Unit for which you want to enter general settings. Clinical Documentation User’s Guide 361 Field Mode Administration 4. Click Settings. 5. Select the Field Mode radio button. 6. Complete the fields of the Weeks to Retain Historical Data on Field Units section as appropriate. 7. Click OK and then to save the changes. Define How Long the Application Retains Synchronization Logs and Audit Trails 1. Open the Administration component. 2. From the menu bar, select Configuration>Business Units. The Business Units window appears. 3. From the list of Business Units, select the Business Unit for which you want to enter general settings. 4. Click Settings. 5. Select the Field Mode radio button. 6. Complete the Weeks to retain synchronization logs and audit trails field as appropriate. 7. Click OK and then to save the changes. Define How Far in Advance Patient Information is Loaded in the Application 1. Open the Administration component. 2. From the menu bar, select Configuration>Business Units. The Business Units window appears. 3. From the list of Business Units, select the Business Unit for which you want to enter general settings. 4. Click Settings. 5. Select the Field Mode radio button. 6. Complete the Scheduling Lookahead Window field as appropriate. 7. Click OK and then 362 to save the changes. Clinical Documentation User’s Guide Field Mode Administration Define the Type of Synchronization 1. Open the Administration component. 2. From the menu bar, select Configuration>Business Units. The Business Units window appears. 3. From the list of Business Units, select the Business Unit for which you want to enter general settings. 4. Click Settings. 5. Select the Field Mode radio button. 6. In the Synchronize section, select the needed radio button: Complete or Partial. 7. Click OK and then to save the changes. Define Which Patients a User Can Download During Synchronization 1. Open the Administration component. 2. From the menu bar, select Configuration>Operators. The Operators window appears. 3. In the list of operators, select the user whose settings you want to edit. 4. Click in the Access Mode field of the Patient Access section, select the patients the user can download from each Business Unit. 5. Click to save the changes. Clinical Documentation User’s Guide 363 Synchronizing Field Mode with Host Mode Synchronizing Field Mode with Host Mode Scheduling Lookahead During synchronization, the application downloads patient data, including discrete data from Clinical Monitoring, to the user’s laptop. The application downloads data on all patients with whom the user has a scheduled visit within a certain time period. You can define this time period, called Scheduling Look Ahead, in the Scheduling Look ahead Window (Days) field (Administration>Business Units>Settings>Field Mode). Data Integrity During Synchronization The application ensures that no data is lost during synchronization. If the application loses its network connection during synchronization, it automatically tries to reconnect and continue the synchronization. If the reconnection fails, an error message appears enabling you to select whether you want to reconnect again or cancel the synchronization and try again later. The application does not lose the information you entered and it does not upload the same information twice. In addition, the application maintains a log of all data uploaded during synchronization. For example, you uploaded your data. Later, the server crashes and is restored from a backup made before you uploaded your data. The next time you synchronize, the application recognizes that the database does not contain your recently‐uploaded data and re‐uploads it. Conflict Management Sometimes, a user wants to update an existing record, but the record was changed in the database since the last time the user accessed it. (Usually, this means that another user changed the record on the server after the Field Mode operator downloaded data to the laptop.) During synchronization, data conflict occurs. This type of conflict is called physical conflict. In this case, the user who updates the record last (during synchronization) selects to accept the original database data, new server data, or new data entered in the Field Mode device. The user can edit the Field Mode entry in the corresponding field of the Data Conflict window. This data conflict resolution process is called Conflict Management. When a user tries to synchronize a record and the application detects a conflict, each conflicting field is displayed with its original value, new server value, and Field Mode user’s value. The application logs these changes, so a supervisor can review them later. 364 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Another type of conflict is a logical conflict. It involves changes to multiple fields or records. Logical conflicts are resolved automatically by the application. They appear on the Conflict History report (Reports>Field Use>Conflict History) for a supervisor to view them. If needed, the supervisor can resolve the conflicts manually as appropriate. Examples of logical conflicts are the following: > A user enters an OASIS Assessment for the patient on the same time as another user. > A user enters a medication with the same dose for a patient but specifying a different route as another user. Patient Code Handling With Allscripts Homecare, the user can specify the patient code in Field Mode if the Generate New Patient Codes option is not selected at your agency in the Settings window (Administration>Configuration>Business Units>Settings>Patient Code). If a user enters a new patient code in Field Mode that conflicts with a patient code that already exists in the database, then the situation will be handled during the Conflict Management process. If you upload the duplicate of a newly entered patient code, you will face a Duplicate Patient Code conflict. The Error: Duplicate Patient Code window opens, where you have to select how to resolve the conflict before the synchronization continues. Non‐Billable Service Codes and Synchronization To perform a successful complete synchronization, when your TimeLog includes non‐billable service codes (for activities such as lunch, case management, and others), whose travel and mileage entries are defined in the Service Codes/Staff window (Administration>General>Service Codes/Staff) as optional, you must have an entry in any Direct Time Duration, Indirect Time Duration, or Travel Time Duration field in the TimeLog window (Transactions>General>TimeLog). Entries in these fields are necessary for a non‐billable service to be considered completed. Clinical Documentation User’s Guide 365 Synchronizing Field Mode with Host Mode Field Mode Synchronization Reports Synchronization Register (Reports>Field Use>Synchronization Register) provides a daily summary of the synchronization activity of all your agency's Field Mode users. Usually, your Field Mode system administrator prints and views this report, paying special attention to users and workstations that did not synchronize within the last 24 hours. For each Field Mode user, the report lists date, time, duration, type, and number of records of the synchronization performed within the defined time period. Synchronizations that did not complete successfully are also logged in the report. In All detail mode, the report also lists the individual patients for whom information was uploaded. A separate section lists Field Mode users who have not synchronized. They are grouped into users who have scheduled visits since their last upload and users with no scheduled visits since their last upload. This report does not list Host Mode users. The Conflict History report (Reports>Field Use>Conflict History) shows a list of resolved conflicts and the users’ choices. Supervisors can then view the report and review the changed information. Field Mode Data Synchronization Window The Field Mode Data Synchronization window enables you to view all data changes in Field Mode since the last time you synchronized: place items on hold, make or edit your synchronization settings, and upload data. The Field Mode data changes are grouped into the following items: > Visit The Visit items contain records associated with a particular visit to a patient as recordedin TimeLog. If you make other changes to the patient’s data apart from adding a visit, all these changes are grouped into the Visit item as well. If there is more than one visit to a patient, each visit is individually displayed in the grid. If multiple visits were performed to the patient on the same day, the Direct Start Time of each visit is displayed in the Completed Items column. Visits are uploaded in the order in which they were performed. If a visit is incomplete or put on hold, any subsequent visits will have the same status until it is completed or released. The Date column displays the visit date. > Patient The Patient items contain records associated with a patient to whom no visit was performed. The Date column displays the edit date. 366 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode > Schedule The Schedule items contain records entered within the Schedule component. These entries are grouped by staff members, not by patients. > Resource The Resource items contain new or changed resource‐related records. > Definitions The Definitions items contain new or changed definition values such as diagnosis codes. The shown date is the edit date. You can select to display either completed or incomplete items. This window displays the selected items and windows containing added or changed items‐related data. Double‐click an item to open all item‐related windows or double‐click a single window in the right window grid to view it. After you verified that the data is correct and ready to be uploaded to the server, enter your password in the Enter your Password for verification field to confirm that the information is correct. In addition, you can define patients whose data you can download from the server, and what you want to do after synchronizing. Review Entries This section contains the following radio buttons displaying information about the number of the corresponding items, the number of items to be uploaded, and the number of items on hold: • 1 completed items. 0 records will be uploaded, 4 records on Hold – Select this radio button to display completed items in the left window grid. • 1 incomplete item. 0 records will not be uploaded – Select this radio button to display incomplete items in the left window grid. Note The numbers of your completed and incomplete items may be different from the numbers in this example. It depends on your entries. If you select to view incomplete item, all records associated with that item appear in the right window grid. Some records can be completed and some incomplete. Incomplete records appear in red. Move the pointer over the record, and a help tag appears explaining why the record is incomplete or listing incomplete fields. Hold Select this check box next to the item you do not want to upload to the server during synchronization. Items on hold are editable in Field Mode and read only in Host Mode. You can put on hold only the Visit and Patient items. Clinical Documentation User’s Guide 367 Synchronizing Field Mode with Host Mode Due to synchronization errors, items remain on hold until the errors are handled. Due to incomplete status, items remain on hold during complete synchronization until they are completed. However, with partial synchronization, you can upload incomplete items to the server and edit them in Host Mode, unless they are manually put on hold. During complete synchronization, you can manually place on hold and remove the hold of completed items only. Allscripts recommends that you complete all items on a daily basis so that patient information is up‐to‐date. Note You can upload multiple visits for the same patient only in the order they were performed. For example, if you have three visits, performed in A, B, C order, and you have A on hold, you cannot upload visits B or C to the server even if they are completed. Move the pointer over the item, and the help tag appears which explains why the completed visits are treated as incomplete. Completed Items This left window grid column displays the list of completed items when you select the corresponding radio button in the Review Entries section. Double‐click the item to open all the windows containing the added or changed item‐related data. Incomplete Items This left window grid column displays the list of incomplete items when you select the corresponding radio button in the Review Entries section. If you select to view an incomplete item, all records associated with that item appear in the right window grid. Some records can be completed and some incomplete. Incomplete records appear in red. Point to the record, and a help tag appears explaining why the record is incomplete or listing incomplete fields. Double‐click the item to open all the windows containing the added or changed item‐related data. Window This right window grid column displays the list of Field Mode windows containing added or changed data associated with the item selected in the left window grid. If you select a Schedule item in the left window grid, a list of one‐week date ranges appear in the right window grid. Double‐click the row to open the window containing the scheduled event in the Schedule component. You can select more than one row pressing and holding Shift (to select contiguous rows) or Ctrl (to select noncontiguous rows) buttons. However, you cannot select more than one week at a time. 368 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Some records in this grid may be completed and some incomplete. Incomplete records appear in red. Move the pointer over the row containing the incomplete record, and the help tag appears which explains why the completed visits are treated as incomplete. Enter your Password for verification In this field, enter your password to verify the statement located above the field. Download Data for This section displays the patient groups whose data you can download from the server. You can select one of the following patients’ group: • Only patients assigned to me – Select this radio button to download data on the patients who are assigned to you. • All patients on my team – Select this radio button to download data on all patients on your team (only if you have sufficient rights). • All patients on my branch – Select this radio button to download data on all patients on your branch (only if you have sufficient rights). • All patients in my Business Unit(s) – Select this radio button to download data on all patients in your Business Units (only if you have sufficient rights). After Synchronizing This section displays the following actions which application can take after synchronizing: • Sleep, then synchronize again at – Select this radio button if you want application to go into sleep mode and synchronize again at the defined time. It is recommended that the time of automatic synchronization is several hours before the start of your working day, because this process may take much time. • Return to Field Mode – Select this radio button if you want application to return to Field Mode. • Stay connected in Host Mode – Select this radio button if you want application to go to Host Mode. Sleep, then synchronize again at In the field next to this caption, enter the time at which you want the laptop to connect to the server and synchronize again. Clinical Documentation User’s Guide 369 Synchronizing Field Mode with Host Mode Download Activities for This section displays the options for resource groups for which the activities will be downloaded from the server. You can select one of the following options: • Myself Only – Select this radio button to download your activities only. • All resources on my team – Select this radio button to download activities of all resources on your team. • All resources on my branch – Select this radio button to download activities of all resources on your branch. Make these my default options Select this check box to apply the current synchronization setup by default. Synchronize Now Click this button to synchronize. Cancel Click this button to close the Allscripts Homecare Field Mode Data Synchronization window and return to Field Mode. Select Patients for Quick Synch Download Window In the Select Patient(s) for QuickSynch Download window, you can select criteria to retrieve a list of patients you need on your Field Mode device or whose information could be changed since the last synchronization. On the Allscripts Homecare toolbar, click the QuickSynch button, and the Select Patient(s) For QuickSynch Download window appears. In the Selection Criteria area, you can select the group of patients to be retrieved: only patients assigned to you, all patients on your team, all patients on your branch, or all patients in your Business Unit. You can also specify the patients’ status or search for a specific patient by the name or code. Select the Make this my default Selection check box to use the selected options for subsequent Quick Synchronizations. After selecting the needed options, click the Retrieve button to display the patients who meet the search criteria in the window grid. Select the Use check box next to the needed patient code. You can also click the Select All button to select the Use check boxes next to all displayed patient codes, or click the Clear All button to clear all Use check boxes in the grid. 370 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode To perform Quick Synchronization, that is, to download the selected patients to your Field Mode device, click the Download button. Show Patients In this section, you can select the group of patients to be displayed in the window grid after they are retrieved from the server. Select from the following options: • Only patients assigned to me – To retrieve patients who are assigned to you. • All patients on my team – To retrieve all patients on your team. • All patients on my branch – To retrieve all patients on your branch. • All patients in my Business Unit(s) – To retrieve all patients in your Business Units. Note Selecting this option can cause a long retrieval process. Show In this section, you can select all available patients or only new patients who meet the defined criteria to be displayed in the window grid after their retrieval from the server. You can select one of the following patient types: • All available patients – To retrieve all available patients who meet the defined criteria. • New patients only – To retrieve only new patients who meet the defined criteria. Status From this drop‐down list, you can select one of the following statuses of patients to be displayed in the window grid after their retrieval from the server: • Active – To retrieve the patients with an Active status. • Inactive – To retrieve the patients with an Inactive status. • Prospects – To retrieve the patients with a Prospective status. • All – To retrieve the patients with the Active, Inactive, and Prospective statuses. Use Select this check box next to the needed patient codes to download the patients. Select All Click this button to select the Use check boxes next to all patient codes in the window grid. Clinical Documentation User’s Guide 371 Synchronizing Field Mode with Host Mode Clear All Click this button to clear the Use check boxes next to all patient codes in the window grid. Search Name Enter the patient name or code depending on what you selected in the In Column drop‐down list. In Column From this drop‐down list, select the parameter for the search of data entered in the Search Name field. The following parameters are available: • Name – Select this parameter if you want to enter the patient name in the Search Name field. • Code – Select this parameter if you want to enter the patient code in the Search Name field. Make this my default Selection Select this check box to use the defined criteria for next Quick Synchronizations by default. Retrieve Click this button to retrieve the patients from the server based upon the defined criteria. Download Selected Patient(s) Click this button to download the selected patients’ data from the server. Cancel Click this button to cancel Quick Synchronization. Updating Allscripts Homecare For Field Mode user, it is recommended to synchronize a Field Mode device prior to the Allscripts Homecare application server upgrade. After synchronization, you should not use your Field Mode device again until the server and the Field Mode device are updated to the new Allscripts Homecare version. 372 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode To upgrade your client workstation to the new release, perform the following steps: 1. Log in to Allscripts Homecare. 2. If you were the last who logged in to Field Mode, select the Synchronize Now check box when logging in to enter the Host Mode. The Allscripts Homecare Field Mode Data Synchronization window appears. 3. Make the appropriate selections and click Synchronize Now. The Confirm dialog appears informing you that a new version of Allscripts Homecare is available. Note If you select the Sleep, then synchronize again at the defined time radio button in the After Synchronizing section of the Allscripts Homecare Field Mode Data Synchronization window, the application performs self update automatically without user’s confirmation. 4. Click Yes. The self update process begins automatically. During the self update, the Allscripts Homecare Self Update window appears. You should not shut down or disconnect your system during this process. 5. Once the system downloads and installs the files for the new Allscripts Homecare version, synchronization begins. Note Depending on the version of Allscripts Homecare from which you upgrade, you may be prompted to log in again. Clinical Documentation User’s Guide 373 Synchronizing Field Modewith Host Mode The synchronization proceeds. When the synchronization is finished, the Field Mode Data Download window appears. 6. Click OK. You log in to Allscripts Homecare. At this time, the workstation is fully updated to the new version of Allscripts Homecare. Data Conflict Window During synchronization, data conflicts can occur. There are two types of data conflicts during synchronization: physical and logical. Logical conflicts are resolved automatically by the application. Physical conflicts are resolved by the user with the help of the application. The Data Conflict window appears when the application detects a physical data conflict during synchronization. The application displays a separate window for each detected conflict. This window displays data that was originally on the server (as you first downloaded it), new data entered in Host Mode while you were disconnected from server, and data you entered in Field Mode. You can accept the original data, the new Host Mode data, or data you entered. The window panes containing original data, new server data, and data you entered in Field Mode are read only. After you accept the data entry by selecting the corresponding radio button, you can click one of the following buttons: > > Back – To make changes to a previously‐resolved data conflict (is available if there are several conflicts of data entered in the same Field Mode window). > 374 Continue – To confirm the data conflict resolution and continue synchronization or view the next conflict window. Cancel – To abort conflict management and synchronization. Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Data Conflict Window Data Conflict Window Fields The ORIGINAL value was This pane displays data that was originally in the database (as you first downloaded it from the server). This data is read only. REVERT to this original entry, cancel changes Select this radio button to cancel your Field Mode entry and another user’s Host Mode entry and to accept the data that was originally on the server (as you first downloaded it). User operator <Name> entered This window pane displays new data entered by another user in Host Mode after you downloaded the original data from server. This data is read only. ACCEPT this entry instead of mine Select this radio button to cancel your Field Mode entry and original data you downloaded before your Field Mode work and to accept another user’s Host Mode entry. Clinical Documentation User’s Guide 375 Synchronizing Field Mode with Host Mode You entered This pane displays data you entered in Field Mode. This data is read only. KEEP my entry, overwrite the previous change Select this radio button to cancel another user’s Host Mode entry and original data you downloaded before your Field Mode work and to accept the data you entered in Field Mode. Back This button is available if there are several conflicts of data entered in the same application window. Click this button to return to a previous conflict. Continue Click this button to confirm the data conflict resolution and continue synchronization or view the next conflict window. Cancel Click this button to cancel conflict management and synchronization. The application returns to Field Mode without uploading or downloading any data. Perform Full Synchronization 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in Field Mode. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. In the Review Entries section, select the type of items you want to appear in the grid. 3. Verify the selected items in the window grid. For more details, see Verify Data Before Uploading. 4. In the Download Data for section, select the appropriate radio button. 376 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode 5. In the After Synchronizing section, select what you want the application to do after synchronization. Note You can access Host Mode on a Field Mode device only by synchronization if you have appropriate permissions. 6. Select the Show Forms Download Dialog check box to make the Select form(s) that should be available in Field Mode window appear during synchronization. 7. Select the Make these my default options check box to apply the current synchronization setup by default. 8. Enter your password in the Enter your Password for verification field. 9. Click the Synchronize Now! button. Download Data for an Individual Patient 1. Select File>QuickSynch from the menu bar. OR Click on the toolbar. The Select Patients for QuickSynch Download window appears. 2. Enter patient name or code in the Search Name field. 3. Select Name or Code (according to your selection in the Search Name field) in the In Column drop‐down list. 4. Click the Retrieve button. 5. Select the Use check box next to the needed patient code. 6. Click the Download Selected Patient(s) button to download the selected patient to your Field Mode device. Clinical Documentation User’s Guide 377 Synchronizing Field Mode with Host Mode Define Patients to Be Downloaded During Synchronization 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. Select the appropriate radio button in the Download Data for section. 3. Select other needed synchronization options. 4. Enter your password in the Enter your Password for verification field. 5. Click the Synchronize Now! button. Perform Quick Synchronization to Download Patient Data 1. Select File>QuickSynch from the menu bar. OR Click on the toolbar. The Select Patients for QuickSynch Download window appears. 2. Select the criteria for the patients you want to retrieve. 3. Click the Retrieve button. 4. Select the Use check boxes next to the patients you want to download. OR Click the Select All button to select the Use check boxes next to all patients in the window grid. 5. Click the Download Selected Patient(s) button to download the selected patients to your Field Mode device. 378 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Verify Data Before Uploading 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. In the left window grid, select the items to verify. 3. Double‐click the item to open all item‐related windows or double‐click the specific window related to the selected item in the right window grid. 4. Change the data you need in the open windows. 5. Click to save the changes. 6. In the Allscripts Homecare Field Mode Data Synchronization window, enteryour password in the Enter your Password for verification field. 7. Click the Synchronize Now! button. Clinical Documentation User’s Guide 379 Synchronizing Field Mode with Host Mode Place Item on Hold to Prevent Uploading During Complete Synchronization 1. Click on the Field Mode toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. To display completed items in the left window grid, in the Review Entries section, select the <n1> completed items. <n2> records will be uploaded, <n3> records on Hold radio button. (Where n1 – amount of completed items, n2 – amount of records which will be uploaded, and n3 – amount of records on hold.) 3. In the left window grid, select the Hold check boxes next to the items you want to place on hold. Note In case of complete synchronization, certain items can be automatically put on hold. They remain on hold until the items synchronization errors are handled or until items are completed. Items that must be 100% completed to be uploaded to the server include Assessments, Problem Charting, and daily TimeLog entries. 4. To display completed items in the left window grid, in the Review Entries section, select the <n1> completed items. <n2> records will be uploaded, <n3> records on Hold radio button. (Where n1 – amount of completed items, n2 – amount of records which will be uploaded, and n3 – amount of records on hold.) 5. Verify the items to upload. For more details, see Verify Data Before Uploading. 6. Select the needed synchronization options. 7. Enter your password in the Enter your Password for verification field. 8. Click the Synchronize Now! button. 380 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Place Item on Hold to Prevent Uploading During Partial Synchronization 1. Click on the Field Mode toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. In the Review Entries section, select the appropriate radio button to display needed items in the left window grid. 3. In the left grid, select the Hold check boxes next to the items you want to place on hold. Note With partial synchronization, you can put on and remove from hold both completed and incomplete items. 4. Verify the items to upload. For more details, see Verify Data Before Uploading. 5. Select the needed synchronization options. 6. Enter your password in the Enter your Password for verification field. 7. Click the Synchronize Now! button. Resolve Data Conflicts During Synchronization When the application detects a data conflict during synchronization, it displays the Data Conflict window. 1. Select one of the following radio buttons to resolve the data conflict: • REVERT to this original entry, cancel changes • ACCEPT this entry instead of mine • KEEP my entry, overwrite the previous change 2. Click Continue to confirm the data conflict resolution and continue synchronization or view the next conflict window. To return to a previous conflict, click Back. Note The Back button is available if there are several conflicts of data entered in the same application window. Clinical Documentation User’s Guide 381 Synchronizing Field Mode with Host Mode Electronically Sign Data Before Uploading 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. Verify the items to upload. For more details, see Verify Data Before Uploading. 3. Select the needed synchronization options. 4. If you agree with the certification statement, enter your password in the Enter your Password for verification field. 5. Click the Synchronize Now! button. Define What to Do After Synchronization 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. Verify the items to upload. For more details, see Verify Data Before Uploading. 3. In the After Synchronizing section, select the appropriate option. 4. Select other needed synchronization options. 5. Enter your password in the Enter your Password for verification field. 6. Click the Synchronize Now! button. 382 Clinical Documentation User’s Guide Synchronizing Field Mode with Host Mode Set Time to Perform Automatic Synchronization 1. Select File>Synchronize from the menu bar. OR Click on the toolbar. OR Select the Synchronize Now check box in the Welcome to Allscripts Homecare Field Mode! dialog window when logging in the Field Mode application. The Allscripts Homecare Field Mode Data Synchronization window appears. 2. Verify the items to upload. For more details, see Verify Data Before Uploading. 3. In the After Synchronizing section, select the Sleep, then synchronize again at radio button. 4. In the field next to the Sleep, then synchronize again at radio button, enter the time for automatic synchronization. 5. Select other needed synchronization options. 6. Enter your password in the Enter your Password for verification field. 7. Click the Synchronize Now! button. Clinical Documentation User’s Guide 383 My Day My Day About My Day Using My Day, clinical staff can organize and navigate their day from one place. Clinicians can view a list of patients that are assigned to them, as well as whether those patients have an OASIS assessment or recertification due. If a clinician has reserved assessments for editing, the assessments that are reserved will also be displayed on the window. Visits that are scheduled for the clinician and tasks assigned will be shown on the My Day window. My Day is a workflow solution designed to help the busy field clinician manage their ever increasing case load. On a single window, the clinician can handle their daily schedule, manage their tasks, and easily check when their patients need to be recertified, need OASIS, received laboratory results, or have an assessment reserved. My Day will appear in Administration>Configuration>Operators>Preferences>Start Up and can be added either as Predefined or Custom. In order to obtain the most benefit from My Day, agencies should be using Patient>Assignments, Scheduling, and Tasks. Also, My Day reflects information through all Business Units to which a clinician has access. My Day can be used in Host Mode as well as in Field Mode. Information contained within this window is designed to assist visiting field staff navigate through their day from one location. Note Note Information displayed in My Day in Field Mode is based on the data obtained during the last synchronization of the field device. 384 Clinical Documentation User’s Guide My Day My Day Window Allscripts Homecare>My Day The My Day window provides quick access to all your scheduling, tasks, patients, and favorites and is divided into four sections: • My Schedule Section – Displays the current day's schedule with detailed information about a patient and time of service. • My Tasks Section – Displays all tasks assigned to the clinician that is logged in to the workstation. • My Patients Section – Displays all patients that the logged in clinician should work with and additional information on the activities that should be done for those patients. • My Favorites Section – Displays the list of programs, web sites, and reports marked as favorite on your device. To learn more about the My Day component, see the About My Day section. My Day Window Clinical Documentation User’s Guide 385 My Day My Schedule Section The My Schedule section is located in the top left corner of the My Day window and displays your current day's schedule. It can also be configured to show additional days if needed. You can double‐ click the patient name to open the TimeLog window to begin your visit documentation. Visit dates in the future may be reviewed, however TimeLog will not open for future dates of service. You can see your scheduling across all Business Units to which you have access and where you have visits scheduled. The My Schedule section contains the following columns and tabs: > Services and Activities – Displays names of patient, service date, and resource type. > Patient Phone – Displays the phone number of a patient. > Date Of Birth – Displays patient’s date of birth. > Time – Displays the time of visit or activity. > Status – Displays the status of the visit. > Authorization Status – Displays the authorization status of the service or visit provided for a patient. This information is stored in Patient>Services>Authorizations. The following authorization statuses can be displayed: • – Status authorized. • – Status pending (after the authorization request was sent to the payer for its approval). • – Status not authorized. > Business Unit – Displays Business Unit to which a patient belongs. > Primary Diagnosis – Displays the patient’s primary diagnosis. This information is entered in Patient>General>Admissions&Status. The diagnosis listed in the Primary Diagnosis tab reflects the primary diagnosis as of the date of service. > Contact Information – Displays the patient’s phone, address, and directions how to get to the patient’s home. This information is defined in Patient>General>Basic. > Schedule Notes – Displays the additional information for the patient. To edit or create a scheduling note, select the Schedule component from the Allscripts Homecare drop‐down list and enter or edit the note within the event. You can print information shown in the My Schedule section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Click the Customize button on the top right corner of the My Schedule section to set the period of time for viewing information in the Customize View: My Schedule window. 386 Clinical Documentation User’s Guide My Day My Schedule Section Customize View: My Schedule This window appears when you click the Customize button at the top of the My Schedule section. Using this dialog, you can make appropriate setup options for schedule preview and usage. Select the following setup options for the My Schedule section: > Enter the number of days in the View today and [__] days field to define for how many days your schedule will be shown. > Click the Fields button to specify what fields will be visible on the My Schedule section and select needed fields in the Show Fields Dialog. This dialog contains the following fields available for selection: Authorization Status, Business Unit, Date Of Birth, Icon, Patient Phone, Services and Activities, Status, and Time. Note All fields chosen in the Show Fields window appear next to the Fields button on the Customize View: My Schedule tab. > To set the default values, click the Reset View button. Clinical Documentation User’s Guide 387 My Day Customize View: My Schedule Window My Tasks Section The My Tasks section is located in the right top corner of the My Day window. It contains all tasks assigned to the clinician logged in to the workstation in Alerts and Tasks>My Tasks. The My Tasks section contains the following columns: > Priority – Indicates the urgency with which the task must be completed. There are such priorities for the tasks: • Low – The low task priority is marked with icon. • Normal and Medium – There is no icons for normal and medium task priorities. • High – The high task priority is marked with icon. • Urgent – The urgent task priority is marked with icon. > Task – Displays tasks that need to be addressed. The tasks for patients can be created and edited in Patient>General>Patient Tasks and for the resources, assigned and edited in Alerts and Tasks>General>Tasks I Created. You can also add a task by right‐clicking the patient’s name on the Assignments tab of the My Patients section in this window. Choose Create Task from the drop‐down menu and the new task will appear in the grid. Compete entry by specifying the rest of the fields. To view patient data, right‐click any option in the Task column and select Open Patient from the drop‐down menu. > Patient – Displays the patient‘s first and last names. Note If the task does not have any patient assigned, the No patient assigned record will appear in the Patient column. 388 Clinical Documentation User’s Guide My Day > Due Date – Displays date and time when the task is due. Due dates are defined in Patient>General>Patient Tasks or in Alerts and Tasks>General>My Tasks. > Patient Code – Displays patient‘s code. Patient codes are defined in Patient>General>Basic. > Task Code – Displays the code of the task. The task codes for the patient are defined in Patient>General>Patient Tasks. > Category – Displays the category of the resource. Resource categories are defined in Administration>General>Resource Types. > Status – Displays the stage at which the task is in the present time. Status options are defined in Patient>General>Patient Tasks or in Alerts and Tasks>General>My Tasks. There are the following status options: • (Not Started) – The task has been created but no action has been taken towards completing it. • (In Progress) – The task was started but not completed yet. • (Completed) – The action required for this task was made. • (Cancelled) – The task was either created in error or is no longer appropriate. • (Decline) – The recipient of the task indicated that this task cannot be completed. This status may require the creator of the task to reassign it to someone else. > Business Unit – Displays the name of the Business Unit in which the assigned task should be completed. > Subject – Displays the subject of the task, which depends on the type of the task and can be manually entered by the task creator or automatically generated by the system. You can print information shown in the My Tasks section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Click the Customize button on the top right corner of the My Tasks section to set appropriate settings in the Customize View: My Tasks window. Clinical Documentation User’s Guide 389 My Day My Tasks Section Customize View: My Tasks This window opens when you click the Customize button at the top of My Tasks section. Here you can make appropriate setup options for tasks preview and usage. Select the following setup options for the My Tasks section: > Click the Fields button to specify what fields will be visible in the My Tasks section and select needed fields in the Show Fields Dialog. This dialog contains the following fields: Business Unit, Category, Due Date, Flag Overdue, Patient, Patient Code, Priority, Status, Task, and Task Code. Note All fields chosen in the Show Fields window appear next to the Fields button in the Customize View: My Tasks window. > Click the Group By button to set the grouping criteria for the information in the My Tasks section and select the needed options in the Group By Dialog. You can group items in the My Tasks section by the following options: Business Unit, Category, Due Date, Flag Overdue, Patient, Patient Code, Priority, Status, Task, and Task Code. Note All fields chosen in the Group By dialog appear next to the Group By button in the Customize View: My Tasks window. > 390 Click the Sort button to set the sorting criteria for the information in the My Tasks section and select the needed options in the Sort By Dialog. There are following sorting options in the Sort By Clinical Documentation User’s Guide My Day dialog: Business Unit, Category, Due Date, Flag Overdue, Patient, Patient Code, Priority, Status, Task, and Task Code. Note All fields chosen in the Sort By dialog appear next to the Sort button in the Customize View: My Tasks window. > Click the Filter button to filter tasks displayed in the My Tasks section and select the needed filtering options in the Filter Dialog. > Select the Warn me if the task is overdue in X days check box and enter number of days to be warned ahead of time about the tasks that are due within the entered number of days. These tasks are flagged yellow in the Patient Tasks section. > To set the default values, click the Reset View button. Customize View: My Tasks Window Show Fields Dialog This dialog appears when you click the Fields button in the Customize View window for each section of the My Day component that allow custom selection of available fields. Click to move selected fields to the Show these fields section. Or select the fields and click to move them to the Available fields section. Fields that are in the Available fields section will be not visible in the My Schedule section. This window consists of two sections: > Available fields – Displays the list of fields available for selection in the corresponding section. Select the needed fields and then click Clinical Documentation User’s Guide to move them to the Show these fields section. Once 391 My Day the field is moved to the Show these fields section, this field name will no longer be displayed in the Available fields section. > Show these fields – Displays the list of fields that are already visible in the corresponding section of the My Day window. Show Fields Window – Customize View: My Tasks Window Group By Dialog Using this dialog, you can set fields grouping criteria for the My Tasks section. This dialog appears when you click the Group By button in the Customize View: My Tasks window. The Group By dialog contains the following sections: > Group items by – In this section, you can identify how items should be grouped in the window. More then one grouping option can be defined. Groups can be identified by the plus symbols (+) that can be selected to display the items within that group. For example, if the first option selected was to group by patient, and then by priority, you can see on your window the patient’s name, then urgent priority tasks for that patient, followed by high priority tasks for that patient, etc. > > 392 Then by – In these sections, you can specify the second and third level of the data that will be grouped in the window. Click the Clear All button to restore all of the grouping settings to defaults. Clinical Documentation User’s Guide My Day Set Grouping Criteria for the My Tasks Section 1. In the Group items by section, select the field that will be used as the first grouping option. 2. Select the Show field in the view check box to make the selected field name visible. 3. Select one of the radio buttons to set either ascending or descending sort order. 4. To set the second and third level of grouping, repeat the above steps in the appropriate Then by sections. 5. Click the Clear All button to restore all grouping settings to their default values. 6. Click OK to save your settings. Otherwise, click Cancel to return to the Customize View: My Tasks window without saving any changes. Group By Dialog Sort By Dialog Using this dialog, you can set sorting options for the My Tasks section. This dialog appears when you click the Sort By button in the Customize View: My Tasks window. The Sort By dialog contains the following sections: > Sort items by – In this section, you can identify how items should be sorted in the window. More then one sorting option can be defined. For example, if the first option selected was to sort by patient, and then by priority, you can see on your window the patient’s name, then urgent priority tasks for that patient, followed by high priority tasks for that patient, etc. > Then by – In these sections, you can specify the second and third level of the data that will be sorted in the window. > Click the Clear All button to restore all of the sorting settings to defaults. Clinical Documentation User’s Guide 393 My Day Set Sorting Criteria for the My Tasks Section 1. In the Sort items by section, select the field that will be used as the first sorting option from the drop‐down list. 2. Select one of the radio buttons to set either ascending or descending sort order. 3. To set the second and third level of sorting, repeat the above steps in the appropriate Then by sections. 4. Click the Clear All button to restore all sorting settings to their default values. 5. Click OK to save your settings. Otherwise, click Cancel to return to the Customize View: My Tasks window without saving any changes. Sort By Dialog Filter Dialog Using this dialog, you can specify what tasks you want to filter for viewing in the My Tasks section. This dialog appears when you click the Filter button in the Customize View: My Tasks window. You can choose from the following options: • • Select the Incomplete tasks radio button to view tasks that have incomplete status. • Select the Include Tasks with no Due Date check box to view the task with no specific date. • 394 Select the All Tasks radio button to view all your tasks. Select the Incomplete Tasks that are overdue radio button to view the late tasks that have incomplete status. Clinical Documentation User’s Guide My Day Filter Dialog My Favorites Section This section is located at the bottom right of the My Day window. My Favorites allows you to access other programs on your device. If you have an access to the Internet and are in the Host mode, you can view the reports you have identified as your favorites within the Report component. Click the Customize button to define the settings for the My Favorites section in the Customize View: My Favorites window. My Favorites Section Clinical Documentation User’s Guide 395 My Day Customize View: My Favorites This window appears when you click the Customize button at the top of My Favorites section. Here you can customize the selections that appear in the My Favorites section. The Customize View: My Favorites window contains the following controls: > Add Application to Favorites – Click this button to add programs other than Allscripts Homecare to the list of favorite applications. > Organize Favorites – Click this button to customize the list order of your favorites. > Reset View – Click this button to reset the values to default. Customize View: My Favorites Window My Patients Section The My Patients section is located in the bottom left corner of the My Day window. The My Patients section consists of the following tabs which allow you to view information about related areas as reports from your field device: • Assignments • Recertification Alert • Reservations • OASIS Due Alert • Imported Medications • Lab Results • Therapy Services The information displayed in these tabs is based on reports that are currently available in Allscripts Homecare within the Patient component under Documents menu and in the Report component. You can open the patient record by double clicking the patient name in the My Patients section. This section includes only those patients to whom you are assigned in Patients>Clinical>Assignments. 396 Clinical Documentation User’s Guide My Day My Patients – Assignments Tab You can view and print an Assignments report using this tab. The Assignments tab contains the following columns: > Patient Code – Displays the code of a patient. The codes are assigned to patients in Patient>General>Basic. > Patient – Displays the patient’s names. The names are defined in Patient>General>Basic. Note You can create a task by right clicking patient name area and selecting the Create Task option. If you do not have full access security privilege to the Alerts and Tasks/My Tasks window, this option is disabled. Note To open the information about the patient, right‐click the patient name area and select the Open Patient option. To view medications list, right‐click the patient name area and select the View Medications List option. > Status – Displays the current patient’s status. > Patient Phone – Displays a phone number of a patient. > Physician – Displays the name of the physician. The information is stored in Patient>General>Admissions & Status. > Physician Phone – Displays the work phone number of the physician. This information is stored in Resource>General>Address & Phone. > Emergency Contact – Displays the information on the person who is defined as emergency contact. This information is stored in Patient>General>Family & Friends. > Emergency Phone – Displays the phone number of the emergency contact. This information is stored in Resource>General>Address & Phone. > Admission – Displays the patient’s latest admission record. > Exit – Indicates the patient’s discharge or date of death if the patient is inactive. > City – Displays the name of the city where the patient lives. > Date of Birth – Displays patient’s birth date. > Zip – Displays the patient’s zip codes. > Master ID – Displays the patient’s master ID if applicable. > Business Unit – Displays name of the Business Unit to which a patient belongs. You can print information shown in the My Patients – Assignments section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Clinical Documentation User’s Guide 397 My Day Click the Customize button at the top right corner of the My Patients section to define setup options that will be displayed in the Assignments tab in the Customize View: My Patients – Assignments window. My Patients – Assignments Tab Customize View: My Patients – Assignments This window appears when you click the Customize button on the Assignments tab of the My Patients section. Here you can select settings for the Assignments tab. In the Customize View: My Patients – Assignments window, there are following controls: > In the Show only patients who are section, you can define what patients will be displayed on the Assignments tab by selecting one of the following options: • • Prospective – Select this radio button to view prospective patients only. • Inactive – Select this radio button to view inactive patients only. • > Active – Select this radio button to view active patients only. All – Select this radio button to view all patients. Click the Fields button to specify what fields will be visible on the Assignments section and select needed fields in the Show Fields Dialog. This dialog contains the following fields available for selection: Admission, Business Unit, City, Date of Birth, Emergency Contact, Emergency Phone, Exit, Master ID, Patient, Patient Code, Patient Phone, Physician, Physician Phone, Status, and Zip. Note All fields chosen in the Show Fields dialog appear next to the Fields button in the Customize View: My Patients – Assignments window. > 398 To set the default values, click the Reset View button. Clinical Documentation User’s Guide My Day Customize View: My Patients – Assignments Window My Patients – Recertification Alert Tab Using this tab, you can view and print the Recertification Alert report. Allscripts Homecare displays recertifications in this window for patients who have recertifications approaching within the period defined. Options for the date parameter view include looking at orders that are due between today and the orders lead time set within the Administration component or for a beginning and ending date range. Note Note To change or edit your orders lead time setting, operations with the appropriate privileges can do so in Administration>Configuration>Business Units>Settings>Orders Settings>Lead Time for Recertification Orders. For example, if today's date is June 10, 2009 and the agency orders lead time is set to 5 days the system will display all orders due between 06/10/09 and 06/15/09. The Recertification Alert tab contains the following columns: > Patient – Displays the name of a patient. The information is defined in Patient>General>Basic. > Team – Displays the name of the team that patient belongs to. > Recert – Displays the date of the patient‘s recertification. > Business Unit – Displays the name of Business Unit to which a patient belongs. You can print information shown in the My Patients – Recertification Alert section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Clinical Documentation User’s Guide 399 My Day Click the Customize button at the top right corner of the My Patients section to define settings for the information displayed on the Recertification Alert tab. You can set appropriate options in the Customize View: My Patients – Recertification Alert window. My Patients – Recertification Alert Tab Customize View: My Patients – Recertification Alert This window appears when you click the Customize button on the Recertification Alert tab of the My Patients section. Here you can select settings for the Recertification Alert tab. In the Customize View: My Patients – Recertification Alert window, there are following controls: > Select the Run from Today and 14 days forward (based on Orders Lead Time setting in the current Business Unit) radio button to include the patients with the corresponding recertification dates. > Select the Date Range radio button to choose the appropriate recertification date. Click down arrows and select begin and end dates from the corresponding drop‐down calendars. > Click the Reset View button to set the default values. Customize View: My Patients – Recertification Alert Window 400 Clinical Documentation User’s Guide My Day My Patients – Reservations Tab With this tab, you can view and print assessment reservations. The reservations displayed here are based on the clinician logged in and are resented when you sign into the application and again at synchronization. The report is based on the information in Patient>Clinical>Assessments>Reservation. The Reservations tab contains the following columns: > Patient – Displays the name of a patient. This information is defined in Patient>General>Basic. > Assessment Date – Displays the date when the visit or the assessment was performed. This date is entered in the Patient>Clinical>Assessments. > RFA – Displays the reason for assessment that is reserved. This information is entered in the Patient>Clinical>Assessments. > Assessed By – Displays the name of the person who completed the assessment, whose identification is made when creating a new assessment. This information is entered in Patient>Clinical>Assessments. > Reserved By – Displays a name of the person who reserved the assessment. The name displayed will be the name of the clinician that is currently logged into the application. Assessment reservations are performed in Patient>Clinical>Assessments. > Reserved Date – Displays the date and time when the assessment was reserved. This date and time is automatically recorded by the system when the reservation option is selected in Patient>Clinical>Assessments. > BusinessUnit – Displays the name of Business Unit to which a patient with the reserved assessment belongs. You can print information shown in the My Patients – Reservations section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Click the Customize button at the top right corner of the My Patients section to set settings for the information on the Reservations tab. You can set appropriate options in the Customize View: My Patients – Assessment Reservations dialog. My Patients – Reservations Tab Clinical Documentation User’s Guide 401 My Day Customize View: My Patients – Assessment Reservations This window appears when you click the Customize button on the Reservations tab of the My Patients section. Here you can select settings for the Reservations tab. In the Customize View: My Patients – Assessment Reservations window, there are following controls: > Enter the appropriate number of days in the Show assessments reserved longer than X days field to define which assessments will appear in the window. > Click the Reset View button to set the default values. Customize View: My Patients – Assessment Reservations My Patients – OASIS Due Alert Tab This tab identifies patients that are assigned to the logged in resource and require OASIS assessment to be completed. There are following columns on this tab: > > Status – Displays the current status code assigned to the patient. Status codes are entered in Patient>General>Admission&Status. > Type Due – Displays the type of OASIS assessments that is due. > Date From – Displays the first date when the assessment can be completed. > Date To – Displays the ending date when the assessment should be completed. > State – Displays the stage at which assessment is currently. > 402 Patient – Displays the names of a patient for whom the OASIS assessment is due. The patient names are entered in Patient>General>Basic. Business Unit – Displays the name of Business Unit to which a patient belongs. Clinical Documentation User’s Guide My Day My Patients – OASIS Due Alert Tab Customize View: My Patients – OASIS Due Alert This window appears when you click the Customize button on the OASIS Due Alert tab of the My Patients section. Here you can select settings for the OASIS Due Alert tab. In the Customize View: My Patients – OASIS Due Alert window, there are following controls: > Select the Run from Today and X days forward (based on OASIS Lead Time settings in the current Business Unit) radio button to default the OASIS Due Alert report to run from today (system date) and X days forward. > Select the Date Range radio button to run the OASIS Due Alert report for the specific date range. Click down arrows and select the needed dates from the Begin Date and End Date drop‐down calendars. > Click the Reset View button to convert all the settings to the default values. Customize View: My Patients – OASIS Due Alert Window Clinical Documentation User’s Guide 403 My Day My Patients – Imported Medications Tab This tab was added to the My Patients section in the scope of Hospice Pharmacia functionality. It shows the status of the medications received in the OMP O09 message through the HL7 inbound interface. Information on the received but not yet confirmed medications is stored in the Imported Medications window for the appropriate patient. Once the medication is confirmed, it is moved to the Medications window for a patient. There are following columns on the Imported Medications tab: > Patient Code – Displays patient‘s code. Patient codes are defined in Patient>General>Basic. > Patient Name – Displays the first and last names of the patient for whom a medication is imported. Patient names are entered in Patient>General>Basic. > Medication – Displays the name of the imported medication. > Primary Physician Name – Displays the first and last names of the primary physician assigned to the patient. > Physician Phone – Displays phone number of the patient’s primary physician. > Confirmed – Displays confirmation status of the imported medication. If the medication is confirmed, it is moved to the Medications window (Patient>Clinical>Medications). If it is not yet confirmed or denied, it is displayed in the Imported Medications window (Patient>Clinical>Imported Medications). > Business Unit – Displays the name of Business Unit to which a patient belongs. You can print information shown in the My Patients – Imported Medications section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Click the Customize button at the top right corner of the My Patients section to set settings for the information on the Imported Medications tab. You can set appropriate options in the Customize View: My Patients – Imported Medications dialog. My Patients – Imported Medications Tab 404 Clinical Documentation User’s Guide My Day Customize View: My Patients – Imported Medications This window appears when you click the Customize button on the Imported Medications tab of the My Patients section. Here you can select settings for the Imported Medications tab. In the Customize View: My Patients – Imported Medications window, there are following controls: > Set the number of days after which the medications will be deleted from the list in the Remove Confirmed Medications From List After X days field. > Click the Fields button to specify what fields will be visible in the Imported Medications tab and select needed fields in the Show Fields Dialog. This dialog contains the following fields available for selection: Business Unit, End Date, MAR, May Administer, No Start Supplemental, No End Supplemental, Confirmed, Medication, Patient Code, Patient Name, Physician Phone, Start Date, and Primary Physician Name. Note All fields chosen in the Show Fields dialog appear next to the Fields button in the Customize View: My Patients – Imported Medications window. > Click the Reset View button to convert all settings to their default values. Customize View: My Patients – Imported Medications Clinical Documentation User’s Guide 405 My Day My Patients – Lab Results Tab This tab displays lab results which have been retrieved, processed, and completed. These lab results are associated with patients for whom the lab results you entered or those that were forwarded to you. There are following columns on the Lab Results tab: > Patient – Displays the first and last names of the patient associated with the lab result. Patient names are entered in Patient>General>Basic. > Lab Test Name – Displays the names of the laboratory tests provided for the corresponding patient. > Primary Physician – Displays the first and last names of the primary physician assigned to the patient for whom the laboratory test was provided. This is not the ordering physician. > Physician Phone – Displays phone number of the patient’s primary physician. > Priority – Displays priority status of the lab result. The possible values are: R – ROUTINE and S – STAT. > Status – Displays the current status of the lab result. The possible values are: F – FINAL, P – PRELIMINARY, C – CORRECTED. > Date Received – Displays the date when the lab result was received. This is the date when the corresponding ORU R01 message was sent by ACL. > Business Unit – Displays name of the Business Unit to which a patient belongs. You can print information shown in the My Patients – Lab Results section using the Print button located at the top right corner of this section. The detailed report will be printed on a separate page. Click the Customize button at the top right corner of the My Patients section to set settings for the information on the Lab Results tab. You can set appropriate options in the Customize View: My Patients – Lab Results dialog. My Patients – Lab Results Tab 406 Clinical Documentation User’s Guide My Day Customize View: My Patients – Lab Results This window appears when you click the Customize button on the Lab Results tab of the My Patients section. Here you can select settings for the Lab Results tab. In the Customize View: My Patients – Lab Results window, there are following controls: > Set the number of days after which the reviewed laboratory results will be deleted from the list in the Remove Reviewed Labs from List After X days field. > Click the Fields button to specify what fields will be visible in the Imported Medications tab and select needed fields in the Show Fields Dialog. This dialog contains the following fields available for selection: Business Unit, Date Received, Lab Test Name, Patient, Physician Phone, Primary Physician, Priority, and Status. Note All fields chosen in the Show Fields dialog appear next to the Fields button in the Customize View: My Patients – Imported Medications window. > Click the Reset View button to convert all settings to their default values. Customize View: My Patients – Lab Results Clinical Documentation User’s Guide 407 My Day My Patients – Therapy Services Tab Using this tab, you can view today’s and upcoming therapy visits that must be performed by a qualified therapist. Therapy visits appear on this tab if they are scheduled to be performed by the curretly logged resource or if they are scheduled for the patient assigned to this resource. You can print the information from this tab by clicking Print in the upper‐right of the My Patients section. For more information on therapy visits, refer to the Schedule User’s Guide. You can change how many days ahead to display therapy services and set the grouping options on the tab by clicking Customize in the upper‐right of the My Patients section. My Patients – Therapy Services Tab Set My Day as Default View on Field Device 1. Open Allscripts Homecare on your device. The Opening Allscripts Homecare dialog appears. 2. Select the Begin With radio button and from the list of available components, select the My Day check box. 3. To set the selected component as default when logging into the Allscripts Homecare application, select the Make this my default starting configuration check box. 408 Clinical Documentation User’s Guide My Day View My Schedule from My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. View My Schedule in the upper left corner of the window to see a list of the patients, their phone numbers, dates of birth, visit time and statuses. 4. Select the tabs on the bottom of the My Schedule section to view Primary Diagnosis, Contact Information or Schedule Notes. View My Tasks from My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. View the My Tasks section in the upper right corner of the My Day window. 4. To change the sort order of the fields, click the column header. 5. To collapse or expand all the items in the view, right click the column and select the corresponding options. View My Favorites from My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. View the My Favorites section in the lower right corner of the My Day window. View My Patients From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. View My Patients in the lower left corner of the window to see a list of Assignments, Recertification Alerts, Reservations, OASIS Due Alerts, Imported Medications, and Lab Results. Clinical Documentation User’s Guide 409 My Day Generate and Print the Assignments Report From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Select the Assignments tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with My Assignments displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. Generate and Print the Recertification Alert Report From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Select the Recertification Alert tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with Recertification Alert displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. Generate and Print the Reservations Report From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Select the Reservations tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with Reservations displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. 410 Clinical Documentation User’s Guide My Day Generate and Print the OASIS Due Alert Report From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Click the OASIS Due Alert tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with OASIS Due Alert displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. Generate and Print the Lab Results Report From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Select the Lab Results tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with Lab Results displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. Generate and Print the List of Imported Medications From My Day 1. Open the Administration component. 2. Select My Day from the Allscripts Homecare drop‐down list. The My Day dialog appears. 3. Select the Imported Medications tab from the My Patients section. 4. Click Print in the upper right corner of the My Patient’s section. The Print Preview window opens with Imported Medications displayed. 5. To print the report, click the Print icon in the upper left corner of the window. 6. To close the report, click the Close button at the top of the report window. Clinical Documentation User’s Guide 411 Chapter 9 ‐ Assessments In This Chapter In this chapter, you can find general information about assessments, along with detailed description on how to edit and view assessments, generate reports on particular assessments, assessments history reports, and more. The chapter consists of the following sections: • • • • • • • • • 412 Assessments Assessments Report Assessment History Report Patient Documents – Assessments OASIS Export OASIS Due Alert Report Patient Documents – OASIS Due Alerts Assessment Editor Assessment Viewer Clinical Documentation User’s Guide Assessments Assessments About Assessments With the assessment templates, you can document an evaluation of the patient’s physical, psychosocial, and environmental status. Allscripts Homecare provides many different kinds of assessments available for use. The type of Assessment you choose to use depends on the discipline, the patient class, and the age of the patient. Discipline Each assessment is built for a specific discipline. When the Resource who will be documenting the assessment is identified on the New Assessment window, the appropriate assessments are available for selection. There are assessments for Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Language Pathology, Medical Social Worker, and Psychiatric Nursing. There are also assessments that are available for any discipline to use. These are identified as discipline – PSA. Examples of these assessments are Bereavement, Supervision, Medicare Secondary Payer, and so on. There are also speciality assessments such as Maternal Child Health, Pediatrics, Determining Terminal Illness, Supervision (Home Health Aide), Medicare Secondary Payer (verification). Patient Class The use of OASIS assessments is defined in Administration>General>Patient Classes. If the Use OASIS check box is selected, then the OASIS questions will appear in the assessment based on the Reason for Assessment selected. Age of the Patient If the patient is under 18 years on the day of assessment, an age‐specific assessment is provided. There are 12 Pediatric Nursing Assessments available based on the following ages: > Birth to 2 Months > 3 Months to 5 Months > 6 Months to 8 Months > 9 Months to 11 Months > 12 Months to 14 Months > 15 Months to 17 Months > 18 Months to 23 Months > 2 Years > 3 Years Clinical Documentation User’s Guide 413 Assessments > 4 Years > 5 Years > 6 Years to 18 Years. The requirement for a completed assessment in order to verify a service as complete, or to be available for synchronization on the field device, is determined in Administration>General>Service Codes/Staff on the Required to Verify and Required to Synchronize tabs. OASIS Assessments The OASIS questions are integrated within the normal SN, PT, OT, SLP, and Psych Assessments. There is also an OASIS Only Assessment for those agencies who do not use Field Devices and data enter the OASIS. The appropriate OASIS questions appear in the assessment based on the Reason For Assessment (RFA) selected by the clinician. The RFA is selected on the New Assessment window. Once initiated, the OASIS Assessment can be validated by the clinician at any time using the Validate button on the Assessment Tool Bar. Allscripts Homecare automatically validates the OASIS assessment at the point the clinician or data entry person and saves the assessment. If there are problems with the validation, they are presented to the clinician or data entry staff for correction. The clinician or data entry staff can correct the validation problem at that point by double‐clicking the error. Allscripts Homecare automatically opens the window where the problem exists. The user can work through all the listed errors until all are resolved. The user can either save or validate again to ensure all OASIS questions are answered correctly. The validations are based on the Center for Medicare and Medicaid Services (CMS) Uniform Data Submission Specifications for the OASIS – B1 (12/2002 Update, Version 1.40). OASIS Assessments are sent to the state from Transactions>OASIS Export. If a locked OASIS assessment has to be re‐opened for any reason, it can be selected and reserved for the appropriate person to make the changes. You can reserve an assessment and edit it only if appropriate privileges are set in Administration>Configuration>Operators>Privileges. Patient Condition Changes When you complete a new OASIS assessment or review previously completed assessment, the icons are displayed at the top right corner of the assessment items. These icons indicate the patient’s condition change comparing with the last response to the same OASIS question of the assessment. Condition change icons are available for OASIS assessments only, but not for all OASIS questions. 414 Clinical Documentation User’s Guide Assessments Condition Change Icons The condition change icons are displayed for the following list of M items: M1034, M1200, M1210, M1220, M1230, M1240, M1242, M1300, M1302, M1306, M0530, M1322, M1330, M1332, M1340, M1350, M1400, M1500, M1615, M1620, M1700, M1710, M1720, M1730, M1745, M1800, M1810, M1820, M1830, M1840, M1845, M1850, M1860, M1870, M1880, M1890, M1910, M2000, M2020, M2030. The patient’s condition change icons are displayed if: > The Show Condition Change check box is selected in Administration>Configuration>Business Units>Settings>Assessments. > The assessments which can be compared should be within one admission period. The patient’s condition change icons are not displayed if: > There is only one assessment within one admission period. > The assessment does not belong to any admission period with the exception that assessment is completed with the RFA9. > There is no answer in the previous assessment for the current question in the current admission period. Clinical Documentation User’s Guide 415 Assessments Condition Change Icons Description Condition Change Icon Description This icon indicates that the patient’s condition declined comparing with the last response to the same OASIS question of the assessment. This icon indicates that the patient’s condition did not change comparing with the last response to the same OASIS question of the assessment. This icon indicates that the patient’s condition improved comparing with the last response to the same OASIS question of the assessment. OASIS Key Icons At the top right corner of the assessment items, the key icon indications are displayed. These key icons indicate assessment OASIS questions critical for correct calculation of the HHRG score. The key icons are displayed for the following list of M items: M0030, M0090, M0100, M1020, M1022, M1024, M1030, M1200, M1242, M1306, M1308, M1320, M1322, M1324, M1330, M1332, M1334, M1340, M1342, M1350, M1400, M1610, M1620, M1630, M1810, M1820, M1840, M1850, M1860, M2000, M2030, M2200. Key Icons 416 Clinical Documentation User’s Guide Assessments Synchronization Only a completed assessment can go through synchronization from the field device to the host. Incomplete assessments remain on the field device until they reach 100% complete. With the Synchronization Registry report you can identify whether there is incomplete documentation on the field device. (Reports>Field Use>Synchronization Registry) Initiate Care Plans Through the Assessments What is this functionality? Clinicians can now identify patient problems to create their Care Plan as they navigate through the assessments. This enhanced clinical workflow can be set up when the agency's QI staff determine the appropriate problems for the assessment tabs using the Assessment Editor tool. The clinician will then be able to access that list when creating the Care Plan through the assessment. Defining Problems for the Patient While completing the assessment template, you can select problems for the patient from the list of predefined problems on the tab sheet level. Note To identify patient problems while completing the assessment, you should first predefine these problems using the Assessment Editor tool. (See Attaching Problems to the Assessment Questions). If there are problems attached to the assessment tab sheets, you can see a paperclip indicator near the tab sheet name. The icon is visible on all tabs except inactive. To select problems for the patient: 1. Open the Patient component and select the patient for which the assessment will be completed. 2. Go to Clinical>Assessments. 3. Select the appropriate assessment from the drop‐down list or create a new one. (See Create New Assessment). Clinical Documentation User’s Guide 417 Assessments 4. Click near the tab sheet name. The Attach Problems dialog opens with the list of predefined problems in the Assessment Editor. 5. Under the Agency Recommended this Tab group, there are Agency predefined problems which you can select for the patient. If the desired problem is not found in the Agency Recommended this Tab group, select the Show All check box to view the Other problems group with the list of all active problems. You can associate problems with the patient by selecting problems from both Agency Recommended this Tab and Other problems groups. 6. Select the problems using the following buttons and keyboard and mouse combinations. Move the selected problem to the right column. Move the selected problem to the left column. Move all problems to the right column. Move all problems to the left column. Ctrl + Right Ctrl + Left Move all problems from the right column to the left. Ctrl + mouse Left button Select several problems in a column. Shift + mouse Left button 418 Move all problems from the left column to the right. Select range of problems. Clinical Documentation User’s Guide Assessments Ctrl + Up/Down + Space Hold down the CTRL key, use Up and Down keys to move through the problems list and use Space key to select several values in a column. Drag&Drop Use mouse Left button to select one problem in one column and drop it to another. Use Shift + mouse Left button to select range of problems in one column and drop it to another. Use Ctrl + mouse Left button to select multiple values in one column and drop it to another. Double‐click Move selected problem from one column to another. 7. After all desired problems are selected, click OK. You can associate problems with the patient on any active tab sheet. When the assessment is 100% complete and saved, the problems move from the Attach Problems dialog to the Patient>Clinical>Problems under the Under Consideration section. You can define problems for the patient each time you reserve the assessment template. Abbreviated OASIS Assessment What is this? A stripped down template with only those M items which identify the patient and those M items which calculate the HHRG/HIPPS score. Who should use this template? Clients who contract with commercial insurance companies (such as TriCare) that require a HHRG/HIPPS score on the claim, Medicare FFS, or other FFS where the insurance code is set to Include HIPPS. The patients may be of any diagnosis or age, including those who are under 18. Who should not use this template? Clinicians who visit Medicare PPS patients. Setting Up Workflow 1. Load the Abbreviated OASIS Only template. 2. At the insurance code level, the Mode for the insurance code type must be PPS or the FFS ‐ Include HHIPS check box must be selected. 3. At the patient class level, the Use OASIS check box must be selected. Clinical Documentation User’s Guide 419 Assessments User Workflow for Completing the Abbreviated Template 1. Admit the patient as usual. 2. In Patient>Clinical>Assessments, select the Abbreviated OASIS Only template, document it, and save. For the Abbreviated OASIS Only template, there are no: • Patient condition changes icons and key icons • Condition Change report • Predictive Probability of Risk report • Validation • OASIS export functionality 3. If you select a new Abbreviated OASIS Only assessment for patients who are over 18 years of age, the following warning message appears. 4. The Abbreviated OASIS Only template is available for RFA's 1, 3, and 4 only. 5. After the Abbreviated OASIS Only template is 100% completed and all M items needed for calculation are filled and template is saved, the Scores icon is available for selection. For PPS mode payers, all relevant information is automatically populated on the PPS Information tab on the Admission & Status window. 6. For PPS and non‐PPS payers for whom the FFS ‐ Include HIPPS check box is selected in the Claim Generation section on the Billing Rules tab (Administration>Financial>Insurance Codes), after completing the Abbreviated OASIS Only template, the information is automatically used for the claim generation. 420 Clinical Documentation User’s Guide Assessments OASIS Assessments Validation To help ensure that your assessments meet OASIS requirements, you can validate any OASIS assessment that is 100% complete and saved butnot yet uploaded during Synchronization. When you validate an assessment, you have the chance to edit M items that fail the validation. Allscripts Homecare validates clinical data items, demographic items, and date‐related items. As the validation process checks the assessment, it creates and displays a grid list of failed edits. The list includes the M number and description along with the specific rule that is being violated, as well as the failure type–Fatal or Warning. Double‐click the item in the grid to display the failure type, M name, M description, and the text of the violation. Alternatively, select the item, then click the Edit button. If the item is within the template, Allscripts Homecare takes you directly to that item within the assessment templates the item is not within the template, Allscripts Homecare displays a message informing you of the location of the violation and where you can edit it (the Admissions & Status window, the Payers window, or the Change Assessment Date function, as appropriate). After you make the change and save, the application re‐validates that item and if it is correct, you proceed to the next item in the violation list until all errors have been corrected. If the assessment is validated and contains no errors, Allscripts Homecare displays the message, "Assessment has validated successfully." If the assessment is validated and contains no errors, but is not 100% complete, Allscripts Homecare displays the message, "Assessment must be 100% complete before Validating successfully." View an OASIS Assessments HIPPS Score Note Note You can also view the HIPPS information while completing an assessment. Follow steps 5‐6. 1. Open the Patient component. 2. Select the patient. 3. Select Clinical>Assessments. 4. Select the assessment whose HIPPS information you want to view. The assessment appears. 5. Click HIPPS Code. The Scores dialog appears. 6. Click OK to close the dialog. Clinical Documentation User’s Guide 421 Assessments Validate an OASIS Assessment Note Note Allscripts Homecare automatically validates all 100% complete OASIS assessments when you save them. Follow the steps below to manually validate an assessment during entry (that is, that is not yet 100% complete). Note Note You can also validate while completing an assessment. Follow steps 5‐6. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment you want to validate. The assessment appears. 5. Click Validate Assessment. The Validate Assessment window appears, listing any violations. If there are no violations, Allscripts Homecare displays a message to that effect. Also, you cannot fully validate an assessment that is not 100% complete; however, you can check the validity of what you have done “so far.” 6. Click OK to close the window. Correct Errors Found in Assessments During Validation Within the Validate Assessment window, select the first error you want to correct. If the selected violation exists within the template itself: 1. Click Edit. Allscripts Homecare takes you directly to the M item within the template to make the necessary changes. 2. Make the appropriate change within the assessment. 3. Repeat the steps above for each violation listed. When there are no more violations, Allscripts Homecare displays a message to that effect. 4. Click Save to save the assessment. 422 Clinical Documentation User’s Guide Assessments If the violation exists within the Admissions & Status window or thePayers window: 1. Make the necessary changes within the appropriate windows. 2. Repeat the step above for each violation listed. 3. Revalidate the assessment. When there are no more violations, Allscripts Homecare displays a message to that effect. Assessments Window Patient>Clinical>Assessments With the Assessment window you can select a new assessment and review previously completed assessments. Use the New button ( ) on the top left side of the window to open the New Assessment window. This window displays the name and number of the patient for whom the user is opening a new assessment. If the visit was initiated from TimeLog, then the new assessment is automatically attached to this visit or telephone call and the logged in clinician is displayed in the Assessed by field. You can change this information if needed. The users can select the assessment template they plan to use. Once the assessment template is selected, the lower portion of the window becomes active. Current And Completed Assessment Bar: The date, name of the resource performing the assessment and the reason for assessment are on the top bar. This bar has a down arrow. When this down arrow is selected it will display all completed assessments. If you would like to review one of the previously completed assessments, by any discipline, just click on it and it will appear. However, you will be required to “reserve” it prior to having access to the completed assessment. The need for the reservation is based on both electronic signature and HIPAA. Next And Previous Arrows: These two arrows are to the left of the top bar and allow you to navigate through all completed assessments. Show Detail: The default is to have this box unchecked. In this mode, only the required tabs are visible to the clinician. If the Show Detail check box is selected, all of the tabs within the assessment, including OASIS tabs are visible in the gray, not required color. All non‐required tabs can be activated either by checking the box on the “basic” window that asks the question to either “See Detail,” or “See Education;” or by right‐clicking and selecting Activate. Any active tab can be deactivated for future visits by right‐clicking and selecting Deactivate; however, this is only for future visits and the tab must be completed for this visit. Clinical Documentation User’s Guide 423 Assessments Assessment Window Assessments Window Fields Add Assessment Click to add a new assessment for this patient. Select Assessment Click to select an existing assessment for this patient. Previous Assessment If you want to view the previous completed assessment for this patient, click . Next Assessment If you want to view the next completed assessment for this patient, click 424 . Clinical Documentation User’s Guide Assessments [Discipline]/All If you want to view only assessments performed by your discipline, click [Discipline]. The name of the discipline that appears here varies. It reflects your resource type. Your resource type is assigned in Administration>Resource Types. If you want to view all assessments, click All, or leave it selected (All is the default selection). Reservation/Release Reservation Click to reserve the selected assessment. The Reserve Assessment window appears. If the button is displayed, the selected assessment is already reserved. Click the button to release the reservation. Create D/T Summary Click to select a discharge summary type for the current patient. Change Reason for Assessment If you want to change the Reason for Assessment for an OASIS assessment, click .The Select Assessment Reason window appears. This window is similar to the New Assessment window. Because of the sequence of the OASIS questions, only the RFAs in the same subset as the original RFA are enabled. Change Assessment Date or Connect to Visit If you want to change the date of this assessment or connect it to a specific visit, click . The Select Date window appears allowing you to change the date or attach the current assessment to a visit. Reassess for the next routine visit Click to customize assessment for the future routine visits. Using the Reassess for the next routine visit option, you can deactivate or activate the assessment tabs only if the Prohibit Deactivation of Tabs check box is not selected in Administration>Configuration>Business Units>Settings>Assessments. The assessment tabs are listed on the left with the check boxes opposite those required for the routine visits. If a patient does not require all the systems review, you can remove the check boxes Clinical Documentation User’s Guide 425 Assessments opposite the tabs that will not be required for the future visits. Similarly, if a patient requires more in‐depth assessment than it is required, you can select the check boxes opposite the tabs that will be required for the future routine visits for this discipline. Note Tabs that you marked as not required must be completed for the current assessment, but they will not be required for future assessments. Tabs that you marked as required should be completed for the current and future assessments. Scores Click to see the scores information. The Scores window appears. The following information can be displayed on this screen: Clinical Score, Functional Score, Service Utilization, NRS Score, Therapy Threshold, Projected Therapy Visits, HHRG Code, NRS Severity, HIPPS Code, and Episode Amount. Whether or not the information listed above will be displayed on the Scores screen depends on the privileges settings on the Privileges tab of Administration>Configuration>Operators screen (in the Category tree select Patient>Clinical>Assessment>Scores and select the check box in the Allow column for those fields to be displayed on the Scores screen). The OASIS assessment must be completed and saved to have this icon active/available for use. M0110 and M2200 (M0826) assessment items are required to fill. Make changes to this assessment The assessment is automatically “locked” when it is saved at 100%. For OASIS assessments this date becomes the recorded lock date. The lock date is updated each time a saved change is made to the assessment until it has been exported into a Standard Production OASIS export file. At that time, for OASIS assessments, the icon is enabled.If a change needs to be made to an OASIS assessment that has been locked, the assessment can be unlocked and changed by clicking . Only a user with the appropriate Operator Privileges will be able to unlock the OASIS assessment. Predictive Probability of Risk Click to open the Predictive Probability of Risk dialog. The button is active only when the following conditions are met: • • 426 Predictive Model license is selected on the Business Units level (Administration>Configuration>Business Units>Basic>Licensing). Selected assessment is OASIS assessment with RFA1, Start of care. (RFA ‐ Reason for Assessment.) Clinical Documentation User’s Guide Assessments • Assessment is 100% complete. Refer to the Run the Acute and Emergent Care Risk Assessment section for more detailed information on Predictive Probability of Risk. OASIS Guidelines Click to open the OASIS Guidelines dialog. In this dialog, you can see the list of M items for OASIS B and OASIS C assessments and specific instructions for each item. The list of M items is displayed in a numeric order. The instructions are read‐only and you cannot edit them. You can search for the item you need by typing in, for example M12 and all items starting with M12 will be highlighted. Validate this assessment Click to validate the current OASIS assessment at any time. The validation will look at all the OASIS questions required for the type of assessment that is being recorded. If there are problems with the validation, they will be presented to the clinician, or data entry staff for correction. The clinician, or data entry staff, can correct the validation problem at that point by double clicking the error. The application will take the user to the point where the problem exists. The user will work through all the listed errors until all are resolved. The user can either save or validate again to ensure all OASIS is answered correctly. The validations in Allscripts Homecare are based on the Center for Medicare and Medicaid Services (CMS) Uniform Data Submission Specifications for the OASIS C. Note The OASIS assessments are completely integrated and all questions are presented within the context of the assessment flow. There is no benefit in selecting the “Validate” icon/ function in order to quickly present the OASIS questions. The earlier in the flow of the assessment that the “Validate” function is used, the more corrections the user will have to resolve. Show Condition Change Report The Condition Change report is generated for OASIS assessments only. To preview, print, or save the Condition Change report, click on the Assessments tool bar in Patient>Clinical>Assessments. The button is active only when: • The Show Condition Change check box is selected in Administration>Configuration>Business Units>Settings>Assessments. • Assessment is 100% completed and saved. • The condition change icons are displayed on the assessment items. Clinical Documentation User’s Guide 427 Assessments To learn more about the report, refer to the Condition Change Report section. Show Detail Select this check box to show all tabs and tree‐view items in this assessment, regardless of whether they are required for an RFA. Clear the box or leave it unchecked to display only the tabs and tree‐view items that are required for an RFA in this assessment. Data Click to view the history of answers to the selected assessment question (non‐OASIS as well as OASIS) in the Field History grid under the Assessment navigation tree on the Data Entry tab. The Data tab contains information on the dates of visits when the previous responses to the selected question were given, the responses themselves, and the name of the clinician who completed previous assessments. The information in the Field History grid changes as you move from question to question. You can run the Assessment History report to view the history of all value changes for each field within an assessment (Reports>Clinical and Patient>Documents). Note History can only be shown between templates of the same version. Graph The Graph tab displays historical items from prior assessments. It displays information for the currently active assessment question. A chart is displayed only for assessment questions that have a numeric answer (for example, blood pressure, weight, and height). Clinical Monitoring Select Yes under Clinical Monitoring Entry to display the Reading screen as part of the Assessments window. If you select No, the Reading screen is not available. Assessments Window ‐ Data Entry Tab The Data Entry tab displays the components of the selected assessment. This area is often referred to as the “Assessment Tree”. The areas that appear in red are required to be completed. Those areas with a cross (+) in front have more tabs below. When the cursor clicks on a tab in the Data Entry Tab, the area to the left displays the tab. In this case we see the Cardiovascular (Basic) tab with all questions and a yellow background. Allscripts Homecare uses as many color and visual hints as possible to help the user track where they are in the assessment. When the question is answered the entire box becomes another color. The remaining questions stay the original color until they are 428 Clinical Documentation User’s Guide Assessments answered. The sequence of questions are right to left, not down one column and then the second column or questions. Note Note Your agency has the ability to set the colors for your assessments in Administration>Configuration>Operators>Settings>Color>Assessments. If your agency policies and procedures allow, you can change the colors for your individual machine by using the icon that looks like several tools together and using Color>Assessments. This icon is on the upper tool bar next to the Help icon. Additional Comments: Most tabs have an Additional Comments box for the free‐text entry of anything that is not covered on the questions, or any comment the clinician wants to make regarding the patient. In an Additional Comments box, select the “Yes” answer, and the free‐text box will become active for you. Field History: Directly under the list of assessment components in the Data Entry tab is a grid showing the history of answers to the same question for assessments in the current admission period. History can only be shown between templates of the same version. The information in the Field History box changes as you move from question to question. There are three columns in the Field History box: Date, Data, and Info. The Date column displays the date when assessment was completed. In the Data column, there are answers to the same questions for assessments in the current admission period. The Info column shows the name of the clinician who completed the assessments. Note Note This graph of numbers as well as the history of changing the values of all fields in an assessment can also be found in the Assessment History report (Reports>Clinical and Patient>Documents). Progress Bar: Immediately below the Field History grid is a bar that shows the percentage of the assessment that is complete. In the screen shot provided above, the assessment is 1% complete. As the clinician completes questions, the percent of the assessment completed increases. When the assessment is 100% complete it can be saved with the clinician's electronic signature and is available for synchronization. Note Note Because answers can vary widely, individual help topics are not available for each question within an assessment. If you are uncertain about how to answer a question, contact your supervisor. Clinical Documentation User’s Guide 429 Assessments Caution As you open Detail and Education tabs, the percentage complete decreases because you have just added more questions to be completed in order to reach 100% complete. Caution If you need to return to a previously entered question on the assessment, be sure to click on the question text, NOT on the Yes button. If you click on the Yes button, you remove the Yes answer, and therefore delete all the answers on the related panel below. Note Note Unlike most other application windows, you cannot use the Enter key to select a field within an assessment template. You must use the space bar or mouse to select a field. However, you can still use the Tab key to move from field to field within a template. Assessments Window ‐ Data Entry Tab 430 Clinical Documentation User’s Guide Assessments Assessments Window ‐ Notes Tab The Notes tab is a large, free‐text area available for any additional documentation needed. Data and information can be added to the Notes tab anytime prior to saving the assessment at 100% completion. Once the assessment has been saved on the host, or saved and sent through the synchronization process from a field device, the assessment must be Reserved in order to enter any data or information on the Notes tab. Assessment Window ‐ Notes Tab Notes If you want to enter free‐text notes for this assessment, enter them in this field. Assessments Window ‐ Revision History Tab When assessment is 100% completed, saved, and put through the synchronization process from the field device to the host, the clinician's electronic signature is applied. If the assessment is done on the host and is saved, the clinician's electronic signature is applied. Signed clinical documentation can not be altered without following specific processes. In Allscripts Homecare, these processes require that the individual making the change has the security privileges to make these changes, and that a complete audit trail is maintained with the original entry stored with the date and time the change was made, what the change was, and who made the change. All of this information is captured on the Revision History. There will be nothing on the Revision History unless there has been a change made Clinical Documentation User’s Guide 431 Assessments to the completed and saved assessment. Revisions to the Assessment require that assessment is reserved. You can copy the revision history content by right‐clicking anywhere on the Revision History screen. Assessments Window ‐ Revision History Tab New Assessment Window Patient>Clinical>Assessments> button Using the New Assessment window, you can select the type of assessment you want to perform (OASIS only, Nursing, Bereavement, Spiritual) and the reason for the assessment. The type and reason for assessment determine the template that appears for the assessment. Usually, when you complete an assessment, it will already be connected to a visit. However, if you need to connect it to a different visit, or if you do not want to connect it to a visit but want to record the clinician doing the assessment, you can do so in this window. When starting an assessment, you are required to select a Reason for Assessment (RFA). The eight OASIS reasons for assessment are part of this selection. Once a Reason for Assessment is selected, the appropriate tabs in the selected assessment are activated. If this is an OASIS Reason for Assessment, 432 Clinical Documentation User’s Guide Assessments then the appropriate OASIS questions are activated. The reasons for completing an assessment in the application are as follows. Note Note Assessment reasons that activate the Discharge/Transfer Summary button are designated with **. > Initial Visit**: The Initial Visit is intended for the first visit for a patient who does not require OASIS. It is also the first visit for any discipline who is not doing the official OASIS Start of Care assessment. > Routine Visit**: A Routine Visit is any scheduled/planned visit that is not the initial visit for this patient or discipline and is not one of the OASIS‐specific visits. > Oncall/Unscheduled Visit**: This reason for assessment is an unanticipated, unplanned visit. > Start Of Care ‐ Further Visits Planned (RFA 1): OASIS reason for the initial assessment. Use this assessment for the first visit to a patient who requires OASIS. > Resumption Of Care (After Inpatient Stay) (RFA 3): OASIS reason for assessment. Use this assessment for a patient returning to homecare after an inpatient stay. Review you agency policies and procedures concerning when this assessment is done. > Recertification (Follow‐up) Assessment (RFA 4): OASIS reason for assessment. This assessment is done at the beginning of a new 60 day episode of care. This assessment is for all 60 day episodes AFTER the initial Start of Care. (RFA 1) > Other Follow‐up (Full Assessment Due To Major Change) (RFA 5): OASIS reason for assessment. Use this assessment when there has been a major change in the patient's condition. Review you agency policies and procedures concerning when this assessment is done. > Transferred To An Inpatient Facility ‐ Patient Not Discharged From The Agency (RFA 6) **: OASIS reason for assessment. Use this assessment when the patient is transferred from the home health agency to an inpatient facility, but not discharged from the agency. Review you agency policies and procedures concerning when this assessment is done. > Transferred To An Inpatient Facility ‐ Patient Discharged From The Agency (RFA 7)**: OASIS reason for assessment. Use this assessment when the patient is transferred to an inpatient facility AND discharged from the agency. Review you agency policies and procedures concerning when this assessment is done. > Death At Home (RFA 8)**: OASIS reason for assessment. Use this assessment when the patient dies at home. > Discharge From Agency (RFA 9)**: OASIS reason for assessment. Use this assessment when the patient is discharged from the agency, but not transferred. Clinical Documentation User’s Guide 433 Assessments Note Note The OASIS Reasons for Assessments (RFA) changed with the December 2003, OASIS Burden Reduction initiative. Reason for Assessment 2 (RFA 2) ‐ Start of Care, No further visits planned, and Reason for Assessment 10 (RFA 10) ‐ Discharge from agency ‐ no further visits after the Start of Care were discontinued. If you attempt to complete an assessment and another assessment with the same RFA already exists for the same date, Allscripts Homecare warns you so that you do not complete the assessment in error. For some RFAs (1, 8, 9), Allscripts Homecare alerts you if another assessment with the same RFA exists for the same admission period. You can also link an assessment to a discipline discharge, agency transfer, or agency discharge by using the D/T Summary function. Items you document in the assessment’s Discharge Summary section appear on the Discharge Summary Report. To document in the DischargeSummary section, you click the D/T Summary button. The button is only available if the Reason for Assessment (RFA) is initial visit, routine visit, oncall/unscheduled visit, 6‐Transferred to an inpatient facility‐patient not discharged from agency, 7‐Transferred to an inpatient facility‐patient discharged from agency, 8‐Death at home, or 9‐Discharge from agency. After you click the button, an additional dialog box appears so you can choose a discharge/transfer summary type. The types are: > Transfer from Agency (not Discharged) > Discharge from this discipline > Discharge from Agency > Discharge Due to Death > No Summary with this Assessment Next, you document the assessment in Discharge Summary section. What you document in the Discharge Summary section appears on the Discharge Summary Report. 434 Clinical Documentation User’s Guide Assessments New Assessment Window Connect to Visit‐Telephone Call/Assessed By If you want to associate this assessment with a visit or phone call, click Connect. The Select Service window appears. If you have already started a Time Log, you should connect this assessment to the appropriate visit or call. If you want to associate this assessment with the resource who did the assessment, click Provided By. Change If you want to associate this assessment with a different visit or telephone call, click Change. Assessed By Click and select the resource from the list. OR Click and search for the resource. If the selected resource has more than one associated role, you must also select the appropriate role for this clinical note. Clinical Documentation User’s Guide 435 Assessments On Enter the date of the assessment. OR Click and select the date. Type of Assessment Click the circle next to the appropriate type of assessment you are completing. You can only choose one type. If personnel in the agency office are entering the assessment, they should generally choose OASIS only. If a clinician is entering the assessment in the field, she might choose the Nursing assessment. Reason for Assessment Click the circle next to the appropriate type of assessment you are completing. You can only choose one reason. D/T Summary Click to select a discharge summary type for the current patient. The Discharge/Transfer Summary Type window appears. Discharge/Transfer Summary Type Window Patient>Clinical>Assessments> button>D/T Summary button The Discharge/Transfer Summary Type window enables you to select a discharge summary type for the current patient when the following Reasons for Assessment (RFAs) are selected: > > Routine Visit > Oncall/Unscheduled Visit > (1) Start of Care > (6) Transferred to an inpatient facility ‐ patient not discharged from the agency > (7) Transferred to an inpatient facility ‐ patient discharged from the agency > (8) Death at home > 436 Initial Visit (9) Discharge from agency Clinical Documentation User’s Guide Assessments After you select a discharge/transfer summary type, the assessment is activated, and appropriate tabs and data fields within the Discharge/Transfer Summary area of the assessment are enabled. When you print the Discharge Summary Report, you can choose a summary type. For example, if you indicate that an assessment is a discharge from discipline SN, you can then include that assessment in the Discharge Summary Report by selecting the Discipline Discharge summary type on the report, and then selecting discipline SN. Note Note When the Discharge or transfer summary is selected, the Discharge/Transfer portion of the assessment is activated. It is found under Care Management in the assessment tree. The percent of assessment completion is also decreased as there are now more questions to answer and therefore a smaller percent of the assessment is complete. Caution If the patient requires OASIS, using the Discharge/Transfer icon does not change the current assessment to one of the OASIS Discharge or Transfer assessments. In this case, the Discharge/Transfer icon must be used after the assessment type has been changed. Discharge/Transfer Summary Type Window Discharge/Transfer Summary Type Window Fields Transfer from Agency (not Discharged) Select this discharge summary type if it is a transfer from an agency to another level of care. Discharge from this discipline Select this discharge summary type if the discharge is from this discipline. Discharge from Agency Select this discharge summary type if the discharge is from the agency. Clinical Documentation User’s Guide 437 Assessments Discharge Due to Death Select this discharge summary type if the discharge is due to the patient's death. No Summary with this Assessment Select this discharge summary type if you do not want a summary associated with the assessment. Create New Assessment 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Click New. The New Assessment window appears. 5. Select the type of assessment and the reason for assessment. Caution Ensure the assessment is connected to the correct patient and visit. 6. Click OK. The Assessments window reappears, with the correct template selected. 7. Complete the assessment as appropriate. Note Allscripts Homecare automatically enters certain information in the template. For a list of that information, refer to the Assessments process guide. 8. Click Save to save the assessment. 438 Clinical Documentation User’s Guide Assessments Create a Discharge or Transfer Summary Note Note Items documented in an assessment’s Discharge Summary section will be pulled to the Discharge Summary Report. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Click New. The New Assessment window appears. 5. Select the type of assessment and the reason for assessment. Caution Ensure the assessment is connected to the correct patient and visit. 6. Click D/T Summary. 7. On the Discharge/Summary Type screen, click the appropriate discharge/summary type. 8. Click OK. The Assessments window reappears, with the correct template selected. 9. Complete the assessment as appropriate. 10. Click Save to save the assessment. Note A discharge or transfer summary can also be initiated from the D/T icon on the Assessment tool bar once an assessment is open. This functionality is provided for those instances when the need for a discharge or transfer is not known prior to initiating the assessment. Clinical Documentation User’s Guide 439 Assessments Connect an Assessment to a Visit or Telephone Call When a service code for either a visit or telephone call is entered in Time log for the selected patient AND the “P” in Time log is used to move to the patient, this area is automatically completed. If the user is not in a visit and wants to attach the assessment after the fact, follow these steps: 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Click New. The New Assessment window appears. 5. Select Connect to Visit/TelephoneCall. The Select Service window appears. 6. Select the visit/telephone call to which you want to attach this assessment. The visit date, service code, and resource that completed the visit are listed in red on the New Assessment window. Note Only visits and telephone calls listed in Time Log as services for the selected patient appear in the Select Service window. Enter Notes for an Assessment Note Note You can also enter notes while completing an assessment. Follow steps 5‐7. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment for which you want to enter notes. If you have the security privileges to change your or others’ documentation, a dialog box appears stating that although this is a completed assessment, you have the security privileges to change it. Click OK. 5. A notice appears stating that this action requires you to reserve this assessment. Click OK. The Reserve Assessment window appears. 440 Clinical Documentation User’s Guide Assessments 6. Complete the Reserve Assessment window and click OK. The assessment appears. 7. Click the Notes tab. 8. Enter the notes. 9. Click Save to save the assessment. Indicate Normal Values for a Patient Note Note You can also enter normals while completing an assessment. Follow steps 8 ‐ 9. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Click New. The New Assessment window appears. 5. Select the Template and the Reason for this Assessment. 6. Select OK. The assessment appears. 7. Begin the assessment. 8. Select the tab where you want to enter normal values. 9. Right click the mouse and select Normal. 10. All fields on the tab will have the value accepted as normal in most adults, or the N/E (Not Evaluated) or N/A (Not Appropriate) value selected. 11. If one or more of these fields should have another value, the user can select the correct value for that field. 12. When the assessment is complete, click Save to save the assessment. Clinical Documentation User’s Guide 441 Assessments Deactivating an Assessment Tab While completing an assessment, you can deactivate any active non‐OASIS tab for the future routine visits. The Deactivation functionality is not accessible if the Prohibit Deactivation of Tabs check box is selected in Administration>Configuration>Business Units>Settings>Assessments. 1. While completing the assessment, right‐click the tab you want to deactivate for the future visits. 2. Select Deactivate. 3. Click OK on the confirmation dialog. The deactivation is for future routine visits. Any active tab that is deactivated must be completed for the current visit. Also, you can deactivate tabs for the future routine visits using the Reassess for the next routine visit functionality. Activating an Assessment Tab You can activate the assessment tabs if the Prohibit Deactivation of Tabs check box is not selected in Administration>Configuration>Business Units>Settings>Assessments. 1. While completing the assessment, right‐click the tab you want to activate. 2. Select Activate. 3. In the Activate dialog, select whether to activate the selected tab for the current assessment only or for the current and future ones. 4. Click OK. After activating the tab, you must complete it for the current and future assessments. You can also activate the assessments tab using the Reassess for the next routine visit functionality. View the Progress of an Assessment 1. Open the Patient component. 2. Selectthe correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment whose progress you want to view. The assessment appears. 5. Look at the progress bar in the bottom left portion of the window. This bar indicates the percentage of the assessment that is complete. 442 Clinical Documentation User’s Guide Assessments View Previous Assessments for a Patient 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Click the Down Arrow next to New Assessment icon to see a list of all assessments. 5. Select the assessment to view. If you have the security privileges to change your or others’ documentation, a dialog box appears stating that although this is a completed assessment, you have the security privileges to change it. Click OK. 6. A notice appears stating that this action requires you to reserve this assessment. Click OK. The Reserve Assessment window appears. 7. Complete the Reservation window. The assessment appears. 8. Review all or part of the assessment. 9. The history of the reservation and any changes will be captured on the Revision History tab. Activating or Deactivating Tabs for Reassessments Using the Reassess for the next routine visit option, you can deactivate or activate the assessment tabs for future visits only if the Prohibit Deactivation of Tabs check box is not selected in Administration>Configuration>Business Units>Settings>Assessments. 1. Open the Patient component. 2. Select the appropriate patient. 3. Select Clinical>Assessments. The Assessments window opens. 4. Select the last completed assessment for review. 5. If you have security privileges to change your or others’ assessments, a dialog appears stating that although this is a completed assessment, you can change it. Click OK. 6. Click Yes in the confirmation dialog to reserve the assessment if you need to make changes. The Reserve Assessment dialog appears. 7. Complete the reservation window and click OK. The assessment appears. Clinical Documentation User’s Guide 443 Assessments 8. Click . The reservation history and any changes are captured on the Revision History tab. 9. Open the assessment section that you want to be assessed or not assessed during the next visit. A list of the assessment tabs in that section appears. 10. Select the check box opposite the tab to be reassessed for future routine visits. 11. Clear the check box opposite tabs that you do not want to be assessed for future routine visits. 12. Click OK. 13. Save the assessment. If you use a completed assessment to identify which tabs need to be assessed during future visits and select check box opposite the tab that was not required for future visits, the assessment becomes incomplete and you should 100% complete it. Tabs that you marked as not required must still be completed for the current assessment, but they will not be required for future assessments. Tabs that you marked as required should be completed for the current and future assessments. Additional Information About Inactivation After you inactivate an assessment, you can re‐activate it provided you have not already exported it. If you have not exported the assessment, the application displays a prompt asking if you want to re‐ active the assessment. If you answer Yes, the application reactivates the visit and returns it to a “Posted” status. If you have already exported it, the application displays a message alerting you that the assessment has been exported and cannot be re‐activated. In order for corrections to be included in an assessment, the visits must be in “Posted” status before you make the corrections to them. Posted status means the visits have been selected for inclusion in an assessment. If an assessment is marked for key field changes and has not yet been exported, the application asks if you want to cancel the resubmission. If you answer Yes, the application cancels the key field changes and returns the visit to a “Posted” status. Some assessments that have been submitted to the state might not be eligible for inactivation if they lack certain key field information. The inactivation process might not be able to match these assessments to the corresponding record in the state's database. 444 Clinical Documentation User’s Guide Assessments Editing Assessments You can freely edit any assessment on your field device before you upload it during synchronization provided two things are true: 1. Your login has permission to edit locked (completed) clinical entries. 2. You are making the changes within the allowed amount of time (ask your system administrator if you are not sure what this time range is). After you upload the assessment, you can no longer edit it on your field device. Even if you are allowed to work in host mode, you cannot edit the assessment on the host. If changes must be made to an assessment after it has been uploaded, it must be reserved for the clinician to make the change on the field device. If you find that you cannot make changes to a 100% complete assessment that you have not yet uploaded, ask your system administrator to check your edit permissions in Administration>Configuration>Operators>Privileges tab. When a user with the appropriate privileges selects an assessment for editing and the assessment has not yet been reserved, the following message appears: “This assessment must be reserved for editing before making changes. Do you wish to reserve this assessment for edit?” When the user clicks Yes, the Reserve Assessment window appears. In Host Mode, if the entered Reserved For user is the same as the user making the reservation, the assessment goes immediately into Edit mode. In Field Mode, the application makes the reservation, but places the assessment into Read‐Only mode. After the field user synchronizes so that the reservation is registered on the Host, the assessment enters Edit mode. When the user completes the assessment edits (closes the Assessments window or switches to another assessment), the following message appears: “If you are complete with editing this assessment then the reservation of the assessment will be released. Is this assessment edit complete?” If the user selects Yes, the assessment reservation is released and the release is then written to the Revision Log for the assessment. If the user selects No, the assessment remains reserved. When a user selects an assessment for edit that was reserved by another user, and the user has privileges to release another user's reservation, the following message appears: “This assessment has been reserved for [user] to edit. Do you want to remove the assessment reservation?” If the user chooses Yes, the reservation is removed, a message verifying the changes appears, and the removal is then written to the Revision Log for the assessment. The user can then reserve the assessment for himself as necessary. If the user does not have privileges to release another user's reservation, the following message appears: “This assessment has been reserved for [user] to edit. You do not have privileges to release the reservation.” Clinical Documentation User’s Guide 445 Assessments Modification to Locked Assessment Window Patient>Clinical>Assessments The Modification to Locked Assessment window enables you to unlock a locked assessment and make changes to it. The assessment may be resubmitted to the state or inactivated depending on the option that is selected. Note Note Assessments can only be unlocked by persons that have the security privilege enabled for “Can alter assessments after the edit period” and “Can unlock a submitted OASIS assessment.” Modification to Locked Assessment Window Modification to Locked Assessment Window Fields OASIS Correction Select this option if the assessment was accepted by the state, but you want to make a correction to the assessment and re‐submit it to the state. When you select this option, the assessment will be flagged for resubmission to the state and will be available in Transactions>General>Export OASIS. OASIS Rejection Select this option when the assessment was submitted to the state but they have rejected it. You will need to correct the assessment and resubmit it. 446 Clinical Documentation User’s Guide Assessments Once you have made your correction and saved it, the assessment will be flagged for resubmission to the state and will be available in Transactions>General>Export OASIS. Non‐OASIS change only Select this option if the assessment does not require correction to any OASIS information (or M question). This assessment will not be flagged for resubmission. OASIS Key change Select this option if you need to make corrections to errors in key fields as defined by CMS and resubmit a corrected OASIS assessment. Assessments that have key field changes will be flagged for resubmission and will be available in Transactions>General>Export OASIS. Note A listing of key fields defined by CMS can be found at http://www.cms.hhs.gov/oasis/ datasubm.asp#a. Inactivate assessment Select this option when assessments have been submitted to the state that should not have been submitted. Inactivated assessments will be flagged for submission in the next OASIS export. Edit an Assessment Caution As with all edits, be sure to follow your agency’s policy. Note Note You can edit an assessment on your laptop if you have not yet uploaded it to the server. If you have uploaded it to the server, it must be “Reserved” for you to edit it on either the server or your laptop. If the assessment is only on your laptop and is not 100% complete, you can edit it freely. If it is only on your laptop and is 100% complete, you can edit it provided the edit period (as specified in Business Unit Settings) has not expired OR you have permission to edit an assessment after the edit period has expired. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. Clinical Documentation User’s Guide 447 Assessments 4. Select the assessment you want to edit. The Assessments window reappears, with the correct assessment selected. 5. Edit the assessment as appropriate. 6. Click Save to save the assessment. Delete an Assessment Caution As with all edits, be sure to follow your agency’s policy. Note Note You can only delete an assessment on your laptop if you have not yet uploaded it to the server. If you have uploaded it to the server, must delete it on the server, provided you have the appropriate permissions (and provided it has not already been exported). If the assessment is only on your laptop and is not 100% complete, you can delete it freely. If it is only on your laptop and is 100% complete, you can delete it provided the edit period (as specified in Business Unit Settings) has not expired OR you have permission to edit an assessment after the edit period has expired. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment you want to delete. The Assessments window reappears, with the correct assessment selected. 5. Click Delete. 6. Click OK to confirm. Allscripts Homecare deletes the assessment. 448 Clinical Documentation User’s Guide Assessments Run the Acute and Emergent Care Risk Assessment Using this functionality, you can identify a patient's acute and emergent risk level based on the patient's OASIS export record. The risk level can be displayed as a grid diagram (the most general information), as a window (detailed information on risk factors), and as a report (used for printing). You can run the Acute and Emergent Care Risk Assessment only when the following requirements are met: • Predictive Model license is selected on the Business Units level (Administration>Configuration>Business Units>Basic>Licensing). • Selected assessment is OASIS assessment with RFA1, Start of care. (RFA ‐ Reason for Assessment.) • Assessment is 100% complete. To run the Acute and Emergent Care Risk, perform the following steps: 1. Open the Patient component. 2. Select the needed patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the OASIS assessment you want to run the Acute and Care Risk Assessment for. The assessment appears. 5. Click the Predictive Probability of Risk button ( ). The Predictive Probability of Risk dialog appears showing you the Acute Care Hospitalization and Emergent Care patient risk factors. The dialog displays patient's risk level based on OASIS export record. The patient's risk level is shown on two separate grids ‐ Acute Hospitalization and Emergent Care. The risk level color equivalent is displayed in the appropriate position in the grid (dark green ‐ Very Low Risk, light green ‐ Low Risk, yellow ‐ Moderate Risk, orange ‐ High Risk, red ‐ Very High Risk). Only one risk Clinical Documentation User’s Guide 449 Assessments level is displayed while the other cells are blank. The word explanation of patient's risk level is shown on the word balloon with a background color same as the risk level displayed in the grid. 6. Click the corresponding risk level in the grid to see the Risk Factor Detail window. The window consists of two columns: • Risk Factor ‐ Displays the name of the risk factor. All the risk factors are divided into 5 sections: Very High Risk Factors, High Risk Factors, Moderate Risk Factors, Low Risk Factors, and Very Low Risk Factors. You can use Expand All and Collapse All buttons to show or hide the detailed information concerning each of the risk factors sections. • Description ‐ Displays the description of the risk factor. You can also use the Printer Friendly Version button to get the predictive probability of risk report. The report contains the following information: • Patient Name ‐ Name of the patient Risk Factor detail is shown for. • Patient Number ‐ Patient code. • Assessment Type ‐ Type of the assessment. • Assessment Date ‐ Date, when the assessment was provided. • Completed By ‐ Name of the resource, who provided the assessment. • Patient’s risk level (Acute Hospitalization or Emergent Care). • Risk factors grouped by risk factor levels. You can print, save, change the view mode, and navigate through report using standard report window buttons on the top panel of the window. 450 Clinical Documentation User’s Guide Assessments Changing a Reason for Assessment (RFA) Some restrictions apply to changing RFAs. You can change an assessment RFA only to another RFA within the same subset. For example, a Start or Resumption of Care assessment RFA can be changed only to another Start or Resumption of Care assessment RFA. Similarly, a Follow‐Up assessment RFA can be changed only to another Follow‐Up assessment RFA, and so on. This restriction is necessary because of the vast differences between the templates in each subset. When you change an assessment's RFA, Allscripts Homecare reinitializes the assessment based on the new RFA. During reinitialization, tabs are enabled or disabled based on the new RFA. Answers you already entered remain intact unless there is no corresponding item in the new template, in which case they are deleted. When you validate the completed assessment, any warning triggered by the new template appear. Change the Reason for Assessment (RFA) Note Note You can also change the RFA while completing an assessment. Follow steps 5‐6. 1. Open the Patient component. 2. Select the correct patient. 3. Go to Clinical>Assessments. The Assessments window appears. 4. If you have the security privileges to change your or others’ documentation, a dialog box appears stating that although this is a completed assessment, you have the security privileges to change it. Click OK. 5. A notice appears stating that this action requires you to reserve this assessment. Click OK. The Reserve Assessment window appears. 6. Complete the Reservation window. The assessment appears. 7. Select the assessment whose RFA you want to change. The assessment appears. 8. Click Change RFA. The Change Reason for Assessment window appears. Clinical Documentation User’s Guide 451 Assessments 9. Select the correct RFA. Note You can change an assessment RFA only to another RFA within the same subset. For example, a Start or Resumption of Care assessment RFA can be changed only to another Start or Resumption of Care assessment RFA. Similarly, a Follow‐Up assessment RFA can be changed only to another Follow‐Up assessment RFA, and so on. This restriction is necessary because of the differences between the questions in each subset. 10. Click OK. 11. Click Save to save the assessment. About Reserving Assessments To make changes on a completed or saved assessment, the assessment must be reserved. The reservation can be for the person making the changes, or in the case of Compliance review, the reservation may be made for the clinician who did the assessment in order for them to make necessary, or recommended changes. A reservation is necessary to allow the clinician to make changes to the assessment on the field device when it is not connected to the host. There is a Reservation icon on the Assessment tool bar. It is the icon that has two people on it with an arrow if there is no reservation and an X, if there is currently a reservation on this assessment. Reservations can be added or released with this icon. If the icon is not used, the clinician will be presented with the Reservation message when they attempt to review a completed assessment. Note Note When an assessment is reserved, no one other than the person that the assessment is reserved for can make any changes to the assessment. However, all others with appropriate security privileges can still view the assessment on either the host or their field device. When Can I Reserve an Assessment? You can “reserve” your own assessments for editing after the edit period has passed if your operator privilege “Can alter assessments after the edit period” is set to Yes. If the privilege is set to Yes, for my own and others' entries, you can reserve an assessment entered by any user at any time. If the privilege is set to No, you cannot reserve any assessment after the assessment's edit period. However, you can still reserve or release any of your own assessments that are still within the edit period. (The assessment edit period is determined in Administration>Configuration>Business Unit>Settings>Assessments.) 452 Clinical Documentation User’s Guide Assessments Field and Host users can reserve assessments for themselves. Host users can also reserve assessments for field users. When an assessment is reserved by or for a field user, the assessment is downloaded to the field device during the next synchronization. While an assessment is reserved, it cannot be edited or exported by a Host user. The assessment is released from the reservation when the field user next synchronizes and the 100% complete edited assessment is uploaded to the Host. Under certain circumstances, authorized users can “release” a reserved assessment. If an authorized user released an assessment's reservation on the Host, then a field user cannot subsequently upload the assessment. That is, if a field user reserves and then downloads an assessment to edit it, and in the meantime, an authorized user releases the reservation on the Host, the field user cannot upload the assessment after editing it. Reserved For If you are in Field Mode, this field is read‐only and defaults to your login. If you are in Host Mode, this field defaults to the your login but you can select another user. Click and select the user for whom you want to reserve the assessment. Notes Enter any notes regarding the reservation of this assessment. Reserve Assessment Window Patient>Clinical>Assessments This window enables you to reserve an assessment. You access this window by clicking the Reserve Assessment button on the main Assessments window. If you are in Field Mode, the Reserved For field is read‐only and defaults to your login. If you are in Host Mode, the Reserved For field defaults to your login but you can select another user. The Reserve Assessment window also includes a Notes field to allow entry of any additional information about the reservation. The reservation is complete when you click OK to exit the Reserve Assessment window and saves the changes in the Assessments window. The reservation is then written to the Revision Log for the assessment. OASIS assessments that have been exported cannot be reserved until they are unlocked by an authorized user. When an OASIS assessment has been unlocked, the Reservation button is available. Clinical Documentation User’s Guide 453 Assessments Reserve Assessment Window Reserve an Assessment 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment you want to reserve. The Assessments window reappears, with the correct assessment selected. 5. Click Reserve Assessment. The Reserve Assessment window appears. 6. Select the user for whom you want to reserve the assessment. If you are in Field Mode, you can reserve assessments only for yourself. 7. Enter any notes pertaining to the reservation. 8. Click OK to confirm. Allscripts Homecare reserves the assessment. If you are in Field Mode, the assessment is downloaded to your laptop and locked on the server so that no one else can access it while you have it reserved. 454 Clinical Documentation User’s Guide Assessments About Releasing Assessments If a Field Mode user is unable to upload a reserved assessment for any reason, that user or another authorized user can release it. In Field Mode, a reserved assessment can be released only by the user who reserved it. In Host Mode, a user can release her own or another user's reserved assessment. The Assessments window includes a new button, Release Reservation, that allows users to release a reserved assessment. If a user is able to release the assessment, then one of the following messages appears: Assessment reserved for current user: “This assessment has been reserved for you to edit. Do you want to release the reservation without making any changes?” Assessment reserved for another user: “This assessment has been reserved for [user]. Reserved assessments should be released by the operator they have been reserved for. If you release this reservation, and [user] makes changes to this assessment in Field Mode, their changes will still be updated when they synchronize. Such changes could potentially overwrite any changes made by another user. Are you sure you want to release this reservation?” If the response to either message is “Yes,” then Allscripts Homecare releases the assessment. The release is then written to the Revision Log for the assessment. If the assessment was released on the Host, the corresponding Field Mode assessment is updated from the Host during the next synchronization. If the assessment was released on a field device, then the corresponding Host Mode assessment is updated from the field device during the next synchronization. In cases where a field user reserves an assessment and then decides to cancel the reservation before uploading it, the release procedure is the same. However, after the user clicks the Release Reservation button, the message reads, “This assessment has been reserved for [user.] Do you want to remove the assessment reservation?” Note Note OASIS assessments that have been exported cannot be reserved until they are unlocked by an authorized user. When an OASIS assessment has been unlocked, the Reservation button is available. Clinical Documentation User’s Guide 455 Assessments Release a Reserved Assessment In Field Mode, a reserved assessment can be released only by the user who reserved it. In Host Mode, you can release your own or another user's reserved assessment. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment you want to release. The Assessments window reappears, with the correct assessment selected. 5. Click Release Assessment. 6. Click OK to confirm the release. The release is then written to the Revision Log for the assessment. If the assessment was released on the Host, the corresponding Field Mode assessment is updated from the Host during the next synchronization. If the assessment was released on a field device, then the corresponding Host Mode assessment is updated from the field device during the next synchronization. Reserved Assessments and Synchronization When synchronization begins from the field device to the host, the application checks for any assessments that the user has reserved but not edited. If there are any, a list of the assessments appears with the following message: “You have not edited the following assessments that were reserved for you. Do you want to continue synchronization?” If the user selects Yes, the window closes and synchronization continues. If the user selects No, then synchronization ends. To edit an assessment in the list, the user double‐clicks the assessment to select it. The assessment then opens. After editing all reserved assessments as appropriate, the user then restarts the synchronization process. When a field user requests a reservation in Field Mode, the system provides a message stating, “You have requested this assessment to edit. You must synchronize before this assessment can be edited.” The field user synchronizes and then the assessment becomes available for editing on the host or field device. If the assessment is newly completed, this message appears: “You cannot reserve a new assessment.” An assessment must have been synchronized in order to be reserved. You can edit the assessment without reserving it prior to its first synchronization. 456 Clinical Documentation User’s Guide Assessments When a field user uploads a reservation request, the application checks the status of the assessment. If it is not already reserved, the reservation is honored. If the reservation has already been made in Host Mode for the same user, the field user's request is ignored as a duplicate. If the assessment is already reserved for another user, the field mode user's request is denied and the following message appears: “Your reservation request for patient [patient name] has been denied. This assessment has already been reserved for editing by [other user's name].” Reservations can be removed by system administrators on the host. Click on the chosen assessment reservation. A message appears stating, “This assessment has been reserved for (user name) to edit. Do you want to remove this assessment reservation?” Select Yes if you wish to remove the existing reservation. When a user uploads a reservation request that is approved, the corresponding assessment is downloaded during that same synchronization. If a Host user has reserved an assessment for a field user, that assessment is downloaded to the field user's laptop during her next synchronization. If the user is set to download either “Only patients assigned to me,” or “All patients on my team,” Allscripts Homecare also includes patients with reserved assessments even if they are not assigned to the user or on the user's team. After synchronization is complete, the application checks to see if there were any reserved assessments included in the records that were downloaded from the Host. If there were, a list of the assessments and this message appears: “The following assessments have been reserved for editing for you.” To edit an assessment in the list, the user double‐clicks the assessment to select it. The assessment then opens. This ensures that users are aware they need to edit assessments reserved for them by other users. Even if they do not realize the reserved assessment has been downloaded and needs to be edited, the synchronization dialog will alert them when they upload records during their next synchronization. An assessment reservation log is available in Reports>Field Use. About Revision History To provide Allscripts Homecare assessments with a full clinical audit trail which maintains a complete history of all entries, changes, and deletions, the Patient Assessments window includes a Revision History tab which displays a scrollable read‐only window containing the audit trail for the assessment. The Revision Log also includes all reservation and release information for an assessment. Allscripts Homecare generates the revision history automatically each time the assessment is saved by comparing the present assessment data to the original data and writing a log of the changes. The log shows all changes for a single edit session in one segment. An edit session begins when a user opens an assessment and ends when the user either closes the assessment, selects a different assessment, or selects a different patient. Clinical Documentation User’s Guide 457 Assessments The revision history includes a header line that shows the original entry date, time, and resource for the assessment. Each edit session included in the revision history has an additional header line that shows the date, time and resource for the edit session. The detail of each edit session shows the old and new responses for each assessment question that changed in the edit session. The identifier line identifies the question in the format: Notebook name/Tab page caption/Group caption. When either an old or new response is not applicable for a question, the revision history displays “No entry.” When an assessment is first being entered, before it has reached 100% completion, no Change Log is generated and the Revision History created at save time shows only a single line. However, the revision history includes special functionality for original entry that only applies to assessments with OASIS. Certain OASIS items are “pre‐filled” with data from the OASIS record. These items are M0080, M0102, M0104, M0110, M0014, M0016, M0018, M0030, M0032, M0040, M0050, M0060, M0063, M0064, M0065, M0069, M0140, M0150, M1010, M1012, M1016, M1020, M1022, M1024. For an OASIS assessment, the Revision History shows any changes made to these pre‐filled values. The application checks each of these items and compares the value generated from the patient record to the value being saved. If these are different, then an entry is written to the revision history, showing the value from the patient record as the OLD value, and the value as edited by the clinician as the NEW value. When an assessment is printed, the contents of the revision history appear at the end of the report. Review an Assessment’s Revision History Note Note You can also review the Revision History while completing an assessment. Follow steps 4‐5. 1. Open the Patient component. 2. Select the correct patient. 3. Select Clinical>Assessments. The Assessments window appears. 4. Select the assessment whose Revision History you want to view. The assessment appears. 5. If you have the security privileges to change your or others’ documentation, a dialog box appears stating that although this is a completed assessment, you have the security privileges to change it. Click OK. 6. A notice appears stating that this action requires you to reserve this assessment. Click OK. The Reserve Assessment window appears. 458 Clinical Documentation User’s Guide Assessments 7. Complete the Reservation window. The assessment appears. 8. Click the Revision History tab. The Revision History appears. Error Grid Patient>Clinical>Assessments This window displays the OASIS errors found within the assessment during OASIS validation. Double‐ click an error to view details (M item, description, rule violated). Select an error and click Edit to correct the error. If the item is within the template, Allscripts Homecare takes you to that item within the assessment template. After you make the change and save, the application re‐validates that item and if it is correct, you proceed to the next item in the violation list. If the item is within the Admissions & Status window or the Payers window, Allscripts Homecare displays a message informing you of the location of the violation and where you can edit it. Validate Assessment Window Adverse Events and Scales Assessments Enhancements The following enhancements are made in the assessments templates within the Allscripts Homecare application for the 5.0 version. > The Fall Evaluation tab is added to the assessment templates to enable entering information on falls while completing the assessment. Refer to the Falls section for more details. Clinical Documentation User’s Guide 459 Assessments > The Infections tab is added to the assessment templates to enable entering information on infections while completing the assessment. Refer to the Infections section for more details. > The Scales tab was added to the assessment templates within the Clinical Monitoring page to enable entering pain, nausea, anxiety, and shortness of breath actual and desired levels while completing the assessment. Refer to the Scales section for more details. And if you are trying to complete assessment template older than 5.1.0 version where falls and infections sections are present, the warning message appears saying: “The assessment template you selected should not be used. Please contact your System Administrator for the updated template.” Thus, it is recommended only to observe the assessment data on the selected template, not to enter or modify them. Falls Patient>Clinical>Assessments>Environment>Safety Using the Fall Evaluation tab, you can enter information on the patient’s fall within the current admission. The tab consists of five sections that provide efficient means for documenting information such as date of the fall, the injuries caused by the fall, the person who reported the fall, the physician notified on the fall, and additional comments if necessary. Falls Evaluation Tab 460 Clinical Documentation User’s Guide Assessments If you have Allscripts Homecare version higher than the 5.0 installed, while opening the Fall Evaluation template on assessments, the warning message will be displayed saying: “Please use the Patient>Clinical>Adverse Events>Falls window to view and document current falls assessments.” Thus, it is recommended only to observe the assessment data on this page, not to enter it. For entering the patient’s fall evaluation data, you should use the Falls window in Patient>Clinical>Adverse Events>Falls. Infections Patient>Clinical>Assessments>General>Infections Using the Infections tab, you can enter information on patient's infections. The tab consists of four sections that enable you to document system infections, systemic infectious daises, infection control protocol initiated, and additional comments if necessary. For the system infections and systemic infectious diseases, you can indicate current and historical items which are used for more accurate evaluation of the patient's condition. Thus, you can easily distinguish whether a patient had an infection present at start of care, or whether a patient subsequently developed an infection for the period while being treated by an agency. Infections Tab If you have Allscripts Homecare version higher than the 5.0 installed, while opening the Fall Evaluation template on assessments, the warning message will be displayed saying: “Please use the Patient>Clinical>Adverse Events>Infections and Patient>Clinical>General Clinical>Protocols Initiated windows to Clinical Documentation User’s Guide 461 Assessments view and document current assessments.” Thus, it is recommended only to observe the assessment data on this page, not to enter it. Entering the patient’s infections evaluation data should be made in Patient>Clinical>General Clinical>Precaution Protocols and Patient>Clinical>Adverse Events>Infections. Scales Patient>Clinical>Assessments>Physical>Clinical Monitoring>Scales Using the Scales tab, you can enter information on pain, nausea, anxiety, and shortness of breath levels. You can enter additional comment for each reading you collect if necessary. The tab contains easy‐to‐use slide bars which enable you to enter actual and desired values for each parameter. Based on the entered data, the graph for each parameter (pain, nausea, anxiety, and shortness of breath) is built and displayed in the bottom part of the tab. This tab is a copy of the Scales tab of the Add/Edit Clinical Data window. You can refer to the Add/Edit Clinical Data section for detailed description of each of the fields and for detailed instructions on how to enter clinical information. Clinical Monitoring Tab 462 Clinical Documentation User’s Guide Assessments Condition Change Report Using the Condition Change Report, you can preview, print, or save information on the patient’s condition changes based on the current and previous responses to the same OASIS question of the assessment. You can access the Condition Change Report window by clicking the Condition Change Report ( ) on the Assessments toolbar in Patient>Clinical>Assessments. Information on the Condition Change Report Field Name Description Question Text Assessment OASIS question. Current Response The response to the OASIS question in the current assessment. Previous Response The previous response to the same OASIS question of the assessment. Example of the Condition Change Report The generated report prints separate pages for each set of OASIS questions according to the patient’s condition changes: Declined, Improved, and Unchanged. The report caption contains the date when assessment was completed, the name of the resource who completed the assessment, the assessment template, name reason for assessment, and the patient’s name and ID the assessment was completed for. Clinical Documentation User’s Guide 463 Assessments Generating Condition Change Report 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Clinical>Assessments. The Assessments window opens. 4. Select the needed assessment from the drop‐down list or create a new one. 5. Click the Condition Change Report ( ) icon on the Assessments toolbar. 6. The Condition Change Report window opens showing patient’s condition changes based on the current and previous responses to the same OASIS question. The OASIS questions in the report are grouped into three sections according to the patient’s condition changes: Declined, Improved, and Unchanged. Click the Expand All button to view all sections in the report. 7. In the Condition Change Report window, click the Print Preview button to view a sample report onscreen. You can print, save, change the view mode, and navigate through report using standard report window buttons on the top panel of the window. 464 Clinical Documentation User’s Guide Assessments Changes To Skilled Nursing Template The changes were made based on a Client Focus Group made up of a wide cross section of Homecare clinicians. Please load the new 6.0 SN template into the Assessment Viewer and use with this document. Pre 6.0 SN Template 6.0 SN Template General General > Homebound Status updated > Immunizations updated to be in line with OASIS C requirements > Education removed > Latest Acute Hospitalization Risk Tool and Screening for Emergent Care/Acute Hospitalization assessments from the MedQic site moved here from Care Management section Clinical Documentation User’s Guide 465 Assessments Pre 6.0 SN Template Physical>Neurological Physical>Neurological > Reorganized to remove the control boxes for less clicks > Added Patient Health Questionnaire 2 and 9 > Added Cornell Scale for Depression (and Instructions for Cornell Scale tab) Physical>Respiratory 466 6.0 SN Template Physical>Respiratory > Lung Sounds (R & L) put into grid format for ease of use. Clinical Documentation User’s Guide Assessments Pre 6.0 SN Template 6.0 SN Template Physical>Cardiovascular Physical>Cardiovascular > Skin Color and Temperature put into grid format for ease of use > Edema section moved Physical>Cardiovascular Physical>Edema > Made into its own Notebook residing underneath cardiovascular > Upper and Lower Extremities out into grid format for ease of use > Edema Scale added Clinical Documentation User’s Guide 467 Assessments Pre 6.0 SN Template Physical>Gastrointestinal Physical>Gastrointestinal > Reorganized to remove the control boxes for less clicks Physical>Nutrition Physical>Nutrition > Moved up in the tree underneath Gastrointestinal Physical>Skin Physical>Skin > Updated the Wound Stage Definitions > Added healing Definitions > Added 6 more wound sites (total 18) > Verbiage changes to the Sites > Added "Present on SOC" check box which will carry over to subsequent assessments to indicate the wound was present on Start of Care Physical>Urinary Physical>Urinary > Reorganized to remove the control boxes for less clicks Physical>Metabolic 468 6.0 SN Template Physical>Metabolic > Reorganized for ease of use Clinical Documentation User’s Guide Assessments Pre 6.0 SN Template 6.0 SN Template Physical>Hematologic>Lymphatic Physical>Hematologic>Lymphatic > Reorganized for ease of use Reproductive (Male) (Female) Reproductive (Male) (Female) > Reorganized for ease of use Functional Status>Mobility Self Care Functional Status>Mobility Self Care > Reorganized for ease of use and as per the Therapy template changes of v 5.0. Devices and Equipment Devices and Equipment > Reorganized for ease of use and as per the Therapy template changes of v 5.0. Clinical Documentation User’s Guide 469 Assessments Pre 6.0 SN Template Caregiver Caregiver > Reorganized for ease of use and as per the Therapy template changes of v 5.0. Care Management>Evaluate>Medication Evaluation 470 6.0 SN Template Care Management>Evaluate>Medication Evaluation > Added a 'Medication Review' section which will allow documentation of Drug Regimen Review within the Assessment template. > The Medications Evaluation are part of the Medications screen and will write to the Adverse Events Report>>Medication Evaluations report and the Care Plan if used form the Medications screen > Do not document in both places Clinical Documentation User’s Guide Assessments Surgical Diagnoses Prefill Logic Surgical Diagnoses are prefilled from the Patient>General>Diagnosis>Surgical Diagnoses for OASIS Only and OASIS integrated templates (PT, OT, SN, ST, and Psychiatric). All Surgical Diagnoses that are active on the M0090 assessment date are prefilled into the M1012 section of the assessment. Diagnoses Group logic is not applied for Surgical codes. Surgical Diagnoses are shown across all Diagnosis Groups regardless whether they fall into Diagnosis Group date range. If you enter the assessment, 100 % complete it, and then save it, all Surgical Diagnoses that are active on the M0090 assessment date are prefilled into the M1012 section of the assessment. For incomplete assessments, there is a prefill logic for surgical diagnoses: > If you enter the assessment, save it incomplete, and add or change the existing surgical diagnoses in the Diagnosis window. Then, after reopening the incomplete assessment, the prefilled diagnoses in the M1012 will not be changed. > There will be the same logic described above if we add incomplete assessment and then change the date of this assessment to the one when some other surgical diagnoses were active. These diagnoses are not prefilled into the newly created assessment after reopening it. > If there is an incomplete assessment that is saved without any answer in the M1012 section, and some surgical diagnosis is added in the Diagnosis window after entering the assessment, then after reopening this assessment, the surgical diagnosis will be prefilled. > If an incomplete assessment was added and some surgical diagnoses were entered manually for the M1012 section, these diagnoses will remain after reopening the assessment. Note Note For incomplete assessment, if you add or change some diagnoses on the Diagnosis window, be sure to make appropriate changes manually in the M1012 section while completing the assessment. Clinical Documentation User’s Guide 471 Assessments Assessment Guidelines for Home Health and Hospice For Home Health Agencies If you are a Medicare certified Home Health agency, you need to use the 6.0 assessment templates when you are using the Allscripts Homecare 6.0. You should use the 6.0 OASIS templates that are updated to OASIS C. You should use the 6.0 OASIS C templates for all assessments with the M0090 date (date the assessment was completed) starting from 1/1/2010. If you are a Medicare certified Home Health agency, any OASIS exports which contain assessments with the M0090 date of 1/1/2010 that are not in the OASIS C format will be rejected by CMS. The claims will also be rejected as the HHRG will be incorrect. If this happens, redo and resubmit the assessment in the OASIS C format. You can do that within Allscripts Homecare or you can use HAVEN. Claims will also need to be voided and replaced in the correct format. For the integrated OASIS templates (SN, Psychiatric, OT, PT, and ST), you will lose your customizations. For all Non‐OASIS and Pediatric templates, all customizations will be kept. If your agency does not use OASIS, you may continue using your old templates; however, they may not contain the latest clinical updates and ease of use of the newest templates. You will not have the ability using the Assessment Editor to add the new Attach Problems feature at the assessment tab level. The Attach Problems feature assists the clinician's workflow in building and updating the Care Plan. For Hospice Agencies If you are a Hospice agency, it is recommended to use 6.0 assessment templates when you are using the Allscripts Homecare 6.0. You may continue using your old templates; however, they may not contain the latest clinical updates and ease of use of the newest templates. You will not have the ability using the Assessment Editor to add the new Attach Problems feature at the assessment tab level. The Attach Problems feature assists the clinician's workflow in building and updating the Care Plan. 472 Clinical Documentation User’s Guide Assessments Upgrading Assessments to 6.0 for Home Health and Hospice 1. Use the Assessment Viewer to become familiar with the flow and content of the latest assessments before customizing. 2. Since we have made changes to the normalization process, the templates may initially be slower to load. If that is the case, run the Assessment Warehouse utility. It is located in the Server>Templates folder. Double click on the ASM_WH.exe and let it run. It may take several hours if you have not run it before, so run it overnight. Note If your agency writes assessment queries, then you are already familiar with this tool. 3. Load the 6.0 templates into your Business Unit directly from the Server>Templates folder. • These are base unedited templates. • If you are using a Test server, these base templates must be loaded into both the Test and Production servers. 4. Edit the template and save your changes. Those templates will automatically be normalized—a process that is needed for you to run Queries. • You can edit the RFA, modify the text and check the text spelling, and make some boxes or tabs invisible if your agency does not want to use those items. • You cannot edit OASIS, Clinical Monitoring, and Skin areas because of the logic that supports those areas. • With the 6.0 templates, you can also attach problems at the tab level. Note You must edit from the 'base' or original 6.0 template. You may make updates to an already edited template, and keep the same name. Do not edit a template and then keep editing and renaming. 5. Print or save to .pdf the Template Edit Report for reference. 6. Test your changes on your Test server or using the Assessment Viewer. 7. After you complete editing on a Test Server, copy over your edited templates to your Production server where the base 6.0 templates are loaded. Modified Templates can be activated in multiple Business Units, except those where problems are attached and the problems set is not the same across those Business Units. 8. After you load your modified templates from the Test server to Production, go back through the Assessment Editor. Open Options\Normalize Templates window and normalize these templates before activating for use (needed for queries and correct work of assessment history and assessment history report). Clinical Documentation User’s Guide 473 Assessments Report Assessments Report Assessments Report Window Reports>Clinical>Assessments Patient>Documents>Assessments Using the Assessments report, you can preview and print patient's assessments for a specified discipline. When the assessment is printed, the revision history information appears at the end of the report. The discrete data from Clinical Monitoring are integrated into assessment and also are printed in the report. When you run the report, a wizard guides you through report steps which enable you to select the appropriate discipline, patients, assessments, and the particular pages of the assessment to be included in the report. You can select to print the assessment with or without data. Using this report, you can print a blank assessment to complete the hard copy by hand. You can view and print the assessment report in Host Mode. You can access the Assessments report using either Reports or Patient component. > Reports>Clinical>Assessments – By accessing the Assessments report from the Reports component, you can define such report parameters as discipline, patients, assessment, and assessment pages to be included in the report. The report creation wizard guides you through the following windows where you can define particular report parameters: • • Assessments Report – Select Assessments • 474 Assessments Report – Select Patients and Time Scope • > Assessments Report – Select Disciplines Assessments Report – Select Pages to Print Patient>Documents>Assessments – By accessing the Assessments report from the Patient component, you can print the report only for the selected patient. For more information, see Patient Documents – Assessments. Clinical Documentation User’s Guide Assessments Report Assessments Report – Generated The Assessments report displays information on the patient’s assessment for a specified discipline within the defined date range. The view of the generated Assessments report may vary according to the selected print options. > If you select to print the assessment report without data, the generated report will display the selected assessment with blank fields. Actually, you will have the hard copy version of the assessment which can be further completed by hand. > If you select to print assessment report with data, the generated report will display only assessment which contains some data. In this case, the report consists of three parts: • Caption – Contains discipline, assessment name, version, patient first and last names, patient code, reason for assessment (RFA), assessor first and last names, and the date when the assessment was completed. • Assessment Body – Displays assessment fields with the completed values. Depending on the type of the assessment, the assessment body of the report changes according to the items specific for particular assessment. • Footer – Contains the assessor first and last names, print date and time, and report page number. Clinical Documentation User’s Guide 475 Assessments Report Assessments Report – Generated Assessments Report – Generated 476 Clinical Documentation User’s Guide Assessments Report Assessments Report – Select Disciplines Reports>Clinical>Assessments Use this window to select the disciplines you want to include in the report. You can also define whether to search for assessment with data or for blank assessments. After you made necessary selections, click Next to go to the Assessments Report – Select Patients and Time Scope window. Assessments Report Window – Select Disciplines Assessments Report Window – Select Disciplines Fields Selected Select the check boxes opposite the disciplines you want to include in the report. ID The ID of the disciplines available for selection. Description The description of the disciplines available for selection. Clinical Documentation User’s Guide 477 Assessments Report Print Assessments Define what assessments you want to print in the report: > > With Data – Select to print only assessments which contain some data (some or all of the assessment fields are completed). Without Data – Select to print only assessments which do not contain any data (all assessment fields are blank). If you select the Without Data option, then all print options will be disabled in the Select Pages to Print window and the printed assessment will be in the old format only. Select All Click to select all disciplines listed in the grid at a time. Clear All Click to clear all disciplines selected in the grid at a time. Next Click to go to the next window of the assessment report creation wizard. 478 Clinical Documentation User’s Guide Assessments Report Assessments Report – Select Patients and Time Scope Reports>Clinical>Assessments Use this window to select patients you want to include in the report and to define date range of the report. After you made necessary selections, click Next to go to the Assessments Report – Select Assessments window. Assessment Report – Select Patients and Time Scope Assessments Report – Select Patients and Time Scope Fields Begin Date Enter the start date for this report. End Date Enter the end date for this report. Add Patients Click this button to select patients for the report. The Select Patients window opens where you can search for the patients you want to include in the report. Clinical Documentation User’s Guide 479 Assessments Report Remove Click this button to remove the selected patients from the list. Remove those patients which you do not want to include in the report. Move Up Click to move the selected records up in the grid. Move Down Click to move the selected records down in the grid. Select All Click to select all patients listed in the grid at a time. Clear All Click to clear all patients selected in the grid at a time. Back Click to go to the previous window of the assessment report creation wizard. Next Click to go to the next window of the assessment report creation wizard. Assessments Report – Select Assessments Reports>Clinical>Assessments Use this window to select the assessments you want to include in the report. You can select one or several assessments. > > 480 If you select one assessment, click Next to go to the Assessments Report – Select Pages to Print window where you can select the assessment pages to include in the report. If you select several assessments, click the Preview tab to print the report. All assessment pages will be included in the report. Clinical Documentation User’s Guide Assessments Report Assessments Report – Select Assessments Selected Select the check boxes opposite the assessments you want to include in the report. Patient ID ID of the patient. Patient Name First and last names of the patient. Date Date when the assessment was completed. Assessed By First and last names of the assessor. Assessment Description Assessment name, version, and reason for assessment. Clinical Documentation User’s Guide 481 Assessments Report Select All Click to select all assessments listed in the grid at a time. Clear All Click to clear all assessments selected in the grid at a time. Back Click to go to the previous window of the assessment report creation wizard. Next Click to go to the next window of the assessment report creation wizard. Assessments Report – Select Pages to Print Reports>Clinical>Assessments Use this window to select assessment pages you want to include in the report and to define other print options. After you made the necessary selections, click the Preview tab. The Assessments report is generated according to the parameters you entered. Assessment Report – Select Pages to Print 482 Clinical Documentation User’s Guide Assessments Report Assessments Report – Select Assessment Pages Fields Assessment Tree It is located in the left section of the window. The assessment tree displays the assessment pages available for printing. When you select a branch from the assessment tree, the right section of the window displays the corresponding items of this branch which you can include or exclude from the report. The assessment branch is colored in green if there were changes in items within that branch during the last assessment edit. The assessment branch is colored in gray if the items within that branch were not modified. Print Options Use this section to define printing options for the report: • Notes – Select this check box to include assessment notes in the report. • OASIS Only – Select this check box to include only OASIS information in the report. Note For 6.0. version, this option is disabled. • Revision History – Select this check box to include revision history information at the end of the report. • M item number only – Select this check box to print only the number of M item without the caption in the report. • Body View – Select this radio button to print the body view part of the assessment in the report. • Body View Only if Completed – Select this radio button to print the body view part of the assessment if this part is completed. Select All Click to select all assessments items listed in the right section of the window at a time. Clear All Click to clear all assessments items selected in the right section of the window at a time. Back Click to go to the previous window of the assessments report creation wizard. Clinical Documentation User’s Guide 483 Assessments Report Generating Assessments Report from Reports Component 1. Open the Reports component. 2. From the menu bar, select Clinical>Assessments. The Assessments Report – Select Disciplines window opens. 3. Select the disciplines you want to include in the report and click Next. The Assessments Report – Select Patients and Time Scope window opens. 4. Select the patients and define the date range for the report and click Next. The Assessments Report – Select Assessments window opens. 5. Select the assessments you want to include in the report. • If you select one assessment, click Next. The Assessments Report – Select Pages to Print window opens. • If you select several assessments, click the Preview tab to generate the report. 6. Select the assessment pages you want to print in the report and click the Preview tab. Generating Assessments Report from Patient Component 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Assessments. The Assessments window opens. 4. Select the assessments you want to include in the report and define the print options. 5. Click the Preview tab to generate the report. 484 Clinical Documentation User’s Guide Assessment History Report Assessment History Report Assessment History Window Reports>Clinical>Assessment History Patient>Documents>Assessment History The Assessment History report displays the assessment history for the patients. The report compiles and prints the history of the assessment data for Nursing, Hospice, OASIS, Nursing OASIS, Physical Therapy, Psychiatric, Occupational Therapy, Maternal Child Health, Speech Language Pathology, and other assessment templates. This report includes discrete data from Clinical Monitoring for a single or multiple patients within the selected date range. Using the Assessment History window, you can select the patients, assessment templates, and pages to print in the report. Note Note Using the Assessment History window in the Patient component, you can generate the report only for the one selected patient. The report creation wizard guides you through the following windows where you can define particular report parameters: • Assessment History Report – Select Patients and Time Scope • Assessment History Report – Select Assessment Template • Assessment History Report – Select Pages to Print Clinical Documentation User’s Guide 485 Assessment History Report Assessment History Report – Generated The generated report prints separate pages for each patient. Pages are sorted by patient’s last name in alphabetical order. Information on the Assessment History Report Field Name Patient ID Patient’s code. Patient Name First and last names of the patient. Assessment Template Tree>Subtree> Key This section displays the information selected in the Select Assessment Template window of the report. For example, if you selected the Respiratory (Basic) check box in the Physical>Respiratory subtree, the field in the generated report will display Physical\ Respiratory\ Respiratory (Basic), followed by the information selected in Patient>Clinical>Assessments. Date Date when assessment was completed. Data Associated assessment information entered by the resource who assessed the patient. Info 486 Description Information on the patient’s visit and assessment template. Clinical Documentation User’s Guide Assessment History Report Example of the Assessment History Report Assessment History Report Clinical Documentation User’s Guide 487 Assessment History Report Assessment History Report – Select Patients and Time Scope Reports>Clinical>Assessment History Using the Select Patients and Time Scope window, you can define the date range for the report and select patients for which the assessment history will be printed. Reports – Assessment History Report – Select Patients and Time Scope Date Range Select the time range the report should be generated for. > > From – Enter the start date. To – Enter the end date. Select Patients The Select Patients grid displays a list of patients and patients’ relative information to include in the report. Click the column title to sort the patients’ information by the selected columns. > > > > > 488 ID – Patients’ codes. Name – Patients’ names. Team – Name of the team to which the patients belong. Class – Patients’ classes. DOB – Date of birth of each patient. Clinical Documentation User’s Guide Assessment History Report > City – City of each patient. Use the following buttons to manage the information: > > > > > > > > Add Patients – Click to add patients from the Select Patient dialog to the list. Remove – Click to remove the patients selected in the Select Patient dialog from the list. Move Up – Click to move the selected patients upwards. Each time you click this button, the selected lines are moved one line upwards. Move Down – Click to move the selected patients downwards. Each time you click this button, the selected lines are moved one line downwards. Select All – Click to select all patients from the grid to include in the report. Clear All – Click to exclude all patients from the grid of the report. Next – Click to go to the next window of the report. Cancel – Click to close the report. Assessment History Report – Select Assessment Template Reports>Clinical>Assessment History Use the Select Assessment Template window to select the assessment template for which you want to print the patients’ assessment history report. Assessment History Report – Select Assessment Template Clinical Documentation User’s Guide 489 Assessment History Report Assessment History Grid > > > > Template Name – Displays the list of all assessment templates in the specified date range. Template Version – Displays the version for the corresponding assessment. Template Modifier – Displays the name of the template modifier specified on the Administration>Configuration>Business Units>Assessments tab. Modified Date – Displays the date when the assessment template was modified. Use the following buttons to manage the information: > > > Back – Click to go to the previous window of the report. Next – Click to go to the next window of the report. Cancel – Click to close the report. Assessment History Report – Select Pages to Print Reports>Clinical>Assessment History Using the Select Pages to Print window, you can view information on the assessment template selected in the previous Select Assessment Template window and select the pages to print in the report. Use the following buttons to manage the information: > Select All – Click to select all check boxes in the entire tree to include in the report. > Clear All – Click to clear all check boxes or in the entire tree. Note To select or clear all check boxes in the entire tree, click to highlight the assessment template at the top. Highlight the subtree to select or clear check boxes only in the subtree. > > Next – Click to generate the report based on the criteria selected in the previous windows. > 490 Back – Click to go to the previous window of the report. Cancel – Click to close the report. Clinical Documentation User’s Guide Assessment History Report Assessment History Report – Select Pages to Print Generating Assessment History Report for an Individual Patient 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Assessment History. The Select Time Scope window opens. 4. Set the date range for printing the assessment history in the Date Range section. Note Help is available for each field in this window by pressing F1 while in the field. 5. Click Next. The Select Assessment Template window opens. 6. Select the assessment template you want to use for the report. 7. Click Next. The Select Pages to Print window opens. 8. Select the assessment items in the left side of the window and select the check boxes in the right side for the pages to include in the report. Clinical Documentation User’s Guide 491 Assessment History Report 9. Click Next to preview the report. The onscreen preview of the assessment history based on the selected criteria opens. Note If you change the criteria in the previous windows after previewing, those changes are not reflected the next time you preview. You have to click the Close button to close the generated report window and re‐enter the report criteria for the new generated preview. Generating Assessment History Report for Multiple Patients 1. Open the Reports component. 2. From the menu bar, select Clinical>Assessment History. The Select Patients and Time Scope window opens. 3. Set the time period for printing the assessment history in the Date Range section. Note Help is available for each field in this window by pressing F1 while in the field. 4. Select the patients for whom you want to print the assessment history. 5. Click Next. The Select Assessment Template window opens. 6. Select the assessment template you want to use for the report. 7. Click Next. The Select Pages to Print window opens. 8. Select the assessment items in the left side of the window and select the check boxes in the right side for the pages to include in the report. 9. Click Next to preview the report. The onscreen preview of the assessment history based on the selected criteria opens. Note If you change the criteria in previous windows after previewing, those changes are not reflected the next time you preview. You have to click the Close button to close the generated report window and re‐enter the report criteria for the new generated preview. 492 Clinical Documentation User’s Guide Patient Documents – Assessments Patient Documents – Assessments Assessments Window Patient>Documents>Assessments With the Assessments window, you can preview and print assessments for the patient. This window displays all assessments for the patient, and you can select the assessment you want to print and define print options for the report. The list of the available assessments includes only those related to the currently selected patient. You can view and print the assessment report in Field and Host Modes. Note Note You can print assessment report from the Report component for several patients. Assessments Window Assessments Window Fields Assessments list This section lists all assessments for the selected patient. Select the check box opposite the assessments you want to include in the report. Clinical Documentation User’s Guide 493 Patient Documents – Assessments Print Options Use the following options for the report: • Notes – Select this check box to include assessment notes in the report. • Revision History – Select this check box to include revision history information at the end of the report. • OASIS Only – Select this check box to include only OASIS information in the report. • M item number only – Select this check box to print only the number of M items without the name in the report. • Body View – Select this radio button to print the body view part of the assessment in the report. • Body View Only if Completed – Select this radio button to print the body view part of the assessment in case this part is completed. • Without data – Select this check box to print only the assessment items without prefilled data. If you select this option, all other print options will be disabled. Generating the Assessments Report 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Assessments. The Assessments window opens. 4. Select the assessments you want to include in the report and define the print options. Note Help is available for each field in this window by pressing F1 while in the field. 5. Click the Preview button to generate the report. 494 Clinical Documentation User’s Guide Patient Documents – Assessment History Patient Documents – Assessment History Assessment History Report Patient>Documents>Assessment History Using the Assessment History report, you can preview and print the assessment history for a patient. This report displays assessment data within the selected date range. For more information on this report, see Assessment History Report. Clinical Documentation User’s Guide 495 OASIS Export OASIS Export Exporting OASIS Assessments After completing OASIS assessments, you must export them to a file for submission to your state agency or third‐party vendor. Use the OASIS Export window to select the assessments to export. You can select assessments according to insurance type, patient, payer, or the date when the assessments were completed. The selected assessments are exported to a file that is stored in the location defined in Administration>Configuration>Business Units>Settings>Exports. When you export assessments, the OASIS Export functionality displays all warnings about the assessments involved in export. You can export the selected assessments in spite of warnings or exclude assessments with warnings from the export. The OASIS Export process uses the same error display logic that is used by the Assessment validation process. However, within OASIS Export, you can only view the error and its detailed information (such as M item, description, and specific rule violated) but not edit the inaccuracies. After the export is complete, the application generates an assessment export report listing the exported and non‐exported assessments. You can sort this report by patient name and assessment date, patient ID and assessment date, or assessment date and patient name. You cannot export reserved assessments. You must either release the assessment or let the user who has reserved the assessment make the appropriate edits and release it. With the OASIS Export wizard, you can: View the OASIS Export Report 1. OASIS Export – Select Mode 2. OASIS Export – Select Assessments to View 3. OASIS Export – Exported/Not Exported/Inactive Assessments Export OASIS Assessments 1. OASIS Export – Select Mode 2. OASIS Export – Select Export Parameters 3. OASIS Export – Select Patients/Assessments/Payers 4. OASIS Export – Select Assessments to Export 496 Clinical Documentation User’s Guide OASIS Export OASIS Export – Select Mode Transactions>General>OASIS Export With the OASIS Export – Select Mode window, you can view the OASIS assessment export report or export the OASIS data to a separate file. OASIS Export – Select Mode Mode • OASIS Export History – Select this radio button to view the report on OASIS export history. After selecting this radio button and clicking Next, the OASIS Export – Select Assessments to View window opens with the selection parameters for the report. • Export OASIS Data – Select this radio button to export OASIS data. If you select this radio button and click Next, the OASIS Export – Select Export Parameters window opens. Clinical Documentation User’s Guide 497 OASIS Export OASIS Export – Select Assessments to View Transactions>General>OASIS Export With the OASIS Export – Select Assessments to View window, you can select the assessment types and also define sorting options for the report. OASIS Export – Select Assessments to View Select Assessments • • Not Exported – Select this radio button to view the assessments that were not exported. • 498 Exported – Select this radio button to view the exported assessments in the report. For the exported assessments, you should define the date range. Inactive – Select this radio button to see the assessments that were inactivated. Clinical Documentation User’s Guide OASIS Export Sort Report By • Patient Name + Assessment Date – Select to sort the report by patient name and then by assessment date. • Patient Code + Assessment Date – Select to sort the report by patient code and then by assessment date. • Assessment Date + Patient Name – Select to sort the report by assessment date and then by patient name. Grouping By Select the Reason for Assessment check box to group the assessments by their reasons for assessment (RFA). OASIS Export – Exported/Not Exported/Inactive Assessments Transactions>General>OASIS Export The OASIS assessment report opens in a separate window of the wizard. The report name and content may differ according to the assessment types and sort options you selected. You can print the report and save it in the available formats. Click Close to return to the OASIS Export – Select Assessments to View window. Clinical Documentation User’s Guide 499 OASIS Export OASIS Export – Select Export Parameters Transactions>General>OASIS Export This window includes various selection parameters you can use to define the assessments to export. You can select assessments according to insurance type, patient, payer, or the date when the assessments were completed. You can also select CMS, Non‐CMS, or Test types of export destination. Caution Allscripts recommends you to include no more than 100 assessment records in a single export file. You set the maximum number of records in an OASIS Export file in Administration>Configuration>Business Units>Settings>Exports. Including more than 100 records can result in "out of memory" messages. OASIS Export – Select Export Parameters Destination • • Non‐CMS – Select to export to any non‐CMS destination. • 500 CMS – Select to export to CMS. Test – Select for test purposes only. Clinical Documentation User’s Guide OASIS Export Use Date Range Select this check box if you want to export assessments completed within a certain date range that also meet the other selection criteria. Use From and To fields to enter the appropriate dates. Clear the check box if you want to export assessments that meet the other selection criteria regardless of completion date. Insurance Type • Medicaid only – Select to export assessments only for Medicaid patients. • Medicare only – Select to export assessments only for Medicare patients. • Medicare and Medicaid – Select to export assessments for Medicaid and Medicare patients. • Non‐Medicare/Non‐Medicaid – Select to export assessments for non‐Medicaid and non‐ Medicare patients. • All patients – Select to export assessments or all patients. (This option is available only if the agency has one Medicaid ID and one Medicare ID.) Note According to CMS, the Non‐Medicare/Non‐Medicaid and All patients options will be disabled for CMS export as of 1/1/2010. Medicare Click and select the appropriate agency Medicare provider number. This number must be included in the export file as M0010. Medicaid Click and select the appropriate agency Medicaid provider number. This number must be included in the export file as M0012. State Assigned Unique OASIS ID If you want to export data using a state‐assigned unique OASIS ID, select the ID in this field. The state ID numbers are stored in Administration>Configuration>Business Units>Settings>Assessments. Clinical Documentation User’s Guide 501 OASIS Export Sort Export Report By • Patient Name + Assessment Date – Select to sort the report by patient name and then by assessment date. • Patient Code + Assessment Date – Select to sort the report by patient code and then by assessment date. • Assessment Date + Patient Name – Select to sort the report by assessment date and then by patient name. Grouping By Select the Reason for Assessment check box to group the assessments by their reasons for assessment (RFA) in the generated report. Select Assessments By • All Assessments – Select to export all assessments that are ready for export. • Individual Assessments – Select to export selected assessments. An assessment selection grid appears that contains all assessments ready for export. You select which assessments to export. In addition, you select which assessments containing OASIS warnings (from the Invalid Assessments grid if applicable) for selected patients to export. • Individual Patients – Select to export assessments for the selected patients. A patient selection grid appears so you can select for which patients to export. Only patients who have assessments ready for export and/or patients who have assessments that meet all selection criteria but have OASIS warnings appear in the grid. All assessments ready for export for the selected patients will be exported. In addition, you can select which assessments containing OASIS warnings (if applicable) for the selected patients should be exported. • Individual Payers – Select to export assessments for the selected patients (this option is valid only if there are two or more payers selected for Insurance Type). Note If you select the All Assessments option, the OASIS Export – Select Assessments to Export window opens, after selecting one of the other options, the OASIS Export – Select Patients/Assessments/Payers window opens. 502 Clinical Documentation User’s Guide OASIS Export OASIS Export – Select Patients/Assessments/Payers Transactions>General>OASIS Export Depending on which options you selected in the Select Assessments By section in the OASIS Export – Select Export Parameters window, the corresponding window opens. > If you select the Individual Patients option, the OASIS Export – Select Patients window opens where you can select assessments of the individual patients for export. > If you select the Individual Assessments option, the OASIS Export – Select Assessments to Export window opens where you can select individual assessments for export. > If you select the Individual Payers option, the OASIS Export – Select Payers window opens where you can select assessments of the individual payers for export. Clinical Documentation User’s Guide 503 OASIS Export OASIS Export – Select Assessments to Export Transactions>General>OASIS Export In this window, you can view any warnings associated with the assessments in the export and select the assessments you want to export. OASIS Export – Select Assessments to Export Submit/Exclude selected assessments • Submit selected assessments – Select to submit selected assessment regardless of warnings. • Exclude all these assessments – Select to remove all the assessments from the export. Use Select the check box opposite the assessment which you want to export. 504 Clinical Documentation User’s Guide OASIS Export Exporting the OASIS Assessments 1. Open the Transactions component. 2. From the menu bar, select General>OASIS Export. The OASIS Export – Select Mode window opens. Note Help is available for each field in this window by pressing F1 while in the field. 3. Select the Export OASIS Data radio button. 4. Click Next. The OASIS Export – Select Export Parameters window opens. 5. Select the appropriate type of export in the Destination section. 6. (Optional) If you want to export only assessments within a certain date range, select the Use Date Range check box and define the start and end dates. 7. Select the appropriate payer in the Insurance Type section. If you select Medicare, Medicaid, or Medicare and Medicaid, select the appropriate agency provider numbers. 8. Select the appropriate OASIS ID. 9. Select the appropriate report sort order. To group assessments by their RFA in the report, select the Reason for Assessments check box. 10. Select either All Assessments or one of the other options to further narrow down the list of assessments to export. 11. Click Next. The OASIS Export – Select Assessments to Export window opens. If there are any warnings associated with the assessments during the export, those warnings appear and you decide whether to export such assessments. 12. Select the assessments you want to include or exclude from the export. 13. Click Next. Allscripts Homecare exports the selected assessments to the location specified in Administration>Configuration>Business Units>Settings>Exports. When the export is complete, the Assessments Export Report opens. Clinical Documentation User’s Guide 505 OASIS Export Assessments Export Report Allscripts Homecare automatically generates the Assessments Export Report after you exported assessments. You can also view the report by selecting OASIS Export History in the OASIS Export – Select Mode window, then selecting appropriate report parameters. This report lists both the exported and non‐exported assessments. You can sort the data in this report by patient name and assessment date, patient ID and assessment date, or assessment date and patient name. Assessments Export Report 506 Clinical Documentation User’s Guide OASIS Export Viewing the Assessment Export Report 1. Open the Transactions component. 2. From the menu bar, select General>OASIS Export. The OASIS Export – Select Mode window opens. Note Help is available for each field in this window by pressing F1 while in the field. 3. Select the OASIS Export History radio button. 4. Click Next. The OASIS Export – Select Assessments to View window opens. 5. Select whether to include exported, non‐exported, or inactivated assessments. 6. (Optional) For exported assessments, define the appropriate date range. 7. Select the appropriate sort option. 8. Click Next. The OASIS Export – Exported/Not Exported/Inactive Assessments window opens with the generated report. Clinical Documentation User’s Guide 507 OASIS Due Alert Report OASIS Due Alert Report OASIS Due Alert Report Window Reports>Clinical>OASIS Due Alert The OASIS Due Alert Report includes a list of all patients who have an OASIS assessment due or overdue. You can report as of the current date, or you can enter a future date to report as‐of. You can also enter a number of lead‐time days‐‐days prior to the patient's OASIS recertification window that the report will include the patient. You can also choose to include all or selected patents on the report, and you can sort the report by patient last name, team, or assessment date. You can also print OASIS Due Alerts through the Patient component. OASIS Due Alert Report Sorting If you want to sort the report by: > > > 508 Patient last name, click By Patient Last Name. Team, click By Team. Assessment date, click By Assessment Date. Clinical Documentation User’s Guide OASIS Due Alert Report Mode If you want to include: > > All patients, click All patients. Selected patients, click Individual patients. Generating OASIS Due Alert Report 1. Open the Reports component. 2. Go to Clinical>OASIS Due Alert. The OASIS Due Alert window opens with the Define tab visible. 3. Complete the report criteria fields as appropriate. Note Help is available for each field in this window by pressing F1 while in the field. 4. Click the Preview tab to view an onscreen preview of the report based on the criteria you entered. 5. Click Print to print the report. Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. Clinical Documentation User’s Guide 509 Patient Documents – OASIS Due Alerts Patient Documents – OASIS Due Alerts OASIS Due Alerts Window Patient>Documents>OASIS Due Alert The OASIS Due Alert report includes all OASIS assessments due, or overdue, for the current patient. You can report as of the current date, or you can enter a future date to report as‐of. You can also enter a number of lead‐time days ‐ days prior to the patient's OASIS recertification window that the report will include the patient. You can also choose to include all or selected patients on the report, and you can sort the report by patient last name, team, or assessment date. You can also print the OASIS due alert for multiple patients through Reports>Clinical. OASIS Due Alerts Window OASIS Due Alerts Window Fields Begin Date Specify the first date in the range for which you want to report. The report includes all credentials set to expire within this range. 510 Clinical Documentation User’s Guide Patient Documents – OASIS Due Alerts End Date Specify the last date in the range for which you want to report. The report includes all credentials set to expire within this range. Printing or Previewing OASIS Due Alerts 1. Open the Patient component. 2. Select the correct patient. 3. Go to Documents>OASIS Due Alerts. The OASIS Due Alerts window opens. 4. Complete the fields on the Define tab as appropriate to include the information you want to print or preview. Note Help is available for each field by pressing F1 while in the field. 5. Click Print to print the selected alerts. OR Choose the Preview tab to preview the selected alerts onscreen. Note Note If you change the criteria on the Define tab after previewing, those changes are not reflected the next time you preview. You must exit the report window and re‐enter it, then re‐enter the report criteria for the new preview. OASIS due alerts are also available in the Orders and Reports components. Clinical Documentation User’s Guide 511 Assessment Editor Assessment Editor About Assessment Editor Assessment Editor is a tool for direct editing the assessments non‐OASIS items within the Allscripts Homecare application. Using Assessment Editor, you can open, edit, and save the existing assessment template. > Editing Item Text at the Notebook, Tab, Box, or Line Level > Checking the Spelling of the Item Text > Making Item Invisible in the Assessment Template > Changing the Assessment Editor Settings > Previewing, Printing, or Saving the Template Edit Report > Attaching Problems to the Assessment Questions Starting Assessment Editor From the Business Units Window 1. Open the Administration component. 2. From the menu bar, select Configuration>Business Units. The Business Units window opens with the Basic tab active. 3. From the list of Business Units on the left, select the Business Unit for which you want to edit an assessment template. 4. Click the Assessments tab in the right pane. 5. Select the assessment template from the assessment list. 512 Clinical Documentation User’s Guide Assessment Editor 6. Click the Edit Template button. The Select a Template Path dialog opens. 7. Select the location for the assessment template and click OK. You can see the location for the modified templates at the bottom left corner of the Assessments window. The Edit Template dialog opens. 8. Enter the input template modifier text. When the template’s edited copy is saved, this template modifier text is displayed in the corresponding Template Modifier field of the assessments list (Administration>Configuration>Business Units>Assessments). 9. In the Edit Template dialog, click OK. 10. The Allscripts Homecare Assessment Editor window opens with the selected assessment open. You can start the Assessment Editor from the Business Units window only. If you try to start Assessment Editor using the AssessmentEditor.exe file, To use the Assessment Editor, go to Administration message appears. Clinical Documentation User’s Guide 513 Assessment Editor Allscripts Homecare Assessment Editor Window The Allscripts Homecare Assessment Editor – [Template Name] window consists of two panes. > Assessment Navigation Tree – The left pane with the assessment structure view displaying the hierarchy of the assessment items. > Items View – The right pane which displays the contents of the item selected in the left pane. The Assessment navigation tree consists of the following levels. > Assessment Name – Top element in the Assessment navigation tree which is not editable. The edited assessment template is saved with this name by default. You can identify your edited assessment template by the template modifier text displayed in the corresponding Template Modifier field in Administration>Configuration>Business Units>Assessments. > Notebook – Set of tabs whose name is displayed only in the Assessment navigation tree. > Tab, Box, Line – Levels of the navigation tree which reflect corresponding assessment items. You can select the notebook to view its contents in the Items View or expand the notebook to view its contents in the Assessment navigation tree. Each assessment notebook may contain tabs and other notebooks. Special icons mark the assessment items on the corresponding level in the Assessment navigation tree. (See Assessment Navigation Tree Icons.) Allscripts Homecare Assessment Editor Window 514 Clinical Documentation User’s Guide Assessment Editor Editing Item Text at the Notebook, Tab, Box, or Line Level 1. Open the assessment in the Assessment Editor. (See Starting Assessment Editor From the Business Units Window.) 2. From the assessment tree in the Allscripts Homecare Assessment Editor window, select the item you want to edit. Click the plus sign (+) to expand the item and minus sign (‐) to collapse it. 3. Click Edit Properties ( ). The Properties window opens for the selected assessment item. 4. In the Text field, edit the text of the item. 5. Check the spelling of the item text. (See Checking the Spelling of the Item Text.) 6. Click OK, and then save your changes. (See Saving Changes in the Assessment Editor.) Note You cannot edit text for the OASIS items. Making Item Invisible in the Assessment Template Note Note Be careful when hiding lines or boxes that have dependencies from other boxes or tabs. 1. Open the assessment in the Assessment Editor. (See Starting Assessment Editor From the Business Units Window.) 2. From the assessment tree in the left pane of the Allscripts Homecare Assessment Editor window, select the item you want to remove from the template. 3. Click the plus sign (+) to expand the item and minus sign (‐) to collapse it. 4. Click Edit Properties ( ). The Properties window opens for the selected assessment item. 5. Clear the Visible check box to remove the item from the assessment template. 6. Click OK, and then save your changes. (See Saving Changes in the Assessment Editor) The item is now visible only if the assessment is opened with the Assessment Editor. Note For OASIS items, the Invisible check box is disabled. Clinical Documentation User’s Guide 515 Assessment Editor Checking the Spelling of the Item Text You can check the spelling of the item text in the Text field of the Properties window. 1. With the mouse pointer in the Text field of the Properties window, press F7. The Spelling Suggestions for <Word> dialog opens. The Current Word field shows the word which is being checked for spelling. 2. In the Suggestions list box, select the suggestion as appropriate. The selected word appears in the Replace With field. OR In the Replace With field, enter the appropriate word to replace the current word. 3. To replace the current word, click Replace. 4. To ignore the current word and go on to the next one, click Ignore. Saving Changes in the Assessment Editor 1. Click Save to save your changes in the Assessment Editor. You can see the status of the saving process in a bar which appears below the assessment items navigation tree. 2. When the changes are saved, the bar displays a 100% completeness of saving and the Information message appears containing the information about the time used to save. 3. Click OK. 516 Clinical Documentation User’s Guide Assessment Editor 4. Close the Assessment Editor. The edited copy of the assessment template is saved. 5. Click Yes in the Confirm message to import the template into Allscripts Homecare. 6. The Information message appears informing you that the selected template is successfully added. 7. Click OK. 8. Click Yes in the Confirm message to activate the template. Initiating Care Plans Through the Assessments What is this functionality? Clinicians can now identify patient problems to build their Care Plan as they navigate through the assessments. This enhanced clinical workflow can be set up when the agency's QI staff determines the appropriate problems for the assessment tabs using the Assessment Editor tool. The clinician will then be able to access that list when building the Care Plan through the assessment. Attaching Problems to the Assessment Questions Using the Assessment Editor, you can attach problems to OASIS and non‐OASIS questions. Problems can be attached to the assessment questions on the tab sheet level only. This functionality works for assessment templates of 6.0 and higher versions. 1. On the Business Units level, select the assessment template you want to edit in the Assessment Editor. (See Starting Assessment Editor From the Business Units Window.) 2. The Allscripts Homecare Assessment Editor window opens with the selected assessment open. 3. From the assessment tree in the left pane, select the tab sheet item to which you want to attach the problems. Clinical Documentation User’s Guide 517 Assessment Editor 4. Click Edit Properties ( ). The Properties dialog opens for the selected assessment tab sheet. 5. In this dialog, click Attach Problems. The Attach Problems dialog opens with the active problems defined in Administration>Clinical>Problems. 518 Clinical Documentation User’s Guide Assessment Editor Use the following buttons and keyboard and mouse combinations forselecting the problems: Move the selected problem to the right column. Move the selected problem to the left column. Move all problems to the right column. Move all problems to the left column. Ctrl + Right Move all problems from the left column to the right. Ctrl + Left Move all problems from the right column to the left. Ctrl + mouse Left button Select several problems in a column. Shift + mouse Left button Select range of problems. Ctrl + Up/Down + Space Hold down the CTRL key, use Up and Down keys to move through the problems list and use Space key to select several values. Drag&Drop Use mouse Left button to select one problem in one column and drop it to another. Use Shift + mouse Left button to select range of problems in one column and drop it to another. Use Ctrl + mouse Left button to select multiple values in one column and drop it to another. Double‐click Move selected problem from one column to another. 6. After selecting all needed problems, click OK in the Attach Problems dialog. 7. Click OK in the Properties dialog. 8. If there are attached problems to the assessment tab sheets, you can see a paperclip indicator near the tab sheet name: . Note You can view the list of predefined problems in Patient>Clinical>Assessment while completing the assessment template and select problems for the patient from that list. (See the Defining Problems for the Patient section). Clinical Documentation User’s Guide 519 Assessment Editor Changing the Assessment Editor Settings 1. From the menu bar, select Options>Settings The Settings window opens. 2. From the corresponding drop‐down lists, select a color or define a custom color for the assessment items. 3. If the available colors are not suitable, click Custom in the corresponding drop‐down list, define the color you want, and add it to custom colors. 4. To set the default colors, click Default Value ( ). 5. Click OK. 6. Save your changes. 520 Clinical Documentation User’s Guide Assessment Editor Template Edit Report The Template Edit Report shows the saved changes made to the assessment template. It contains information on the assessment item, the changed item property, and the original and current value of the changed item property. Information on the Template Edit Report Field Name Description Node Path to the changed assessment item (the notebook, tab, box, or line) in the assessment items navigation tree. Original Value Original value of the changed assessment item. Current Value Current value of the changed assessment item. Property Change The changed property of the assessment item. The following values are available: > Problems > Text > Visible Example of the Template Edit Report Clinical Documentation User’s Guide 521 Assessment Editor Previewing, Printing, or Saving the Template Edit Report 1. Open the assessment template using the Assessment Editor. (See Starting Assessment Editor From the Business Units Window.) 2. Make changes to the assessment template items as appropriate. (See Editing Item Text at the Notebook, Tab, Box, or Line Level and Making Item Invisible in the Assessment Template.) 3. Save your changes. (See Saving Changes in the Assessment Editor.) 4. Select Options>Template Edit Report. The Print preview window opens. Note The Template Edit Report menu is available only if you made and saved the changes to the selected assessment template. 5. Click Print to print the report. 6. Save the report as an Excel or Acrobat file. Assessment Navigation Tree Icons The following navigation tree icons are used in the Assessment Editor: Level Item Assessment Name Assessment name Notebook Notebook Tab Icon Tab Tab sheet 522 Clinical Documentation User’s Guide Assessment Editor Level Item Line Icon Check box Multiple check boxes in one line Combo box Lookup combo box List box Scroll box Radio button Button Mask edit Allergies box Medications box Diagnosis box Panel Size panel Memo field Label Rich label Measures label Date edit Edit Spin edit Image Clinical Documentation User’s Guide 523 Assessment Viewer Assessment Viewer About Assessment Viewer The Assessment Viewer is an easy‐to‐use utility that allows you reviewing new and updated templates without importing them into Homecare. The Assessment Viewer also allows clinicians to practice using an assessment template before using it in the field. You can customize the colors of the template, save the template, and e‐mail it to your clinicians. > Viewing the Assessment Template > Changing the Template Colors > Creating a Distribution Package Starting Assessment Viewer 1. Go to Misys Homecare\Server\Templates. 2. Double‐click the AssessmentViewer.exe file. The Allscripts Homecare Assessment Viewer window opens. 524 Clinical Documentation User’s Guide Assessment Viewer Viewing the Assessment Template 1. Start Assessment Viewer using the AssessmentViewer.exe file (See Starting Assessment Viewer). 2. From the menu bar, select File>Open. The Open dialog opens. 3. From the Files of type drop‐down list, select AssessmentTemplates (*.ast). 4. From the Look in drop‐down list, browse for proper folder, select the assessment template, and then click the Open button. The Template Preview Params dialog opens. 5. In this dialog, make sure to select the appropriate RFA. If you want to view OASIS information, select the Include OASIS Info check box. 6. After you have entered all information, click OK. Clinical Documentation User’s Guide 525 Assessment Viewer The Allscripts Homecare Assessment Viewer window opens. This window consists of two panes: • Assessment Navigation Tree – The left pane with the assessment structure view displaying the hierarchy of the assessment items. • Items View – The right pane which displays the contents of the item selected in the left pane. 7. Select the assessment items in the Assessment Navigation Tree to view the items content in the Items View pane. 526 Clinical Documentation User’s Guide Assessment Viewer Changing the Template Colors 1. From the menu bar, select Options>Settings The Settings window opens. 2. From the corresponding drop‐down lists, select a color or define a custom color for the assessment items. 3. If the available colors are not suitable, click Custom in the corresponding drop‐down list, define the color you want, and add it to custom colors. 4. To set the default colors, click Default Value ( ). 5. Click OK. 6. Save your changes. Creating a Distribution Package 1. Start Assessment Viewer using the AssessmentViewer.exe file (See Starting Assessment Viewer). 2. Open the assessment template that will be in the distribution package (See Viewing the Assessment Template). 3. From the menu bar, select File>Create Distribution Package or click on the toolbar. 4. In the Save dialog, select the location to save the file. 5. Enter the file name in the File name field. 6. Select Executable Files (*.exe) in the Save as type field. 7. Click Save. You can now e‐mail the file to the clinicians to practice with the assessment template. Clinical Documentation User’s Guide 527 Chapter 10 ‐ Clinical Monitoring In This Chapter This chapter describes the Clinical Monitoring functionality. It can help you learn how to add, edit and view clinical data, and gather all the necessary information inside generated reports. The chapter consists of the following sections: • • • • • • 528 Clinical Monitoring Add/Edit Clinical Data View Clinical Data Revision History Scales Report Lab Results Report Clinical Documentation User’s Guide Clinical Monitoring Clinical Monitoring About Clinical Monitoring With the Clinical Monitoring functionality, you can perform entry, storage, and retrieval of vital signs, measurements, specific labs, spirometry readings, and define scales as distinct clinical measures in the Allscripts Homecare database to provide improved data reporting capabilities and support patient outcome studies. These clinical readings can be entered into Allscripts Homecare as part of a patient assessment, outside of a patient assessment, or as an incoming HL7 message. The clinical monitoring data are stored in the following windows: > Add/Edit Clinical Data > View Clinical Data > Revision History Setting Up Clinical Monitoring The Clinical Monitoring setup requires security privileges that should be assigned to all operators who will access the Add/Edit Clinical Data, View Clinical Data, and Revision History windows. Each window has a separate privilege. Clinical Monitoring also includes the HL7 Interface used to process data records provided by Telemedicine vendors. This interface is an add‐on product and requires an additional purchase to use in Allscripts Homecare. The configuration and use of this interface is described in the HL7 Interface Configuration User’s Guide and HL7 User’s Guide documents. Clinical Documentation User’s Guide 529 Add/Edit Clinical Data Add/Edit Clinical Data Add/Edit Clinical Data Window Patient>Clinical>Clinical Monitoring>Add/Edit Clinical Data The Add/Edit Clinical Data window allows you to collect readings and enter clinical monitoring data that include: • Vital Signs • Measurements • Labs • Spirometry • Scales For each tab, the data entry area is different depending on the specific clinical monitoring reading you need to capture. The right section of the window has an additional comment area for all values. For example, the Vital Signs tab contains the Environment Evaluated at Time of Vital Signs check box, and the Labs tab – the Anticoagulation Therapy and Future Labs schedule options. Based on entered values, a graph is built in the bottom of each tab. It reflects the trend of the particular clinical monitoring reading. All detailed data entered in the tabs appear in the corresponding grid when you double‐click the graph you need. 530 Clinical Documentation User’s Guide Add/Edit Clinical Data Add/Edit Clinical Data Window – Trend View Add/Edit Clinical Data Window – Grid View Clinical Documentation User’s Guide 531 Add/Edit Clinical Data Add/Edit Clinical Data Window Fields Collect Readings Click the Collect Readings button to collect clinical monitoring data. The Allscripts Homecare automatically completes the Date and Time fields. The current date and time are defaulted to these fields, but these values can be edited manually. In addition, when capturing clinical monitoring reading via a patient assessment, the date of assessment will be used as the default date for the clinical monitoring readings. Date Enter the date for the reading or select it from the drop‐down calendar. Time Enter the time when the reading was collected. Reading Level Note To assign a reading level note to the clinical monitoring record, click . The Reading Level Note dialog appears. The note will be displayed as an icon on the View Clinical Data window grids. Clear To remove a reading, click . If the reading was saved in Host Mode, it cannot be deleted. Clinical Note and Task A clinical note ( ) or task ( ) can be assigned to the clinical monitoring record using the corresponding buttons. However, these items cannot be assigned to a record not saved in the database. In addition, they cannot be assigned to the clinical readings collected through the assessment. For assessment capture readings, the clinical note or task must be directly assigned in the assessment. Edit To make changes to the reading, click the Edit button. You can only edit the data entered manually (Source equal M). For records entered via HL7 (I), Assessment (A), or Converted (C), the data cannot be edited using this button. Assessment data can be changed in the assessment assigned to the record and HL7 data can only be marked as erroneous. 532 Clinical Documentation User’s Guide Add/Edit Clinical Data Trend Click the Trend button to perform a trend analysis on data points for the selected patient. The Select Data to Trend dialog appears. Date Enter the date when the clinical monitoring data was collected for each reading. Time Enter the time when the clinical monitoring data was collected for each reading. Note This column provides a visual indication that a clinical note for the clinical monitoring record exists. Task This column provides a visual indication that a task for the clinical monitoring reading record is assigned. Vital Signs Tab – Temperature Subtab This tab displays the patient’s temperature and the method by which it was taken. Vital Signs Tab – Temperature Subtab Clinical Documentation User’s Guide 533 Add/Edit Clinical Data Temperature Subtab Fields Value Enter the patient’s temperature in the Value field. Measure The units of measure assigned to the temperature reading. Select one of the radio buttons to set the appropriate unit of measure. The available options include Fahrenheit and Celsius. Method The method used to capture the reading value. Select one of the radio buttons to define the needed measure option. The available options include Oral, Tympanic, Rectal, Cutaneous, and Axillary. Vital Signs Tab – Pulse Subtab This tab displays the patient’s pulse data for the reading. Vital Signs Tab – Pulse Subtab Pulse Subtab Fields Value Enter the patient’s pulse in the Value field. 534 Clinical Documentation User’s Guide Add/Edit Clinical Data Location The location on the patient’s body where the pulse reading was taken. Select one of the radio buttons to set the needed pulse location option. You can select from the Apical, Carotid, Peripheral, Radial, and Pedal options. Rhythm/Quality The patient’s pulse characteristics. Select the needed check boxes to define the rhythm and quality options. You can select from the Regular, Bounding, Faint, Irregular, and Impalpable options. Vital Signs Tab – Respiration Subtab This tab displays the patient’s breath data for the reading. Vital Signs Tab – Respiration Subtab Respiration Subtab Fields Value Enter the patient’s respiration information in the Value field. Rhythm/Quality This field displays the respiration characteristics. Select the check boxes to define the rhythm and quality of the respiratory sounds or enter the necessary information in the Other field if no option is suitable. You can select from the Regular, Cheyne‐Stokes, Shallow, and Dyspnea options. Clinical Documentation User’s Guide 535 Add/Edit Clinical Data Vital Signs Tab – Blood Pressure Subtab This tab displays the patient’s systolic and diastolic blood pressure. Vital Signs Tab – Blood Pressure Subtab Blood Pressure Subtab Fields Systolic Enter the systolic component of the patient’s blood pressure. Diastolic Enter the diastolic component of the patient’s blood pressure. Location The side of the patient’s body where the blood pressure was taken. Select one of the radio buttons to set the needed option. The available options include Left and Right. Extremity The extremity where the blood pressure was taken. Select one of the radio buttons to set the needed option. The available options include Arm and Thigh. 536 Clinical Documentation User’s Guide Add/Edit Clinical Data Position The patient’s body position when the blood pressure reading was taken. Select one of the radio buttons to set the needed option. The available options include Sitting, Standing, and Lying. Measurements Tab – Height Subtab This tab displays the patient’s height reading. Measurements Tab – Height Subtab Height Subtab Fields Value Enter the patient’s height in the Value field. Measure The units of measure assigned to the height reading. Select one of the radio buttons to set the needed option. The available options include Feet & Inches, Inches, and Centimeters. Clinical Documentation User’s Guide 537 Add/Edit Clinical Data Measurements Tab – Weight Subtab This tab displays the patient’s weight reading, method used to record reading, and general characteristic for the record. Measurements Tab – Weight Subtab Weight Subtab Fields Value Enter the patient’s weight in the Value field. Measure The units of measure assigned to the reading. Select one of the radio buttons to set the needed option. The available options include Pounds & Ounces, Pounds, Ounces, and Grams. Method The method used to capture the weight reading value. Select one of the radio buttons to set the needed option. The available methods include Agency Scale and Patient Scale. General Indicates how the patient’s weight reading was taken. Select one of the radio buttons to set the needed option. You can set the Measured or Verbally Reported option. 538 Clinical Documentation User’s Guide Add/Edit Clinical Data Last Visit The patient’s weight gain or loss since the last weight reading was captured. This value is calculated once the current reading is entered but can be edited manually if needed. Select this check box to make manual editing active. The following options become available: > > > > Date – Select the date of the last visit from the drop‐down calendar. Time – Enter the time of the visit. Weight Gain – Select this check box to indicate the patient’s weight gain. Enter the gain amount in the field next to the check box. Weight Loss – Select this check box to indicate the patient’s weight loss. Enter the loss amount in the field next to the check box. Last 3 Months The patient’s weight gain or loss based on the patient’s weight reading captured within three months or more previously to the current reading. The system goes three months back and use the closest to this point reading. If no record is available, this value is not calculated. This value will be calculated once the current reading is entered, but can be manually entered if needed. Select this check box to make manual editing active. The following options become available: > > > > Date – Select the date from the drop‐down calendar. Time – Enter the time of the visit. Weight Gain – Select this check box to indicate the patient’s weight gain. Enter the gain amount in the field next to the check box. Weight Loss – Select this check box to indicate the patient’s weight loss. Enter the loss amount in the field next to the check box. Clinical Documentation User’s Guide 539 Add/Edit Clinical Data Measurements Tab – Head Circumference Subtab This tab displays the patient’s head circumference reading for the record. Measurements Tab – Head Circumference Subtab Head Circumference Subtab Fields Value Enter the patient’s head circumference value. Measure The units of measure assigned to the reading. Select one of the radio buttons to set the needed option. The available options include Inches and Centimeters. 540 Clinical Documentation User’s Guide Add/Edit Clinical Data Measurements Tab – Extremity Subtab This tab displays the patient’s diameter measurements for a specific location on the body. Measurements Tab – Extremity Subtab Extremity Subtab Fields Value Enter the patient’s extremity value in the Value field. Measure The units of measure assigned to the extremity reading. Select one of the radio buttons to set the needed options. The available options include Inches and Centimeters. Location The side of the patient’s body where the extremity measurement reading was captured. Select one of the radio buttons to set the needed option. The available options include Left and Right. Extremity The extremity of the patient’s body where the measurement was captured. Select one of the radio buttons to set the needed option. The available options include Upper Arm, Thigh, Calf, Lower Arm, Knee, and Ankle. Clinical Documentation User’s Guide 541 Add/Edit Clinical Data Measurements Tab – Chest Circumference Subtab This tab displays the patient’s chest circumference value measured during reading collection. Measurements Tab – Chest Circumference Subtab Chest Circumference Subtab Fields Value Enter the patient’s chest circumference value. Measure The units of measure assigned to the chest circumference reading. Select one of the radio buttons to set the needed option. The available options include Inches and Centimeters. 542 Clinical Documentation User’s Guide Add/Edit Clinical Data Measurements Tab – Abdominal Girth Subtab This tab displays the measurement of the patient’s abdominal girth taken for the record. Measurements Tab – Abdominal Girth Subtab Abdominal Girth Subtab Fields Value Enter the patient’s abdominal girth value. Measure The units of measure assigned to the reading. Select one of the radio buttons to set the needed option. The available options include Inches and Centimeters. Clinical Documentation User’s Guide 543 Add/Edit Clinical Data Labs Tab – Pulse Oximetry Subtab This tab displays the patient’s oxygen saturation reading, the amount of oxygen, and patient activity level for the record. Labs Tab – Pulse Oximetry Subtab Pulse Oximetry Subtab Fields Value Enter the patient’s pulse oximetry value. Oxygen This field indicates whether the oxygen is present at the time of the reading capturing. The following options are available: • Yes – Select to indicate that the oxygen is present. Enter the notes in the field next to the radio button. • No – Select to indicate that the oxygen is not present. Activity Enter the patient’s level of activity by selecting one of the radio buttons. The available options include At rest and With Activity. 544 Clinical Documentation User’s Guide Add/Edit Clinical Data Labs Tab – Glucose Subtab This tab displays the patient’s recorded glucose reading, patient condition, and device type used for the record. Labs Tab – Glucose Subtab Glucose Subtab Fields Value Enter the patient’s glucose reading value. Condition The patient’s condition at the time of the reading capturing. Select one of the radio buttons to set the needed option. The available options include Fasting, Random, and Post Prandial. Then, enter the number of hours in the Specify field or select the needed number of hours from the drop‐ down list. Device The type of device used to capture the patient’s reading. Select one of the radio buttons to select the needed option. The available options include Unknown, Not Applicable, and Specify Type. If you select the Specify Type radio button, enter the type of the device in the field below the radio button. Clinical Documentation User’s Guide 545 Add/Edit Clinical Data Last Visit The patient’s glucose reading data for the last time when it was captured. This value is calculated once the current reading is entered but can be entered manually as well. The following fields are available in this section: > > > > Date – Select the date of the last visit from the drop‐down calendar. Time – Enter the time of the last visit. Value – Enter the glucose reading value in this field. Condition – Select one of the radio buttons to define the condition of the patient at the time of the last reading. The available options include Fasting, Random, and Post Prandial. Then enter the number of hours in the Specify field or select the needed number of hours from the drop‐down list. Labs Tab – PT/INR Subtab This tab displays the patient’s ProTime reading and international normalized ratio reading for the record. Labs Tab – PT/INR Subtab PT/INR Subtab Fields Value – PT The patient’s ProTime reading value. Enter the needed option in the Value – PT field. 546 Clinical Documentation User’s Guide Add/Edit Clinical Data Value – INR The patient’s international normalized radio reading value. Enter the needed option in the Value – INR field. Spirometry Tab – Peak Flow Subtab This tab displays the patient’s maximum ability to expel air from the lungs for the record. Three values can be recorded in one peak flow measurement. Spirometry Tab – Peak Flow Subtab Peak Flow Subtab Fields Value The patient’s spirometry reading value. Enter the needed options in the Value – Peak Flow 1, Value – Peak Flow 2, and Value – Peak Flow 3 fields. Clinical Documentation User’s Guide 547 Add/Edit Clinical Data Scales Tab With this tab, you can capture responses to actual and desired levels for any or all indicators defined for an individual patient at a specific date and time. The indicators for which you can document a response are: Pain, Nausea, Anxiety, and Shortness of Breath (SoB). Each indicator consists of two slide bars which enable you to describe both the current actual level as well as the desired level of a specific indicator. A zero response assumes that the indicator was assessed and was not present at the time of assessment. Additional response selections are captured on the 1 ‐ 10 rating scale with 1 being the best state and 10 – the worst. As the slide bar is raised to some level, the part of the pointer from 0 to the documented level is filled with color. The actual level is colored in green and is represented with a solid line. The desired level is pastel violet and is displayed as a broken line. Below each indicator, you can view the sparkline buttons with actual and desired levels of that indicator in the small graph view. Click the needed sparkline button to display the actual data of the selected indicator on the graph in the lower section of the window. Scales Tab 548 Clinical Documentation User’s Guide Add/Edit Clinical Data Scales Tab Fields Pain Set the actual and desired level of pain for the selected patient. Nausea Set the actual and desired level of nausea for the selected patient. Anxiety Set the actual and desired level of anxiety for the selected patient. Shortness of Breath Set the actual and desired level of breath shortness for the selected patient. Scales Graph The Scales graph displays the detailed information on the changes of patient’s actual indicators of the clinical monitoring data measured during the defined period. The graph lines are colored according to the clinical monitoring data values. Pain is colored green, nausea – blue, anxiety – red, and shortness of breath – yellow. When you put the mouse pointer to the point indicating clinical monitoring data collection date on the graph, the pop‐up appears with the accurate information about the reading value, date and time of the value recording, and the name of the selected clinical monitoring value. Clinical Documentation User’s Guide 549 Add/Edit Clinical Data Reading Level Note Window The dialog opens when you click the Reading Level Note button ( ) in the Add/Edit Clinical Data window. After entering the information and clicking OK, a note is added to the reading and is marked as completed (the check mark appears on the Reading Level Note button ). Reading Level Note Window Date The date when the reading was taken. Time The time when the reading was taken. Resource Name The name of the resource that captured the reading. Value The value of the selected reading. Additional Comments Enter the additional information on the reading in this field. 550 Clinical Documentation User’s Guide Add/Edit Clinical Data Enter Clinical Monitoring Data 1. Open the Patient component. 2. Select a patient whose data you want to retrieve. 3. Go to Clinical>Clinical Monitoring>Add/Edit Clinical Data. The Add/Edit Clinical Data window opens with the Vital Signs tab active. 4. Click the tab you need and then click the Collect Readings button. 5. Enter the date and time in the Date and Time fields if you need to change current time set by default. 6. Enter the corresponding data in the appropriate tabs. 7. Save your settings. Link Clinical Monitoring Record to Clinical Notes 1. Open the Patient component. 2. Select the patient whose data you want to retrieve. 3. Select Clinical>Clinical Monitoring>Add/Edit Clinical Data from the menu bar. The Add/Edit Clinical Data window appears with the Vital Signs tab active. 4. Click the tab you need and then click . The Clinical Notes window appears where you can enter discipline summary of clinical notes for the selected patient. Note This button is available only if the clinical monitoring record is saved. Once you start to enter a new record, the button becomes unavailable and is enabled again after the record is saved. 5. Enter the needed information in the Clinical Notes window and then click OK. A note is added to the reading and is marked as completed (the check mark appears on the Associate Clinical Note button Clinical Documentation User’s Guide ). 551 Add/Edit Clinical Data Link Clinical Monitoring Record to Patient Tasks 1. Open the Patient component. 2. Select the patient whose data you want to retrieve. 3. Select Clinical>Clinical Monitoring>Add/Edit Clinical Data from the menu bar. The Add/Edit Clinical Data window appears with the Vital Signs tab active. 4. Click the tab you need and then click . The Patient Tasks dialog opens. Note This button is available only if the clinical monitoring record is saved. Once you start entering a new record, the button becomes unavailable and is enabled again after the record is saved. 5. Enter the needed information in the Patient Tasks window and click OK. A task is added to the reading and is marked as completed (the check mark appears on the Associate Task button 552 ). Clinical Documentation User’s Guide Add/Edit Clinical Data Create Trend from the Add/Edit Clinical Data Window 1. Open the Patient component. 2. Select the patient whose data you want to retrieve. 3. From the menu bar, select Clinical>Clinical Monitoring>Add/Edit Clinical Data. The Add/Edit Clinical Data window appears with the Vital Signs tab active. 4. Go to the tab you need, and then double‐click the graph you want to view as a trend. The clinical monitoring data appear in the grid view. 5. Click the Trend button. Note To view clinical monitoring data for the Scales tab, select the reading for which you want to create trend. 6. Select the reading you need. Clinical Documentation User’s Guide 553 Add/Edit Clinical Data The trend for the selected patient’s clinical data appears. 7. Click the Preview button to print the trend graph. 554 Clinical Documentation User’s Guide Add/Edit Clinical Data The Patient’s Clinical Data Trend report appears with the detailed parameters for the selected clinical data. 8. Click Trend to return to the trend view or Close to exit. Clinical Documentation User’s Guide 555 View Clinical Data View Clinical Data View Clinical Data Window Patient>Clinical>Clinical Monitoring>View Clinical Data Note Note To access the View Clinical Data window, you must have the appropriate operator privileges assigned in Administration>Configuration>Operators. Consult your system administration if you need assistance in accessing this window. In this window, you can view readings data either graphically in the form of trends or in grids. You can also control the level of specificity of data displayed on the window using the control options in the Display section of the window. The data are shown graphically by default. To view the grid display, double‐click the individual graph. The View Clinical Data window contains five tabs: > Vital Signs > Measurements > Labs > Spirometry > Scales Note Note All fields and columns of these tabs absolutely correspond to the ones in the Add/Edit Clinical Data window and you can find their description in the Add/Edit Clinical Data Window section. 556 Clinical Documentation User’s Guide View Clinical Data View Clinical Data Window – Graph View View Clinical Data Window – Grid View Clinical Documentation User’s Guide 557 View Clinical Data View Clinical Data Window – Fields Admission Select one of the radio buttons to choose the appropriate admission type. You can select from the following options: • Current – Select this radio button to view clinical monitoring data only for current admission of the patient. • Current & Previous – Select this radio button to view clinical monitoring data for current and all previous admissions of the patient. Date Range Select the time for which you want the clinical monitoring data to be displayed. You can select from the following options: > > > Last Two Weeks – Select this radio button to generate the data for the last two weeks. Last Four Weeks – Select this radio button to generate the data for the last month. Custom Date Range – Select this radio button to define time manually in the From and To fields. Enter the needed dates in the corresponding fields or select the begin and end date from the drop‐down calendars. Number of Readings To generate clinical monitoring data for the recent readings, select the Last radio button and enter the number of readings you need to view in the Last field. Refresh Click the Refresh button generate the data for the selected patient or to refresh it after making changes in the Display section. 558 Clinical Documentation User’s Guide View Clinical Data Units of Measure Click the button to define units of measure for the reading in the Units of Measure dialog. For the reading options you need, select the units of measure from the corresponding drop‐down list. Click OK to save your changes or Cancel to discard saving. Preview Click the Preview button to view the Patient Data Report onscreen. This button is available in graph view of the View Clinical Data window. Show erroneous data Select this check box to display the data that was marked as erroneous. Suppress empty rows Select this check box to exclude empty rows from the readings displayed onscreen. Trend Click to view clinical data as a trend and to perform the trend analysis for the patient. Edit Click the button to make changes to the onscreen options. You are directed to the section where the selected clinical data were entered in the Add/Edit Clinical Data window. Close Click the Close button to exit the tab. Clinical Documentation User’s Guide 559 View Clinical Data Access and View Clinical Data 1. Open the Patient component. 2. Click and select a patient whose data you want to retrieve. 3. Select Clinical>Clinical Monitoring>View Clinical Data from the menu bar. The View Clinical Data window opens with the Vital Signs tab active. 4. Click the tab you need and then select the appropriate options in the Display section. 5. To include erroneous data from the readings in the window, select the Show Erroneous Data check box. 6. Click Refresh. The patient’s clinical data for the selected number of readings appear on the active tab in the window. Create Trend from the View Clinical Data Window 1. Open the Patient component. 2. Click and select a patient whose data you want to retrieve. 3. Select Clinical>Clinical Monitoring>View Clinical Data from the menu bar. The View Clinical Data window opens with the Vital Signs tab active. 4. Go to the tab you need and then double‐click the graph that you want to view as a trend. 5. The clinical monitoring data appear on a separate tab. 6. Click Trend. The trend for the selected patient’s clinical data appears. 560 Clinical Documentation User’s Guide View Clinical Data 7. Click Preview to view the trend in report mode. The Patient’s Clinical Data Trend report appears with the detailed parameters for the selected clinical data. You can print or save this trend as a separate file using the buttons on the report toolbar. Clinical Documentation User’s Guide 561 View Clinical Data 8. Click Trend to return to the trend view or Close to exit the tab. 562 Clinical Documentation User’s Guide View Clinical Data Create a Patient Data Report 1. Open the Patient component. 2. Click and select a patient whose data you want to retrieve. 3. Select Clinical>Clinical Monitoring>View Clinical Data from the menu bar. The View Clinical Data window opens with the Vital Signs tab active. 4. Go to the tab you need and then click the Preview button. The Clinical Monitoring – Patient Data Report window appears for the active tab. 5. To view detailed information, go to the next page of the report. The Clinical Monitoring – Patient Data Report window appears with the detailed information. You can print or save this report as a separate file using the buttons corresponding on the toolbar. Clinical Documentation User’s Guide 563 View Clinical Data 6. Click the Close button to return to the active tab. 564 Clinical Documentation User’s Guide Revision History Revision History Revision History Window Patient>Clinical>Clinical Monitoring>Revision History You can review and audit all changes made to the Clinical Monitoring records in the Revision History window. You can select level of specificity of the revision history records in the Display section (right pane) of this window. Clinical monitoring record changes include adding, editing, and deleting of the records. Note Note To access this window, you must have the appropriate operator privileges assigned in Administration>Configuration>Operators. Revision History Window Clinical Documentation User’s Guide 565 Revision History Revision History Window Fields Admission Select one of the radio buttons to select the appropriate admission type. You can select from the following options: • Current – Select this radio button to include clinical monitoring record changes only for current admission of the patient. • Current & Previous – Select this radio button to include clinical monitoring record changes for current and all previous admissions of the patient. Date Range Select the time for which you want the clinical monitoring history to be displayed. You can select from the following options: > > > Last Two Weeks – Select this radio button to generate history for the last two weeks. Last Four Weeks – Select this radio button to generate history for the last month. Custom Date Range – Select this radio button to define time manually in the From and To fields. Enter the needed dates in the corresponding fields or select the begin and end date from the drop‐down calendars. Number of Readings To generate clinical monitoring history for the recent readings, select the Last radio button and enter the number of readings you want to view in the Last field. Refresh Click the Refresh button to generate the history for the selected patient or to refresh the data after making changes in the Display section. 566 Clinical Documentation User’s Guide Scales Report Scales Report Scales Report – Generated Reports>Clinical>Clinical Monitoring The Scales report provides information on the patients’ actual and desired indicators which include anxiety, pain, nausea, and shortness of breath. The ability to report on tracked indicators will assist agencies in identifying areas for improvement. Indicators can be documented for an individual patient, but may also be reported in a summary manner. Information on the Scales Report Field Name Description Patient Code Code of the patient defined in Patient>General>Basic. Patient Name The first and last names of the patient whose clinical monitoring data were collected. Primary Physician The first and last names of the primary physician assigned to the patient. Team The team to which the patient belongs. Admission (SOC) The patient's admission date. This date is obtained from the current admission date in Patient>General>Admissions & Status. Discharge Date The patient's discharge date. This date is obtained from the current discharge date in Patient>General>Admissions & Status. Primary Diagnosis The patient's primary diagnosis. This value is entered in Patient>General>Admissions & Status. Rating Date The date when the clinical monitoring value was rated. Time The time when the clinical monitoring value was rated. Actual Rating The actual value (0‐10 scale) captured for corresponding clinical monitoring indicator. This value is set in Patient>Clinical>Clinical Monitoring>Add/Edit Clinical Data. Desired Rating The desired value (0‐10 scale) captured for corresponding clinical monitoring indicator. This value is set in Patient>Clinical>Clinical Monitoring>Add/Edit Clinical Data. # of Days from SOC Number of days from the patient’s start of care. Summary/Aggregate Section Clinician Clinical Documentation User’s Guide The first and last name of the resource who collected clinical monitoring value for the patient. 567 Scales Report Field Name Description Number of Patients Admitted During Report Period Number of patients admitted during the period specified on the Define tab. Number of Patients Reassessed During Report Period Number of patients reassessed during the date range specified on the Define tab. Improvement Rating at 2 Days After SOC, % Percentage ratio of the patient’s clinical monitoring value improvement in two‐days‐period after the start of care. Example of the Scales Report 568 Clinical Documentation User’s Guide Scales Report Clinical Monitoring Window Reports>Clinical>Clinical Monitoring The Clinical Monitoring window consists of two tabs: > Clinical Monitoring Window – Define Tab – Use this tab to define date range, patients mode, type of clinical monitoring values, branches, teams, and summary options for the report. The more details you provide, the more accurate report results will be. > Preview tab – Use this tab to view the report results onscreen. To learn more about the data displayed on the generated Scales report, see the Scales Report – Generated section. With the help of this window you can generate the report. Clinical Monitoring Window – Define Tab Use this tab to specify the information you want to include in the report. You can also use Preview tab to preview the report onscreen. Clinical Monitoring Report – Define Tab Clinical Documentation User’s Guide 569 Scales Report Clinical Monitoring Window – Define Tab Fields Date Range Define the date range to include in the report clinical monitoring data indicated within the specific period. > > Begin Date – Enter the start date for this date range. End Date – Enter the end date for this date range. Mode Select the mode for generating the report. You can choose one of the following options: > > All Patients – Select this radio button to run the report for all patients in the Business Unit. Individual Patient – Select this radio button to define the patients for the report manually in the Select Patient dialog. Type Select the type of clinical monitoring data you want to view in the report. You can select the following options: > > > > Pain – Select this check box to include the information on patient’s pain level in the generated report. Nausea – Select this check box to include the information on patient’s nausea level in the generated report. Anxiety – Select this check box to include the information on patient’s anxiety level in the generated report. Shortness of Breath – Select this check box to include the information on patient’s shortness of breath level in the generated report. Optional Selection Criteria Use this section to define patient’s branch and team that will be included in the report. You can make selections directly by patients, assigned resources, branches, and teams. • Branch – From this drop‐down list, select the branch you want to include in the generated report. If you want to generate report for all branches, leave this field blank. • Team – From this drop‐down list, select the team you want to include in the generated report. If you want to generate report for all teams, leave this field blank. Summary Options Enter the number of days when the patient was reassessed after the start of care to include those patients into the generated report. 570 Clinical Documentation User’s Guide Scales Report Generating Scales Report 1. Open the Reports component. 2. From the menu bar, select Clinical>Clinical Monitoring. 3. The Clinical Monitoring window appears with the Define tab active. Enter the values in the Define tab fields as appropriate. 4. Select the Preview tab to view the report onscreen. 5. Click Print to print the report. If you change the criteria on the Define tab after preview, those changes do not take effect until the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. Clinical Documentation User’s Guide 571 Lab Results Report Lab Results Report Lab Results Report Generated The Lab Results report provides information on Lab Results received from ACL (Advocate Commercial Lab). You can define parameters to select the lab results you are interested in. These parameters include date range, lab test name, priority status, result status, specific patients, resources, branches, and teams. Also there is a free text box where you can enter any text to search for in the existing lab results. The generated report consists of two sections: > > 572 Lab Results List – Located on the right side of the window. It displays the list of Lab Results which meet the criteria entered on the Define tab. Main Report – Located on the right side of the window. It displays the actual Lab Results information. Clinical Documentation User’s Guide Lab Results Report Example of the Lab Interface Report Lab Results Report Window Reports>Clinical>Lab Results Report Lab Results window consists of two tabs: > Lab Results Report Window – Define Tab – Use this tab to define date range, lab test name, priority status, result status, patients, resources, branches, and teams to run the report for. The more details you provide, the more accurate the report results will be. > Preview Tab – Use to view the report results. Clinical Documentation User’s Guide 573 Lab Results Report Lab Results Report Window – Define Tab Use this tab to specify what information to include in the report. You can also use Preview Tab to preview the report on the screen. Lab Results Report – Define Tab Lab Results Report Window – Define Tab Fields Date Range Sent to Lab Define the date range to include in the report lab results which were requested within the specific time period. The date of lab result request is stored in the Date Requested field in the Imported Lab Results window; this is the date when the request record was entered in the system (based on the received requisition number). > 574 Begin Date – Enter the begin date for this date range. Clinical Documentation User’s Guide Lab Results Report > End Date – Enter the end date for this date range. Date Range Received from Lab Define the date range to include in the report lab results which were received within the specific time period. The date when lab result is received is stored in the Date Received field in the Imported Lab Results window; this is the date when the corresponding ORU R01 message was sent by the ACL. > > Begin Date – Enter the begin date for this date range. End Date – Enter the end date for this date range. Optional Selection Criteria Use this section to set Lab Results Report selection criteria. • Lab Test Name – Click down arrow and select the appropriate lab test name from the drop‐ down list. The lab test name is entered when creating a lab result request. Only lab results with the selected lab test name will be included in the generated report. • Priority Status – Click down arrow and select the lab result priority status. Only lab results with the selected priority status will be included in the generated report. The Priority Status is received together with the Lab result in the ORU R01 message. The following priority statuses are possible: • • • R – Routine S – STAT Result Status – Click down arrow and select the lab result status. Only lab results with the selected status will be included in the generated report. The Priority Status is received together with the Lab result in the ORU R01 message. The following priority statuses are possible: • F – Final • P – Preliminary • C – Corrected • Enter text for data to search within Lab report – Enter a free text in this text box to search for it within the received lab results. Only lab results with found occurrences will be included in the generated report. • Display Historical Lab Results – Select this check box to include historical lab results in the generated report. The lab result becomes historical after a certain period of time that is set in Administration>Configuration>Business Units>Settings>Lab Interfaces. Clinical Documentation User’s Guide 575 Lab Results Report Select By Use this section to define patients whose lab results will be included in the report. You can make selections directly by patients, assigned resources, branches, and teams. • All Patients – Select this radio button to include lab results for all patients in this report. • Specific Patients – Select this radio button to include lab results only for selected patients in the report. The Select button to the right of the Specific Patients option becomes active. Click this button to select which of the patients will be included in the report. The Select Patient dialog appears. • All Resources – Select this radio button to include lab results for all resources (Ordering Physician, Primary Physician or any forwarding resource) in the report. • Specific Resources – Select this radio button to include lab results only for selected resources in the report. The Select button to the right of the Specific Resources option becomes active. Click this button to select which of the resources will be included to the report. The Select Resource dialog appears. • Branch – Select this radio button to filter lab results on the branch level. The list of available branches appears in the grid below the Branch option. Select the corresponding check boxes in the Include column to run the report only for selected branches. You can use the Select All or Clear All buttons to correspondingly select or clear all the check boxes in the grid at once. You can also select whether to filter lab results by patients’ or by resources’ branches. • • • By Patients – Click this tab to include in the report only lab results that belong to patients within to the selected branches. By Resources – Click this tab to include in the report only those lab results that were requested by or forwarded to resources within the selected branches. Team – Select this radio button to filter lab results in the team level. The list of available teams appears in the grid below the Team option. Select the corresponding check boxes in the Include column to run the report only for selected teams. You can use the Select All or Clear All buttons to correspondingly select or clear all the check boxes in the grid at once. You can also select whether to filter lab results by patients’ or by resources’ teams. • • 576 By Patients – Click this tab to include in the report only lab results that belong to patients within to the selected teams. By Resources – Click this tab to include in the report only those lab results that were requested by or forwarded to resources within the selected teams. Clinical Documentation User’s Guide Chapter 11 ‐ Adverse Events In This Chapter This chapter provides information on the features of Adverse Events functionality. It can help you study, document and view any adverse events regarding patients that undergo treatment in health care provider’s agency. The chapter consists of the following sections: • • • • Adverse Events Adverse Event Report Falls Report Infections Report Clinical Documentation User’s Guide 577 Adverse Events Adverse Events What Is Adverse Event? An adverse event is any worsening in health, side‐effect, or unintended or unintentional harm or suffering that occurs with a patient who is receiving the treatment. The Adverse Events functionality added to Allscripts Homecare affects the areas of the application including setup of adverse events and precaution protocols (Allscripts Homecare Administration Staff), documentation of adverse events, and preview of the corresponding data on related reports (Clinical Staff). Following is the list of application areas related to adverse events functionality: > Administration Setup: • Fall Injuries (Administration>Clinical>Fall Injuries) • Infection Systems (Administration>Clinical>Infection Systems) • Infectious Diseases (Administration>Clinical>Infectious Diseases) • Precaution Protocols (Administration>Clinical>Precaution Protocols) > Falls (Patient>Clinical>Adverse Events>Falls) > Infections (Patient>Clinical>Adverse Events>Infections) > Changes to Adverse Events Assessments (Patient>Clinical>Assessments) > Precaution Protocols (Patient>Clinical>General Clinical) > Reports: • Adverse Event Report (Reports>Clinical>Adverse Event) • Falls Report (Patient>Documents>Falls) • Medication Evaluation Report (Patient>Documents>Medication Evaluation) • Infections Report (Patient>Documents>Infections) • Care Plan Report (Reports>Clinical>Care Plan, Patient>Documents>Care Plan, Orders>Demand Documents>Care Plan) About Falls Prior to version 5.1, patient falls were documented within the assessments only (Patient>Clinical>Assessments>Environment>Safety). Beginning with version 5.1, you can only observe historical data in the Safety assessment section. To document a new fall, you should use the Falls Window in Patient>Clinical>Adverse Events. 578 Clinical Documentation User’s Guide Adverse Events Falls Window Patient>Clinical>Adverse Events>Falls With the Falls window, you can view, enter, and modify information on the falls adverse events (see Documenting Patient’s Falls) that occurred with an individual patient, identify whether the fall caused injuries or not, the person who observed or notified the physician of the patient’s fall, and additional comments on the fall adverse event. The Falls window consists of two columns in the left section, which displays the date of the fall and indicates whether the patient experienced injuries during the fall. There are two tabs in the right section of this window: > Injuries Tab – Includes information about injuries types the patient had as a result of the fall. > Observed/Reported/Notified Tab – Includes information about whether a clinician observed patient after the fall, the person who reported the fall, and notification of the physician. Note Note If the fall date in the left section of the window is followed by an asterisk (*), it represents the fall entry date as the exact date of a fall is unknown. The Falls window contains the following fields: Date of Fall Enter the date when the fall occurred. This date will be displayed in the left section of the window. If you do not know the exact date of fall, select the Unknown check box next to the Date of Fall field. Unknown Select this check box if you do not know the exact date of the fall. The system will use the documentation date in the left section of the window. This date is followed by an asterisk which indicates the fall entry date, not the exact date of the fall. Comments Enter additional comments about a fall related to injuries or observation/reporting/notifications, up to 1000 alphanumeric symbols. Clinical Documentation User’s Guide 579 Adverse Events Injuries Tab Use the Injuries tab to record any injuries resulting from the fall. In the Injury section, select the check box opposite the needed injury type caused by a fall. If you select the None apparent check box, all other injury types will be disabled. If no injuries are selected from the list, the None apparent check box will be automatically selected. Note Note The fall injury types displayed in this window are set up in Administration>Clinical>Fall Injuries. Falls – Injuries Tab 580 Clinical Documentation User’s Guide Adverse Events Observed/Reported/Notified Tab Use the Observed/Reported/Notified tab to document additional information about the fall. This tab contains the following controls: > Observed by Clinician – Indicates whether the fall was observed by a clinician. > Reported By – In this section, you can document who reported the patient’s fall: • Patient – Select this check box if the patient personally reported the fall. • Primary Caregiver – Select this check box if the patient’s primary caregiver reported the fall. • Other – Enter the name of the person who reported the patient’s fall. Also, you can click and select a person from the Select Resource dialog. • Notified – In this section, record the physician that was notified of the fall and the person that performed the notification: • Physician – Select the notified physician by clicking Physician dialog. Click • and selecting a person from the to clear the selected physician name in this field. By – Enter the name of the person who notified the physician. Also, you can select the person who performed the notification by clicking Resource dialog. and selecting this person from the Select • Date – Enter the fall notification date in this field. This field is optional and is empty by default. • Time – Enter the fall notification time in this field. This field is optional and is empty by default. Note You can complete By, Date, and Time fields only if the Physician field is completed. Otherwise, they will be disabled. Clinical Documentation User’s Guide 581 Adverse Events Falls – Observed/Reported/Notified Tab Documenting Patient’s Falls 1. Go to Patient>Clinical>Adverse Events>Falls. The Falls window appears with the Injuries tab open. 2. Click to create a new fall entry. 3. In the top section of this window, enter the fall date in the Date of Fall field if it is known, otherwise select the Unknown check box. Note If the exact date of the fall is unknown, the Fall Date field value will automatically display the fall entry date which will be followed by the asterisk sign (*). 4. In the Injury section, select the type of the injury caused by the fall. 5. Go to the Observed/Reported/Notified tab. 6. Select the Observed by Clinician check box to indicate that clinician observed the fall. 7. In the Reported By section, select a person who reported the fall to the physician. You can select patient, patient’s primary caregiver, or other person. 582 Clinical Documentation User’s Guide Adverse Events 8. In the Notified section, select the name of the physician who was notified of the fall in the Physician field. Record the name of the person who performed the notification in the By field. 9. If needed, enter additional comments to the patient fall in the Comments section. 10. Save your changes. About Infections In version 5.0, patient infections were documented within the assessments only (Patient>Clinical>Assessments>General>Infections). Beginning with version 5.1, you can only observe historical data in the General assessment section. To enter new infection information, you should use the Infections Window in Patient>Clinical>Adverse Events. Infections Window Patient>Clinical>Adverse Events>Infections With the Infections window, you can view, enter, and modify information on the infections for an individual patient. The window consists of two tabs that enable you to document system infections, infectious diseases, and additional comments if necessary. Both current and historical data can be recorded for infection systems and infectious diseases. This feature provides agencies with the ability to easily distinguish whether an infection was present at start of care or whether a patient subsequently developed an infection while being treated by an agency. The Infections window consists of two sections: the bottom section displays the type of an infection, its start and end dates, and additional comments. The top section contains two tabs: > Infections Tab > Infectious Diseases Tab To document patient’s infections, complete the following fields in the properties section at the bottom of the Infections window: System/Disease Type Select the type of system infection or infectious disease from this drop‐down list. The list contains all infection systems or infectious diseases that are currently active in the system. Note Infection systems and their statuses are defined by the Allscripts Homecare administrator in Administration>Clinical>Infection Systems, and infectious diseases in Administration>Clinical>Infectious Diseases. Clinical Documentation User’s Guide 583 Adverse Events Start Date Enter the start date for the selected infection or select the date from the drop‐down calendar. This date cannot be in the future and cannot be earlier than the patient’s admission date. If the infection start date is earlier than the admission date, the following error message will be displayed on save “Patient Infections data can be entered for Active patients only.” Note To view the admission date of a patient, go to the Admissions & Status window in Patient>General. End Date If an infection is no longer active, enter the end date in this field or select the date from the drop‐ down calendar. This date cannot be in the future but can be defined later than the patient’s discharge date. Note To view the admission and discharge dates for a patient, go to the Admissions & Status window in Patient>General. Comment Enter additional comments about the selected infection, up to 1000 alphanumeric symbols. Note To save changes, be sure to click the OK button in the Comments drop‐down box. Otherwise, all entered information will be lost. Show Options Select the filtering options for displaying infection systems or infectious diseases in this window: • • 584 Show Detail – Select this check box to view infection comments, if any. Show History – Select this check box to see infection systems or infectious diseases that a patient had historically. Historical infections are those which have end date entered. Clinical Documentation User’s Guide Adverse Events Infections Tab Use the Infections tab to enter or modify information on system infections (infections that occur within a particular body system, for example, respiratory infection, gastrointestinal infection, reproductive infection, skin infection, etc) a patient has currently or had before and enter additional comments regarding these infections. This tab opens with the Show History check box selected by default which allows viewing all system infections for the selected patient. Even if an infection system is currently inactive in the system but was previously documented for the patient, it is displayed for that patient regardless of its current state: active or inactive. But if you want to add a new infection, you can select only currently active infection systems. The Infections grid contains the following columns: Type, Start Date, End Date, and Comments that reflect information entered in the properties section of the window (lower section). You can sort, group, or filter information in this grid to easily find the needed infection. To group data by any column, drag the needed column header to the free space above the grid and the data will be grouped in the hierarchical order. Click the needed column header to sort by that column data. To filter by specific data, click next to the needed column name and select the criteria you want to filter by. You may filter patient’s infections by multiple columns at once using the Custom Filter dialog where you can choose how to display data and setting needed logical parameters. When data are filtered by any ofthe parameters, the down arrow becomes highlighted in blue ( filters, click down arrow and select (All) from the drop‐down list. ). To clear all Infections – Infections Tab Clinical Documentation User’s Guide 585 Adverse Events Documenting Patient’s System Infections 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Clinical>Adverse Events>Infections. The Infections window appears with the Infections tab active. 4. Click to add a new infection system and enter appropriate information in the System properties section. 5. From the Type drop‐down list, select body system where the infection you want to record is located. 6. Enter the start date and comments for the selected system infection in the corresponding fields. If the infection has ended, enter the end date for the selected infection in the End Date field. 7. Save your changes. Infectious Diseases Tab Use the Infectious Diseases tab to enter or modify information on infectious diseases a patient has currently or had historically and enter additional comments regarding the disease. This tab opens with the Show History check box selected by default which allows viewing all infectious diseases of the selected patient. Even if an infectious disease is currently inactive in the system but was previously documented for the patient, it is displayed for that patient regardless of its current state: active or inactive. But if you want to add a new disease, you can select only currently active infectious diseases. The Infections grid contains the following columns: Type, Start Date, End Date, and Comments that reflect information entered in the properties section of the window (lower section). You can sort, group, or filter information in this grid to easily find the needed infection. To group data by any column, drag the needed column header to the free space above the grid and the data will be grouped in the hierarchical order. Click the needed column header to sort by that column data. To filter by specific data, click next to the needed column name and select the criteria you want to filter by. You may filter patient’s infections by multiple columns at once using the Custom Filter dialog where you can choose how to display data and setting needed logical parameters. When data are filtered by any of the parameters, the down arrow becomes highlighted in blue ( filters, click down arrow and select (All) from the drop‐down list. 586 ). To clear all Clinical Documentation User’s Guide Adverse Events Infections – Infectious Diseases Tab Documenting Patient’s Infectious Diseases 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Clinical>Adverse Events>Infections. The Infections window appears with the Infections tab active. 4. Go to the Infectious Diseases tab and then click to add a new infectious disease. 5. From the Type drop‐down list in the Disease properties section, select infectious disease you want to record. 6. Enter the start date and comments for the selected infectious disease in the corresponding fields. If the infectious disease has ended, enter the end date for the disease in the End Date field. 7. Save your changes. Clinical Documentation User’s Guide 587 Adverse Events Electronic Signature and Conflicts for Adverse Events Adverse Events Electronic Signature If a fall or infection created in Field Mode is uploaded to Host Mode, it becomes electronically signed. Clinicians using field devices can edit details of these adverse events before synchronization. When the signed fall or infection is in Host Mode, only a user with appropriate security privilege can edit it. This restriction ensures the integrity of the documentation after a clinician has electronically signed it. To modify signed details, you should have the Can alter locked clinical entries (other than assessments) security privilege assigned in Administration>Configuration>Operators>Privileges. Then, you will get the following warning message when trying to modify adverse event signed details: “This item was originally entered in Field Mode. It has been electronically signed by the author. Your security privilege allows you to override this restriction. If this is anything more than a simple error correction, you must document this change in a Clinical Note.” and you will be able to change the information entered in Field Mode. Viewing Electronic Signature for Adverse Events To view information about electronic signature, you should put the cursor over the documented item, and on the toolbar click the Show Audit Trail ( Information window. ) button to view the Audit Trail The following is the example of audit trail information showing when and by whom the selected item was created, last modified, and electronically signed. > Falls Electronic signature for falls applies on the fall level (not for each injury type) and on each field in the Observed/Reported/Notified tab. To view audit trail information, you should select the documented fall date in the left section of the Falls window, and then click Show Audit Trail or select a field in the Observed/Reported/Notified tab to view audit trail information. 588 Clinical Documentation User’s Guide Adverse Events > Infections Electronic signature applies for each infection system and infectious disease (the audit trail information can be viewed by selecting infection type and clicking ). Adverse Events Conflict Management During synchronization, the conflicts can occur which should be resolved for correct data upload. The conflict resolution process is called Conflict Management. The results of conflict resolution appear on the Conflict History report (Reports>Field Use>Conflict History). There are two types of data conflicts that can occur: > Physical Conflict – This type of conflict occurs when a Field Mode user changes information that already exists on the server. In case of falls and infections physical conflict, the last synchronized data from Field Mode always win the conflict and no manual data resolution is necessary. > Logical Conflict – When information on the server was added or changed by two users, the synchronization process detects a logical conflict. This type of conflict involves changes to multiple fields or records and is resolved automatically by the application. Note To learn more about conflicts and their resolution, refer to the Conflict History Report. The following additional messages are displayed on the Conflict History report for adverse events conflicts: > Falls If a user changes any fall data in Field Mode and Host Mode, then the following message will appear: “Fall of [Fall date] has been changed for this patient. Please review the entry and update if needed.” If a user changes the following fields in Field Mode and Host Mode: • Date of Fall • Comments • Observed by Clinician • Reported by Patient • Reported by Primary Caregiver • Reported by Other (check box and text field) • Physician Notified • Notified By Clinical Documentation User’s Guide 589 Adverse Events • Notified Date and Time Then additional messages will be displayed for each field: “Fall: field [field name] Previous value [value] entered by [Operator Name] Current value [value] entered by [Operator Name]” If a user changes fall injuries in Field Mode and in Host Mode, then the following message will appear: “Fall Injuries have been changed for this patient. Please review the entry and update if needed.” If a Field Mode user changes fall data and a Host Mode user deletes fall then the message “Record from table [table name] was deleted by another user. [Fall name]” will be displayed and appropriate data will be deleted after synchronization. Warning message “Record from table PTC_FALL was deleted by another user. Click OK to continue.” will be shown during synchronization. If a Field Mode user deletes a documented fall and a Host Mode user changes some data for the same fall, then no messages are logged on the Conflict History report and appropriate data will be deleted in Host Mode as well. > Infections If users change the same data for an infection system or infectious disease in Field Mode and Host Mode, then the following message will be logged on the Conflict History report: “[System name] Infection System information has been changed for this patient. Please review the entry and update if needed.” If a Field Mode user adds data for an infection system or infectious disease and Host Mode user also adds data for the same system or disease, then the following message will be displayed: “[System name] Infection System information has been changed for this patient. Please review the entry and update if needed.” Host Mode and Field Mode data for details will be present for the appropriate infection system or infectious disease. If overlap occurs for an infection system or infectious disease details, the following message will be displayed: “[System Name]/[Disease Name] system/disease entry for period [MM-DD-YYYY] - [MM-DD-YYYY] overlaps with an existing entry. Please review the entry and update if needed.” Host Mode and Field Mode details will be present for the appropriate infection system or infectious disease. If a Field Mode user changes some data in the appropriate field (for example, Start Date) and Host Mode user changes the same data, then the following message will be logged: “Infection: field [field name] Previous value [value] entered by [Operator Name] Current value [value] entered by [Operator Name]” If a Field Mode user changes data for infection details and a Host Mode user deletes details, then the message “Record from table [table name] was deleted by another 590 Clinical Documentation User’s Guide Adverse Events user. [infection system/disease name]” will appear and appropriate data will be deleted after synchronization. Warning message “Record from table PTC_INFECTION_SYSTEM_DETAIL was deleted by another user. Click OK to continue.” will be shown during synchronization. If a Field Mode user deletes infection details and a Host Mode user changes some data for the same detail records, then no messages appear and appropriate data will be deleted in Host Mode as well. Clinical Documentation User’s Guide 591 Adverse Event Report Adverse Event Report Adverse Event Report – Generated Reports>Clinical>Adverse Event The Adverse Event report displays data on falls and infections adverse events, and medication evaluation. The report is generated for active patients only and can be selected for individual patients (Detail) or for all patients (Summary) in the Business Unit within a defined date range. The Summary also contains the rate of occurrence for each adverse event. The rate is defined by the number of patients assessed during the specified date range and the number of Yes and No responses regarding the documents on falls (Patient>Clinical>Adverse Events>Falls), medications evaluation (Patient>Clinical>Medications), and infections (Patient>Clinical>Adverse Events>Infections). For infections, the start and end dates (if applicable) are displayed. If the infection date (start or end) does not fall within the report date range selected on the Define tab, the infection will not be displayed on the report. The Adverse Event report shows currently active infections or infections started and ended for the defined time period within the patient’s admission. This provides agencies the ability to monitor only infections while the patient is admitted to their agency. The report consists of two subreports: > Detail – Patient specific information on adverse events documented during the specified date range. > Summary – Summarized information on the rate of occurrence for each adverse event and the number of patients involved in each event during the specified date range. Information on the Adverse Event Report – Detail Field Name Patient Name First and last name of the patient who had a documented adverse event during the specified period. Patient Code Code of the patient who had a documented adverse event during the specified period. The codes are assigned to patients in Patient>General>Basic. Date 592 Description The date when the adverse event occurred. If the fall date is not known, the date the fall is documented will be displayed followed by the asterisk (*) indicating the exact date is unknown. For infections, the start and end dates are displayed. Clinical Documentation User’s Guide Adverse Event Report Field Name Description Location Patient's location at the time of the adverse event which can be specified on the Define tab if Detail view is selected in the Show section. The location displayed is the location identified in Patient>General>Admission & Status. If no location is specified, home is the default location. Event Type Type of the occurred adverse event specified on the Define tab. Example of the Adverse Event Report – Detail Information on the Adverse Event Report – Summary Field Name Description Total Number of Total number of patients active during the specified period. Active Patients in the Period Event The list of adverse events occurring during the specified period. Number of Events Number of adverse events occurring during the specified period. Rate of Occurrence Rate of occurrence for each adverse event. Number of Patients involved in Events Number of patients involved in each adverse event during the specified period. Clinical Documentation User’s Guide 593 Adverse Event Report Field Name Description Percentage of Patients involved in Events Percentage of patients involved in each adverse event. Total Number of Events in the Period Total number of adverse events occurring during the specified period. Example of the Adverse Event Report – Summary 594 Clinical Documentation User’s Guide Adverse Event Report Adverse Event Report Window Reports>Clinical>Adverse Event Using the Adverse Event window, you can preview and print the information on the adverse event types, patients involved in adverse events, and patients’ locations. You can define the date range, specific patients, and sort the information you want to view in the report. To learn more about the generated Adverse Event report, see the Adverse Event Report – Generated section. The Adverse Event window consists of the following tabs: > Define Tab > Preview tab With the help of this window you can generate the report. Adverse Event Report – Define Tab Use the Define tab to specify the information you want to include in the report. You can also use the Preview tab to view a sample report onscreen. Adverse Event Report – Define Tab Clinical Documentation User’s Guide 595 Adverse Event Report Adverse Event Report – Define Tab Fields Date Range Select the time range the report should be generated for. > > Begin Date – Enter the start date. End Date – Enter the end date. Show > > > Detail – Select this radio button to view the details in the report. Summary – Select this radio button to view summarized information based on all patients in the report. If you select this option, the Filter and Sort by sections become inactive. Both – Select this radio button to view the summary and the details in the report. If you select this option, the Filter and Sort by sections become inactive. Filter Use this section to set filtering options for the report. > > All Patients – Select this radio button to run the report for all patients in the Business Unit. Specific Patients – Select this radio button to specify one or more patients by searching and adding the needed patients in the Select Patient dialog. Note If you want to change settings for the specific patients, click the Select button. > > Event Type – Select the event type from the drop‐down list. The available event types include: Fall, Fall with Injury, Infection (displays name of the system infection), Drug Interactions, Significant Side Effects, Duplicate Drug Therapy, and Ineffective Drug Therapy. By default, the report is generated for all event types. Location – Select patient locations from the drop‐down list to include in the report. The available locations include: Home, SNF/Nursing home, Hospital, Respite, CLHF (Congregate Living Health Facility), and RCFE (Residential Care Facility for the Elderly). By default, the report is generated for all available locations. Sort by Define the sorting rules for the report. Select one of the following options: > > By Patient Name, then Date, then Location – Select this radio button to display the information in the report sorted by patient name and then by date and location. By Date, then Location, then Event Type, then Patient Name – Select this radio button to display the information sorted by date, then location, event type, and patient name. The sorting option applies on the column values order, not the columns themselves. 596 Clinical Documentation User’s Guide Adverse Event Report Generating the Adverse Event Report 1. Open the Reports component. 2. From the menu bar, select Clinical>Adverse Event. The Adverse Event Report window appears with the Define tab active. 3. Select the time period the report should be generated for in the Date Range section. Note Help is available for each field in this window by pressing F1 while in the field. 4. Enter the values in the Show, Filter, and Sort by sections on the Define tab as appropriate (for more information on fields, see also Adverse Event Report – Define Tab). 5. Click the Preview tab to view the report onscreen. Note If you change the criteria on the Define tab after preview, those changes do not take effect until the next time you preview. You shouldclick Close on the Preview tab and then click the Preview tab again. 6. Click Print to print the report. 7. Click to save the report in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide 597 Falls Report Falls Report Falls Report – Generated Patient>Documents>Falls The Falls report displays information on falls adverse events both with and without injuries that occurred with an individual patient within the Business Unit. The report is generated for the current date. This report also includes information about a physician notification of a fall, a person who reported the fall to the physician, and additional comments. The report is based on documentation entered in Patient>Clinical>Adverse Events>Falls. Information on the Falls Report Field Name Description Patient Code Code of the patient who had a fall during the specified period. The codes are assigned to patients in Patient>General>Basic. Patient Name First and last name of the patient who had a fall during the specified period. SOC Date The patient's admission date. This date is obtained from the current admission date in Patient>General>Admissions & Status. If the fall happened before the patient’s admission date, the SOC Date field will be blank. Fall Date The date when the fall occurred. If the fall date is not known, the date the fall is documented will be displayed followed by the asterisk (*) indicating the exact date is unknown. Injuries The documentation of injuries caused by a fall. If a patient had no documented injuries, the <None apparent> value is displayed in this column. Observed By Clinician Indicates whether the clinician observed the fall. Reported By: Patient\PCG\Other 598 Indicates the person who reported the patient's fall. Several selections are available: Patient – Displays Yes if the patient reported the fall personally. PCG – Displays Yes if the patient's primary caregiver reported the fall. Other – Displays documented information about the person who reported the fall. Clinical Documentation User’s Guide Falls Report Field Name Description Notified Section Physician The name of the physician who was notified about the patient’s fall. By The name of the person who notified the physician about the fall. Date/Time Date and time of the fall notification. If only a date was entered in the Falls window, the Time field is blank on the report. Comments Additional comments related to the documented fall. Example of the Falls Report Falls Report Window Patient>Documents>Falls Using the Falls window, you can preview and print information falls adverse events both with and without injuries for an individual patient within the defined date range. To learn more about the generated Falls report, see the Falls Report – Generated section. With the help of this window you can generate the report. Clinical Documentation User’s Guide 599 Falls Report Generating the Falls Report 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Falls. The Falls window opens with the Preview tab displaying the report onscreen. 4. Print the report. 5. Click 600 to save the report in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide Infections Report Infections Report Infections Report – Generated Patient>Documents>Infections The Infections report displays information on the documented infections for an individual patient. This report includes information about the patient who had an infection, name of the infection system, additional comments, and start and end dates of the infection. The report is based on documentation entered on the Infections tab in Patient>Clinical>Adverse Events>Infections. Information on the Infections Report Field Name Description Patient Code Code of a patient who had an infection during the specified period. The codes are assigned to patients in Patient>General>Basic. Patient Name First and last names of the patient who had an infection during the specified period. SOC Date The patient's admission date. This date is obtained from the current admission date in Patient>General>Admissions & Status. Start Date The start date of an infection. End Date The end date of an infection. End date is shown only when the infection has ended. Infection System The name of the body system where an infection is located. Comments Additional comments related to the documented infection. Clinical Documentation User’s Guide 601 Infections Report Example of the Infections Report Infections Report Window Patient>Documents>Infections Using the Infections window, you can preview and print information on the documented infections that an individual patient had. You can select to view historical infections data or generate the report for selected system infections. To learn more about the generated Infections report, see the Infections Report – Generated section. The Infections window contains the following tabs: > Define Tab > Preview tab With the help of this window you can generate the report. 602 Clinical Documentation User’s Guide Infections Report Infections Report – Define Tab Use the Define tab to specify the information you want to include in the report. You can also use the Preview tab to view a sample report onscreen. Infections Report – Define Tab Infections Report – Define Tab Fields Show Select the time range the report should be generated for. > Show Historical Data Since – Select this check box to include infections since the certain date and enter this date in the drop‐down calendar. If you do not select this check box, the report will show only currently active infections. Filter Use this section to set filtering options for the report: > Infection System – Select a system from the drop‐down list to display a specific system data on the report. By default, the report is generated for all infection systems. The drop‐down list displays all infection systems that are currently active in the system. Note The infection systems are defined in Administration>Clinical>Infection Systems. Clinical Documentation User’s Guide 603 Infections Report Generating Infections Report 1. Open the Patient component. 2. Select the appropriate patient. 3. From the menu bar, select Documents>Infections. The Infections window appears with the Define tab active. 4. To view additional infections information, enter the date since which the report should be generated in the Show Historical Data Since section. Note Help is available for each field in this window by pressing F1 while in the field. 5. From the Infection System drop‐down list, select the system to generate the report for that body system. To see all infection systems on the generated report, leave this field clear. 6. Click the Preview tab to view an onscreen preview of the report based on the entered parameters. Note If you change the criteria on the Define tab after preview, those changes do not take effect until the next time you preview. You should click Close on the Preview tab and then click the Preview tab again. 7. Print the report. 8. Click 604 to save the report in the Excel, Acrobat, or ASCII format as appropriate. Clinical Documentation User’s Guide Chapter 12 ‐ Co‐Signature In This Chapter This chapter describes the Co‐Signature functionality. You can learn about the Co‐Signature wizard by referring to the following section: • Co‐Signature Wizard Clinical Documentation User’s Guide 605 Co‐Signature Wizard Co‐Signature Wizard What Is Co‐Signature? The Allscripts Homecare Co‐Signature functionality provides Homecare and Hospice agencies the ability to electronically co‐sign documentation generated by clinicians at the point‐of‐care. This feature of the Allscripts Homecare application assists agencies in meeting compliance mandates for State Practice Acts, regulations and individual agency policies and procedures. The Allscripts Homecare application provides the capability for each Business Unit to enable Co‐ Signature functionality based on their unique needs. Multiple set‐up options are available including: > Defining types of documentation requiring co‐signature > Selecting disciplines requiring co‐signature of their documentation > Defining users with co‐signature rights Assumptions – Knowledge of State Practice Acts, regulatory mandates and agency policies and procedures. Goals – Allow electronic signature to be applied to defined clinical documentation generated from the point‐of‐care. Before you can use Co‐Signature, the functionality must be set up by Allscripts Homecare administrator. The following are areas of the application where Co‐Signature setup is performed: > Co‐Signature (Administration>Configuration>Organizations>Co‐Signature) > Business Units – Settings – Signature (Administration>Configuration>Business Units>Settings>Signature>Co‐Signature) > Resource Types – Co‐Signature Settings Tab (Administration>General>Resource Types>Co‐ Signature Settings) Also, Co‐Signature information is displayed on the Audit Trail Information window after a clinical item has been processed through the Co‐Signature wizard. 606 Clinical Documentation User’s Guide Co‐Signature Wizard Co‐Signature Window Transactions>General>Co‐Signature With the Co‐Signature wizard, you can search for all electronically signed clinical documentation, select items depending on the defined search criteria and decide whether to co‐sign, skip, or deny co‐ signing the selected clinical documents. For denied clinical documentation, the tasks for fixing corresponding documents are automatically generated for the resource that originally signed those documents with the ability to assign these tasks to an alternate resource. The Co‐Signature wizard includes the following steps: > Step 1 – Search – Set search criteria for clinical documents you want to co‐sign and select the needed documents. > Step 2 – Preview – Preview selected clinical documents in simple and detailed views and select items for further co‐signing or denial processing. > Step 3 – Denial Reason – Enter the reason that the item is being denied co‐signature and assign tasks for the resource who will be responsible for fixing denied clinical item. > Step 4 – Records Processing – Review the selected clinical documents for correctness and approve for processing. > Step 5 – Processing Results – View the co‐signature processing results with status description and print detailed summary report. Step 1 – Search The first step of the wizard allows searching for clinical documents that were electronically signed during the Field Mode synchronization. The search returns clinical items that satisfy defined Co‐ Signature setup options and are ready for co‐signing. The denied items that currently are in the process of fixing or are already co‐signed are not shown in the search results section. If co‐signature has been denied and the generated task subsequently completed, the fixed clinical item will appear in this section again. The Co‐Signature window is divided in two sections: > Search Parameters Section – Set search parameters for electronically signed clinical documents that need to be co‐signed in the current Business Unit. You can search by date range, operator that originally signed clinical document, related patients, and clinical item types. You can use fewer criteria to return broader search results, or you can complete more fields to narrow down your search to more specific results. > Search Results Section – Displays information about the electronically signed clinical documents found based on the set search criteria. The status bar at the bottom of the window displays Clinical Documentation User’s Guide 607 Co‐Signature Wizard number of entries found at your request and selected for processing, as in the following example: . If the search returned no results, change search criteria or complete fewer search fields to broaden the search. In the search results section, you can also resort the column headings. For example, if you want to see clinical item types in the first column, you can drag and drop the Item Type column heading to the appropriate position. Allscripts Homecare retains the header order until you exit this window or the application. You can customize search results view using the grouping option which allows you to group data shown on the grid by different columns. To activate this feature, move the mouse over the column by which the data should be grouped. Then, hold down the left mouse button and drag the column to the space above the grid. You can drag several columns for grouping, and the data in the grid will be grouped in hierarchical order. In the following example, data are grouped by the Item Type and Sign Date columns and sorted in the defined order: Patient – Originally Signed By – Description. You can operate with the search results using the following buttons on the grid: Select All: Click to select all items either in the Selected or the Found section of the grid. To select individual items, hold down the Ctrl key and left‐click each needed item. Clear All: Click to deselect all items currently selected either in the Selected or the Found section of the grid. Add Selected: Click to move the selected items from the Found to the Selected section of the grid. 608 Clinical Documentation User’s Guide Co‐Signature Wizard Remove Selected: Click to delete the selected items from the Selected section of the grid. Step 1 – Search Search Parameters Section Use the following fields to define your search parameters: • Date Range – Select the time period to search for electronically signed clinical documents. Use the Begin Date and the End Date fields for this purpose: • Begin Date – Enter the start date or select a date from the drop‐down calendar. • End Date – Enter the end date or select a date from the drop‐down calendar. The default date range values are the following: End Date field is set to current date and Begin Date to the same day one month prior. For example, end date is 03/04/2009, and begin date is automatically set for 02/04/2009. Both end and begin dates can be changed. • Originally Signed By – Select the operator who has electronically signed clinical documents you want to search for. You can select either all operators in the current Business Unit or individual operator from the Select Operator dialog. By default, the application displays All, which allows you to search for clinical documents signed by all operators in the Business Unit. Multiple selection of operators can be done by additionally searching clinical items of the same or other operator and adding found results to the list of previously selected items (lower section of the grid). Clinical Documentation User’s Guide 609 Co‐Signature Wizard • Patient – Select the patient for whom clinical document you want to search for is completed. You can search for all patients, an individual patient, or several patients using the Select Patient dialog. • Clinical Item Type – Select clinical item types you want to search for. You can search by all item types or one item type at a time. However, you can perform extra search by the same or other item type and add found results to the list of previously selected items (lower section of the grid). • Description – Displays short description of a clinical document you want to search for. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. You can perform clinical documentation search using the following buttons: • Search – Click this button to initiate the clinical items search based on the criteria you entered. • Clear – Click this button to remove all the criteria entered in the fields above. • Set As Default – Click this button to store entered search criteria, grouping, and sorting field panels so this combination will be used each time you perform a search from this dialog. Search Results Section The results grid contains the following columns with the items matching the search criteria you set: • • Originally Signed By – Displays full name of the operator who completed the found clinical document. • Sign Date – Displays date when the found clinical document was electronically signed. • Patient – Displays full name of the patient for whom the found clinical document was completed. • 610 Item Type – Displays item type of the found clinical document. Description – Displays short description of the found clinical document. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. Clinical Documentation User’s Guide Co‐Signature Wizard Step 2 – Preview This step of the wizard allows previewing selected clinical documents and choosing an action for each item. Beginning from this step, you can print a brief report about the selected clinical documents and preview their detailed description. An action for each clinical item must be selected to proceed with the wizard. Step 2 – Preview Clinical Documents Grid The grid with clinical documents selected for processing contains the following columns: • Originally Signed By – Displays the full name of the operator who completed the documentation selected for the co‐signature processing. • Sign Date – Displays the date when clinical documents were electronically signed. • Patient – Displays the full name of the patient for whom the selected clinical documents were completed. • Item Type – Displays types of clinical documents selected for the co‐signature processing. • Description – Displays a brief description of the corresponding clinical document. To view detailed information about the selected clinical documents, use the Show Details check box at the bottom of the window. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. • – Click this button to generate a detailed preview for assessments only. This preview displays extensive information about the completed assessment (Co‐Signature – Assessments Clinical Documentation User’s Guide 611 Co‐Signature Wizard Preview). Select the Show Details check box at the bottom of the window to preview all other items. Detailed information on clinical documents can also be viewed by clicking the Print button, which generates the Co‐Signature Report. Select Action Select one of the following radio buttons for further processing of the selected clinical documents: • Co‐Sign – Co‐sign the selected clinical document. • Deny – Deny co‐signing the selected clinical document. • Skip – Skip the selected clinical document and exclude it from the co‐signing process. Skipped items will be available for future searches. Show Details Select this check box to view columns displayed in the grid with the detailed description of each clinical item type. The description appears in the line below the item type and shows advanced information about the corresponding clinical document. Note For more information on clinical document details, see Clinical Documentation Detailed Description section. Print Click this button to generate the Co‐Signature Report which displays detailed information about the patient’s clinical documentation subject to the co‐signature processing. Note On the Preview and Denial Reason steps of the wizard, clinical items are displayed without the processing results indicators. The Records Processing and Processing Results steps display the results of the co‐signature processing with the corresponding indicators: – successfully processed and 612 – processed with warnings. Clinical Documentation User’s Guide Co‐Signature Wizard Step 3 – Denial Reason This step displays clinical documents selected for co‐signature denial on the previous page of a wizard. You should enter denial reason for each item that explains why you disagree to co‐sign the selected documents. If no items were selected for denial in the previous step, this step will be skipped and you will be directed to the Records Processing dialog. Step 3 – Denial Reason This page of the wizard contains the following controls: Originally Signed By – Displays the full name of the operator who completed the documentation selected for the co‐signature processing. Sign Date – Displays the date when clinical documents were electronically signed. Patient – Displays the full name of the patient for whom the selected clinical documents were completed. Item Type – Displays types of clinical documents selected for the co‐signature processing. Description – Displays a brief description of the corresponding clinical document. To view detailed information about the selected clinical documents, use the Show Details check box at the bottom of the window. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. – Click this button to generate a detailed preview for assessments only. This preview displays extensive information about the completed assessment (Co‐Signature – Assessments Preview). Select the Show Details check box at the bottom of the window to preview all other items. Detailed information on clinical documents can also be viewed by clicking the Print button, which generates the Co‐Signature Report. Clinical Documentation User’s Guide 613 Co‐Signature Wizard Denial Reason Enter the reason for denying co‐signature of the selected clinical item in this drop‐down box, up to 800 alphanumeric characters. You will not be able to proceed to the next page until you specify denial reason for each clinical item. Note To save changes, be sure to click the OK button in the Denial Reason drop‐down box when you finish entering the reason text. Otherwise, all entered information will be lost. Task Assigned To Select the operator for whom a task for fixing denied clinical document should be created. A task will be automatically generated for the resource that initially signed each denied clinical item. To send the task to an alternate operator, search for this person by clicking <Select another operator> and choose that operator from the Select Operator dialog. Show Details Select this check box to view columns displayed in the grid with the detailed description of each clinical item type. The description appears in the line below the item type and shows advanced information about the corresponding clinical document. Note For more information on clinical document details, see Clinical Documentation Detailed Description section. Print Click this button to generate the Co‐Signature Report which displays detailed information about the patient’s clinical documentation subject to the co‐signature processing. Note On the Preview and Denial Reason steps of the wizard, clinical items are displayed without the processing results indicators. The Records Processing and Processing Results steps display the results of the co‐signature processing with the corresponding indicators: – successfully processed and 614 – processed with warnings. Clinical Documentation User’s Guide Co‐Signature Wizard Step 4 – Records Processing This step of the wizard displays clinical documents categorized to be co‐signed or denied. You can view if the documents are ready for co‐signing or whether they contain warnings. To initiate the co‐ signature processing, click the Process button and enter your password to authenticate that you approve processing. Step 4 – Records Processing This page of the Co‐Signature wizard contains the following controls: Items to co‐sign This tab displays information on the clinical items selected for co‐signing and contains the following columns: • Action – Displays icons that indicate the co‐signature processing results. The processing results can be marked as positive: (processed with warnings). (successfully processed – co‐signed) and negative • Originally Signed By – Displays the full name of the operator who completed clinical documentation selected for the co‐signature processing. • Sign Date – Displays the date when clinical documents were electronically signed. • Patient – Displays the full name of the patient for whom the selected clinical documents were completed. Clinical Documentation User’s Guide 615 Co‐Signature Wizard • Item Type – Displays types of clinical documents selected for the co‐signature processing. • Description – Displays a brief description of the corresponding clinical document. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. Items to deny This tab displays information on the clinical items denied co‐signature, and contains the following columns: • Action – Displays icons that indicate the co‐signature processing results. The processing results can be marked as positive: (processed with warnings). (successfully processed – denied) and negative • Originally Signed By – Displays the full name of the operator who completed clinical documentation selected for the co‐signature processing. • Sign Date – Displays the date when clinical documents were electronically signed. • Patient – Displays the full name of the patient for whom the selected clinical documents were completed. • Item Type – Displays types of clinical documents selected for the co‐signature processing. • Description – Displays a brief description of the corresponding clinical document. To learn more about each clinical document type description, see Clinical Documentation Detailed Description section. • Denial Reason – Displays the reason why the selected clinical document was denied. Legend This section displays the legend about the items processing with the number of clinical documents processed. The following are conventions explaining the results of the co‐signature processing: • • 616 – This symbol indicates that the items were processed correctly without any errors or warnings. – This symbol indicates that the processed items included some warnings. The hint opposite the processed clinical document displays a description of the problem appeared during the items processing. For example, a clinical document contains warning because it has been already processed by another person. Clinical Documentation User’s Guide Co‐Signature Wizard Co‐Signature Statement This field shows the text that will be applied on the clinical documentation after co‐signing. The statement is defined on the Organization level in Administration>Configuration>Organizations>Co‐Signature, and on the Business Units level in Administration>Configuration>Business Units>Settings>Signature>Co‐Signature. Password Verification Enter your primary password to confirm the processing of the selected clinical documents. The following text reflects your approval or denial for co‐signature items: “By entering the password I acknowledge that I have read and accepted the terms of the statement. I understand that co-signing may not be reversed”. Show Details Select this check box to view columns displayed in the grid with the detailed description of each clinical item type. The description appears in the line below the item type and shows advanced information about the corresponding clinical document. Note For more information on clinical document details, see Clinical Documentation Detailed Description section. Print Click this button to generate the Co‐Signature Report which displays detailed information about the patient’s clinical documentation subject to the co‐signature processing. Note On the Preview and Denial Reason steps of the wizard, clinical items are displayed without the processing results indicators. The Records Processing and Processing Results steps display the results of the co‐signature processing with the corresponding indicators: – successfully processed and – processed with warnings. Process Click this button to initiate processing of the selected clinical documents. Warning Once the co‐signature processing for the selected clinical documentation is started, it cannot be reversed. Clinical Documentation User’s Guide 617 Co‐Signature Wizard Step 5 – Processing Results This step of the wizard displays information on the co‐signature processing results with the completion status indicators. This page is divided into two sections: Items to co‐sign and Items to deny that contain clinical documents based on actions selected for their processing. The legend of the processed documentation is shown below the grid. Also, you can view the detailed description of the processed items and print the summary report about the results of the co‐signature processing. After the co‐signature processing is finished, the results can be viewed by putting the cursor over the icon to see the additional information in a hint. The grid contains the same fields as in the previous steps of the wizard and the only difference is that the Action column displays the processing results indicators: – successfully processed and – processed with warnings. The following are possible ways of processing results displayed in hints: > > 618 Co‐signed – The hint about the successfully co‐signed clinical document displays the name of the person who co‐signed this document and processing date (MM/DD/YYYY) and time (hh:mm). Processed with Warnings – The hint displays the warning reason (for example, the selected clinical document has been already co‐signed by another operator), name of the person who performed co‐signature action, and the processing date (MM/DD/YYYY) and time (hh:mm). Clinical Documentation User’s Guide Co‐Signature Wizard > Denied – The hint on the denied clinical document displays the name of the person who denied co‐signing the document, denial date (MM/DD/YYYY) and time (hh:mm). Clinical Documentation Detailed Description The following table displays detailed description of each clinical document displayed on the Co‐ Signature wizard available by selecting the Show Details check box below the clinical items grid. Clinical Item Description Assessment Discipline, Assessment Name, Version, Date Example: SN Phone Visit 5.0, Date 04/10/2009 Clinical Note Discipline, Description of Use, Start and End Dates, Note Itself (from new line). Example: SN, Care Plans, Start: 04/13/2009, End: 04/17/2009 Note text Medication Medication Name, Dose, Frequency, Route, Start and End Dates. Example: Antacid Anti-Gas Reg Strength By Mouth Suspension 200-200-20 MG/5ML 2 ML mg p.c. PO, Start: 04/07/2009, End: 04/30/2009 Projected Visits Discipline, Lo, Hi, Period, Duration, PRN, PRN Reason, Start and End Dates. Example: DS, 2-11x/ mo x 9 mos x 0h30m, Start: 03/ 25/2009, End: 04/30/2009 Clinical Documentation User’s Guide 619 Co‐Signature Wizard Co‐Signature Report The Co‐Signature report displays detailed information about clinical documentation subject to co‐ signature processing. This report is generated from Transactions>General>Co‐Signature. The report is triggered by clicking the Print button at the bottom of the Co‐Signature window beginning from the second step of the wizard. The report does not include the Define tab and is generated according to the parameters entered as search criteria in the Search step of the Co‐Signature wizard. When you run this report from the Preview and Denial Reason steps of the wizard, clinical items are displayed without the processing results indicators. The Records Processing and Processing Results steps display the results of the co‐signature processing with the corresponding indicators: – successfully processed and – processed with warnings. Information on the Co‐Signature Report Field Name Description Items to Co‐Sign Section Item Type Patient Displays the patient for whom the selected clinical documents were completed. Originally Signed By 620 Displays types of clinical documents selected for co‐signature processing. Displays the operator who completed the clinical documentation selected for co‐signature processing. Clinical Documentation User’s Guide Co‐Signature Wizard Field Name Description Items to Deny Section Item Type Displays types of clinical documents selected for the co‐ signature denial. Patient Displays the patient for whom the selected clinical documents were completed. Originally Signed By Displays the operator who completed the clinical documentation selected for co‐signature processing. Denial Reason Displays the reason why the selected clinical document was denied. Items to Skip Section Item Type Displays types of clinical documents skipped from co‐signature processing. Patient Displays the patient for whom the selected clinical documents were completed. Originally Signed By Displays the operator who completed the clinical documentation selected for skipping. Clinical Documentation User’s Guide 621 Co‐Signature Wizard Example of the Co‐Signature Report 622 Clinical Documentation User’s Guide Co‐Signature Wizard Save, Preview, or Print the Co‐Signature Report 1. Open the Transactions component. 2. From the menu bar, select General>Co‐Signature. The Co‐Signature window appears as the wizard, which guides you through the selection and processing actions for the appropriate clinical documents. 3. Beginning from the Denial Reason step, click the Print button at the bottom of the window to generate the report. The generated report appears with the open Preview tab. 4. Click 5. Click to print the report. to save the report in the Excel, Acrobat, or ASCII format as appropriate. Co‐Signature – Assessments Preview The Assessments preview displays the information on the patient’s assessments that were selected for the co‐signature processing. The generated report preview consists of three parts: > Caption – Located at the top of the report. It contains discipline, assessment name and version, patient’s first and last names, patient code, reason for assessment (RFA), assessor first and last names, and date of the assessment completion. > Assessment Body – Displays assessment fields with the entered values. Depending on the type of the assessment, the assessment body of the report changes according to the items specific for particular assessment. > Footer – Located at the bottom of the generated report page. It contains the assessor first and last name, print date and time, and report page number. You can save or print the generated assessment preview using the standard printing panel. For assessments older than 5.0 version, the full form of assessments will be shown, and for assessments 5.0 version and higher, short form will be generated. Clinical Documentation User’s Guide 623 Co‐Signature Wizard Example of the Assessment Preview ‐ Short Form 624 Clinical Documentation User’s Guide Co‐Signature Wizard Example of the Assessment Preview ‐ Full Form Clinical Documentation User’s Guide 625 Co‐Signature Wizard Co‐Signature Tasks Tasks that are created in the Denial Reason step of the Co‐Signature wizard for denied clinical documents are displayed in the My Tasks window (Alerts and Tasks) of the assigned resource and in the My Tasks section (My Day) of that resource. Tasks can also be accessed by patient. You can manage these tasks by changing the status of a task, reassigning a resource responsible for the task completion, and entering free‐text information about a task in the comments section. The other fields cannot be changed for co‐signature tasks in order not to loose the integrity between denied clinical document and corresponding task. Tasks assigned to denied clinical item cannot be deleted until the item is fixed and then co‐signed. When the task is completed, the fixed item appears on the Co‐Signature wizard and is again eligible for co‐signature. Once the item is successfully co‐signed, the denial information for this item is deleted. Managing Co‐Signature Tasks While in Host or Field mode, you can view the indication of a received co‐signature task in Alerts and Tasks>General>My Tasks and in My Day>My Tasks. The co‐signature tasks are displayed for the resource to whom they were assigned and also these tasks are associated with a patient for whom the denied clinical document was completed. The main goal of the co‐signature tasks is to allow a resource to fix clinical documentation denied during the Co‐Signature process. You can start completing co‐signature tasks assigned to you either in the My Day component (step 1) or in the My Tasks window in Alerts and Tasks>General (step 3). Note Note For each field within the My Day and My Tasks windows, help is available by pressing F1 while in the field. To complete co‐signature task, perform the following steps: 1. Open the My Day component. The My Day window appears where all your tasks, patients, and daily schedule can be viewed. The following information is present in this section: • • Task Code – The task code based on the type of the task. • Task – The description of the task, which depends on the type of the task. • 626 Priority – The urgency with which the task must be completed. Patient – The name of the patient for whom the denied clinical document was completed. Clinical Documentation User’s Guide Co‐Signature Wizard • Due Date – The date when the task is due. • Status – The stage at which the task is at present. • Subject – The subject of the task, which depends on the type of the task and can be manually entered by the task creator or automatically generated by the system. 2. In the My Tasks section, you can view information about all tasks assigned to you. To process the co‐signature task, right‐click the needed task and select Open Task. The Alerts & Tasks component opens with the My Tasks window active, where you can change the status of the task, reassign this task to another resource, and enter additional comments about the task. Note You can also access co‐signature task directly from the My Tasks window. Clinical Documentation User’s Guide 627 Co‐Signature Wizard This window contains fields that are identical to the My Tasks section in the My Day component. The lower section of this window contains the following controls: • Task Code – Displays the task code of the selected task. The description of the task code appears to the right of the field. Task code for the co‐signature task is disabled. Note Codes and descriptions for the co‐signature tasks are defined in Administration>General>Patient Tasks. • Subject – Displays subject of the co‐signature task. The subject is generated automatically by the system and cannot be edited manually. Standard subject for co‐signature tasks contains the following required lines: denial reason, clinical item type, description, name of the person who originally signed the document, and sign date and time. Example Denial reason: Incomplete information given by the assessor. Please update assessment more detailed. Clinical item: Assessment Description: SN Phone Visit 5.0, Date: 04/10/2009 Signed by Elizabeth Anderson on Apr 10 2009 628 1:19PM Clinical Documentation User’s Guide Co‐Signature Wizard • Assigned To – Displays the ID and name of the person who is assigned the task. If needed, you can reassign the task to another resource by entering the resource’s ID or name in this field. The reassigned task will disappear from your tasks and will automatically appear in the My Tasks window of the assigned resource. • Patient – Displays the ID number of the patient that the selected task is to be performed for. The patient name appears to the right of the field. You cannot change patient code because the co‐signature task is created for fixing denied clinical document exactly for this patient. • Due Date – Displays the date when this task is due. This field is not editable because the due date information is taken from the co‐signature setup. Note The default due dates for co‐signature tasks are defined on the Tasks tab in Administration>Configuration>Organizations>Co‐Signature on the Organization level, and in Administration>Configuration>Business Units>Settings>Signature>Co‐ Signature on the Business Unit level. • Ended Date – In this field, you can enter the date when this task is completed. If you do not enter the date in this field, it will show current date and time for task completion. • Status – Displays the current status of the task. • Priority – Displays the urgency with which the task must be completed. Priority identification can be done using the following selection options: Low, Normal, Medium, High, and Urgent. Note The priority for co‐signature tasks are taken from the Tasks section in Administration>Configuration>Organizations>Co‐Signature on the Organization level, and in Administration>Configuration>Business Units>Settings>Signature>Co‐ Signature on the Business Unit level. • Comment History – Displays the history of comments about the task in process of the task completion. You can see the status of the task when the comments were entered, resource who entered comments, and comment entry date and time. • Comment – In this section, you can enter additional comments about the task in the process of task completion. To add a comment, click , then double‐click in the field that appears to enter free‐text comments about this task. Click OK to save changes. 3. To fix a denied clinical document, right‐click the corresponding task and select to open the needed document. Clinical Documentation User’s Guide 629 Co‐Signature Wizard The example below shows how patient’s assessment can be opened from the My Tasks window. You will be directed to that document’s window for the appropriate patient. 4. Complete the identified modifications designated for document fixing (entered as the denial reason) and save your changes. 5. To proceed, go to the My Tasks window and select the task you want to work on. 6. Select the task and from the Status drop‐down list select the status for this task. The following statuses are available for selection: • (Not Started) – The task has been created but no action has been taken towards completing it. • (In Progress) – The task was started but not completed yet. • (Completed) – The action required for this task was made. • (Cancelled) – The task was either created in error or is no longer appropriate. • (Decline) – The recipient of the task indicated that this task cannot be completed. This status may require the creator of the task to reassign it to someone else. 7. To mark the co‐signature task as completed, select Completed from the Status drop‐down list and save your changes. The task disappears from the list of assigned tasks. 8. When the task is marked as completed, the Assigned To field automatically changes the caption to Completed By and you can change the name of the resource in this field prior to saving. 630 Clinical Documentation User’s Guide Index Numerics 486 Info window 131 486 information editing 133 entering 133 A abbreviated OASIS assessment 419 about resolving visits in 308 access clinical data 560 Active Orders report 287 Active Patients by Discipline report 188 previewing 188 printing 188 Active Patients by Problems report 186 previewing 187 printing 187 activities permitted entering/editing 91 Add/Edit Clinical Data create patient’s trend 553 Labs Tab Glucose Subtab 545 PT/INR Subtab 546 Pulse Oximetry Subtab 544 Measurements Tab Abdominal Girth Subtab 543 Chest Circumference Subtab 542 Extremity Subtab 541 Head Circumference Subtab 540 Height Subtab 537 Weight Subtab 538 Reading Level Note window 550 Scales Tab 548 Spirometry Tab Peak Flow Subtab 547 Vital Signs Tab Blood Pressure Subtab 536 Pulse Subtab 534 Respiration Subtab 535 Temperature Subtab 533 Add/Edit Clinical Data window 530 Clinical Documentation User’s Guide addresses editing for patients 35 entering for patients 34 inactivating for patients 35 admission about entering visits prior to 307 admissions editing status change information for patients 66 entering physicians for patients 67 entering preadmission visits 69 entering status change information for patient 65 overriding orders certification start date 67 Admissions & Status NPI options 48 Admissions & Status window 49 about 47 about admissions 47 about discharges 47 about readmissions 47 pre‐admissions 39 admitting patients 64 advance directives entering/editing 91 adverse events 578 falls 579 infections 583 overview 578 Adverse Events report 592 Adverse Events window 595 allergy entering/editing for orders 91 approving order 279 assessment linking to a discipline discharge or agency transfer or discharge 439 reservation 454 631 Index Assessment Editor edit item text in notebook, tab, box, or line level 515 make item invisible in assessment template 515 open assessment 525 overview 512 save changes 516 spell check item text 516 start from Business Units window 512 assessment editor attaching problems to assessment questions 517 initiate care plans 517 Assessment Editor window 514 Assessment Export Report viewing 507 assessment history 495 Assessment History report 485 Assessment History window 495 Assessment Viewer overview 524 Assessments Discharge/Transfer Summary Type window 436 assessments 423, 474 about 413 acute and emergent care risk assessment 449 changing reason for 451 connecting to visit or phone call 440 correcting errors in OASIS 422 deactivating tabs in 442 define problems for the patient 417 deleting 448 editing 447 edits 445 entering 438 entering notes 440 exporting OASIS assessments 505 inactivation 444 indicating normal values on 441 indicating tabs not required for reassessment 443 initiate care plans 417 OASIS Due Alert report 508 OASIS Export 497 printing assessments 494 reactivating tabs in 442 reasons for (RFA) 451 632 releasing 455 reserving 452 reviewing revision history 458 validating OASIS 422 viewing HHRG score 421 viewing previous 443 viewing progress of 442 Assessments Export Report 506 Assessments report 474 Assessments window 423, 493 assessments, OASIS about exporting 496 Assignment Report Generate from My Day 410 Assignments 97 assignments 93 editing for patients 96 entering for patient 95 Assignments report previewing 98 printing 98 assignments tab 397 Assignments window 93 attaching problems to assessment questions 517 audit trails retaining on field devices 362 authorizations pre‐admissions 40 B Batch Timelog about 331 Bereavement services about entering 307 C Care Plan report 166 care plans previewing demand 169 previewing patient 168 printing demand 169 printing patient 168 Certification of Terminal Illness inactivating 300 reprinting 300 Clinical Documentation User’s Guide Index certification periods viewing 115 changing reason for assessment (RFA) 451 Charting History 179, 180 previewing 185 printing 185 charting history viewing patient’s progress 179 Charting History window 183 charts/clinical notes previewing 107 previewing patient 110 printing 107 printing patient 110 Charts/Clinical Notes window 108 Clear Scheduled Times window 329 clinical data access 560 view 560 Clinical Monitoring 347 clinical monitoring overview 529 settings 529 Clinical Monitoring window 569 clinical notes editing 105 entering 105 Clinical Notes Window 99 Condition Change report 463 contract services 78 printing 82 Contract Services Report 78 previewing 82 printing 82 correcting errors in OASIS assessments 422 co‐signature 607 clinical documentation description 619 definition 606 denial reason 613 overview 606 preview 611 processing results 618 records processing 615 report 620 search 607 Clinical Documentation User’s Guide co‐signature denial reason 613 co‐signature overview 606 co‐signature preview 611 co‐signature processing results 618 co‐signature records processing 615 Co‐Signature report 620 co‐signature search 607 Co‐Signature window 607 Create Patient Diagnoses Group 77 create Patient Data Report View Clinical Data window 563 trend Add/Edit Clinical Data window 553 View Clinical Data window 560 creating discipline or transfer summary 439 order run 277 CTI inactivating 300 Patient component 298, 301 printing 299, 301 process 302 reject 302 reprinting 300 D data retaining on field devices 361 saved on laptops 353 deactivating assessment tabs 442 Default View Set My Day on field device 408 define problems for the patient 417 denial reason co‐signature 613 Diagnoses Create Patient Diagnoses Group 77 diagnoses discontinuing for patients 77 entering for patients 76 finding 76 patient diagnoses group dates 74 view across periods 75 633 Index diagnosis codes expired 154 Diagnosis window 71 diet entering/editing for orders 91 directives advanced entering/editing 91 discharge summaries previewing patient 84 printing patient 84 Discharge Summary window 83 Discharge/Transfer Summary Type window in Assessments 436 discharging patients 65 discipline creating a summary 439 disciplines problem reports 188 discontinue medications 212 discontinuing diagnoses for patients 77 problems 175 DME entering/editing for orders 91 document patient’s falls 582 document patient’s infectious diseases 587 document patient’s system infections 586 Drug/Drug Interactions window 216 durations 308 entering for a visit 328 F Face Sheet window 140 face sheets previewing patient 140 printing patient 140 fall adverse events 579 Falls report 598 Falls window 579, 599 field devices determining licensing 356 loading patient information on 362 ownership 353 retaining audit trails on 362 retaining data on 361 retaining synchronization logs on 362 saved data on 353 setting up for initial Synchronization 358 Field Mode about 346 Clinical Monitoring 347 enabling users to work in 357 field device ownership 353 loading patient information on 362 My Day 347, 384 Patient list management 354 patient lists 354 setup checklist 355 system administrators 353 field units see field devices 356 field use only status codes about 355 functional limits entering/editing 91 E encounter date report 305 entering for patients 327 evaluate medications 197 exporting OASIS assessments 505 exports OASIS assessments 497 634 G general clinical information editing for orders 90 entering for orders 90 reviewing 92 general clinical information for the 485/CPOC entering 90 General Clinical window 86 goals entering for problems 174 Clinical Documentation User’s Guide Index H M HHRG score viewing for OASIS assessments 421 hold medications 210 Hospice Benefit Information 62 Host Mode 308 enabling users to work in 357 MAR activating 239 adding PRN medication to 241 adding scheduled medication to 240 changing medication administration times on 242 creating new 239 deactivating 240 editing entries 243 mark as reviewed 240 patient’s signature 245 printing 257 PRN medication, documenting a response on 244 PRN medications, documenting administration on 244 scheduled medications, documenting administration on 243 updating with new medications 242 MAR Review Status report printing 247 Medication Administration Actual vs Scheduled 248 Medication Administration Actual vs Scheduled Report 248 medication administration record (MAR) activating 239 adding PRN medication to 241 adding scheduled medication to 240 changing medication administration times on 242 creating new 239 deactivating 240 editing entries 243 mark as reviewed 240 printing 257 PRN medication, documenting a response on 244 PRN medications, documenting administration on 244 scheduled medications, documenting administration on 243 updating with new medications 242 medication descriptions 262 previewing patient 265 printing patient 265 Medication Descriptions window 264 I ICD9 codes expired 154 indicating PRN visits in TimeLog 328 indirect time recording 326 infections adverse events 583 Infections report 601, 602 Infections report window 602 Infections window 583 initiate care plans through the assessments 417 interactions check medication 214 interventions entering for problems 175 L Lab Results Report Generate from My Day 411 lab results tab 406 laptops as field devices 353 saved data on 353 licensing determining for field devices 356 link clinical monitoring record to clinical notes 551 patient tasks 552 List of Imported Medications Generate from My Day 411 lookahead determining on field devices 362 Clinical Documentation User’s Guide 635 Index Medication Entry window 221 Medication Evaluation report 252 Medication Evaluation report 252, 254 Medication Evaluation window 254 medication groups entering 209 medication kits add for patients 216 medication lists 266 previewing 267 previewing patient 269 printing 267 printing patient 269 Medication Lists window 268 medication, PRN response to, documenting on MAR 244 medications 243 add special instructions 209 adding PRN to MAR 241 adding scheduled to MAR 240 changing administration times on MAR 242 check interactions 214 check prior adverse reactions 214 deleting 211 descriptions 262 discontinue 212 editing 208 enter special instructions 208 entering 207 evaluate 197 hold 210 lists 266 new, adding to active MAR 242 pharmacy notification 270 PRN, documenting administration on MAR 244 resume held 211 Medications Kits window 215 Medications window 190 Hold/Resume History Tab 204 Medication Group Details Tab 205 Medication Hold and Resumption Details Tab 202 Medication Order Entry Tab 198 Modification Details Tab 200 MediSpan Prior Adverse Reaction Check window 213 636 mental status entering/editing 91 mileage 308 entering for a visit 328 My Day 385 about 384 Field Mode 347 Generate and Print Assignment Report 410 Generate and Print Lab Results Report 411 Generate and Print List of Imported Medications 411 Generate and Print OASIS Due Alert Report 411 Generate and Print Recertification Alert Report 410 Generate and Print Reservations Report 410 My Schedule 386 Set Default View on field device 408 View My Favorites 409 View My Patients 409 View My Schedule 409 View My Tasks 409 My Day overview 385 My Day window 385 My Favorites View from My Day 409 my favorites 395 my favorites section 395 My Patients View from My Day 409 my patients 396 my patients section 396 My Schedule My Day 386 View from My Day 409 My Schedule section 386 My Tasks View from My Day 409 my tasks 388 my tasks section 388 N New Assessment window 432 New Medication window 218 New Patient window 36 normal values indicating 441 Clinical Documentation User’s Guide Index notes entering clinical 105 entering for assessments 440 NPI options for Admission & Status 48 O OASIS abbreviated assessment 419 OASIS assessment Condition Change report 463 OASIS assessments 414 about exporting 496 alerts due 508 Assessments Export Report 506 correcting errors in 422 exporting 505 OASIS key icons 416 patient condition changes 414 predictive probability of risk 449 registers data 506 validating 422 OASIS Due Alert Report Generate from My Day 411 OASIS Due Alert report 508 previewing 509 printing 509 oasis due alert tab 402 OASIS due alerts previewing 511 printing 511 OASIS Due Alerts window 510 OASIS Export window 497 OASIS Exports viewing registers data for 507 OASIS key icons 416 On‐Call Summary report 152 previewing 153 printing 153 Open Orders report 295 order approving 279 printing 279 order run creating 277 selecting to process 278 Clinical Documentation User’s Guide orders audit report 296 creating 274 editing general clinical information 90 entering general clinical information 90 entering/editing DME/supplies, safety, diet, alergies 91 open orders 295 Orders Management window 41 posting signed orders 283, 284 previewing 294 printing patient 40 printing signatures 44 recertification alerts 295 rejecting 285 reprinting by patient 281 reprinting by run 282 retrieving signatures 44 orders audit report generating 296 Orders Management window 41 Orders Recertification Alert report 295 Orders Signature window 290 orders, signed accelerate posting 285 organizations determining field device licensing 356 overview adverse events 578 co‐signature 606 P PAR check 214 patient about Patient Basic information 31 add medication kits 216 add special medication instructions 209 assessment history report 491 assessment report 484 check medication interactions 214 check prior adverse reactions for meds 214 clinical monitoring data 551 create clinical data trend 560 deleting medications 211 discontinue medications 212 637 Index documents Active Orders report 287 Falls report 598 Infections report 601 Medication Evaluation report 252 Visit Record report 124 editing medications 208 entering assignments 95 evaluate medications 197 hold medications 210 medication groups 209 medications 207 resume held medications 211 special medication instructions 208 view clinical data 556 patient assessments 413 Patient Basic about Patient Basic information 31 Patient Basic window 31 patient condition changes 414 Patient Data Report 563 Patient Diagnoses Group Dates window 74 Patient Documents Visit Record window 130 Patient Education report 144 previewing 145 printing 145 Patient Expired ICD9 report 154 previewing 155 printing 155 patient falls report 598 patient infections report 601 patient labels previewing patient 143 printing patient 143 Patient Labels window 142 Patient list management in Field Mode 354 Patient lists Field Mode 354 patient signature capturing through TimeLog 329 patient signature document previewing and printing 148 638 patient tasks previewing patient 151 printing patient 151 Patient Tasks window 149 patient’s active orders 287 patient’s adverse events 592, 595 patient’s assessment history 485 patient’s falls 579 document 582 patient’s infections 583 patient’s infectious diseases document 587 patient’s medications 190 patient’s reading level note 550 patient’s revision history 565 patient’s system infections document 586 patient’s visit record 124 patients about admissions 47 about readmissions 47 about status 47 adding 38 admissions 49 admitting 64 clinical notes 105 determining which ones users can download during Synchronization 363 discharging 65 discontinuing diagnoses for 77 discontinuing problems 175 documenting progress 178 editing 486 information 133 editing address & phone number 35 editing assignments 96 editing personal information 34 editing projected visits 115 education 144 entering 485/CPOC information 90 entering 486 information 133 entering address & phone number 34 entering diagnoses 76 entering personal information 34 entering projected visits 114 entering referrals 66 entering supplies 327 entering visits 327 Clinical Documentation User’s Guide Index expired ICD9 codes 154 inactivating address & phone number 35 physicians 49 pre‐admissions 39 previewing care plans for 168 previewing Charting History for 185 previewing charts/clinical notes for 110 previewing discharge summaries for 84 previewing face sheets for 140 previewing medication lists for 269 previewing OASIS due alerts for 511 previewing orders 294 previewing patient labels for 143 previewing patient tasks for 151 printing assessments for 494 printing care plans for 168 printing Charting History for 185 printing charts/clinical notes for 110 printing discharge summaries for 84 printing face sheets for 140 printing medication descriptions for 265 printing medication lists for 269 printing OASIS due alerts for 511 printing orders for 40 printing patient labels for 143 printing patient tasks for 151 problem reports 186 readmitting 69 reprinting orders by 281 reviewing general clinical information for 92 selecting 34 status 49 viewing previous assessments for 443 PDA workflow 28, 29, 30 permitted activities entering/editing 91 Pharmacy Medication List previewing 272 printing 272 Pharmacy Medication List report 270 phone calls connecting assessments to 440 phone numbers editing for patients 35 entering for patients 34 inactivating for patients 35 Clinical Documentation User’s Guide post signed orders 285 posting signed orders 284 posting signed orders 283 pre‐admissions admitting a patient 46 authorizations 40 deactivating a patient 46 generating orders 43 Orders Management window 41 signing orders 43 preadmissions patients 39 precaution protocols entering/editing 91 preview co‐signature 611 preview, print, or save Template Edit report 522 previewing accumulated Visit Records 129 Active Patients by Discipline report 188 Active Patients by Problems report 187 Assignments report 98 Charting History 185 charts/clinical notes 107 Contract Services Report 82 demand care plans 169 medication lists 267 OASIS Due Alert report 509 OASIS due alerts 511 On‐Call Summary report 153 patient care plans 168 patient charts/clinical notes 110 patient discharge summaries 84 Patient Education report 145 Patient Expired ICD9 report 155 patient face sheets 140 patient labels 143 patient medication descriptions 265 patient medication lists 269 patient tasks 151 Pharmacy Medication List 272 639 Index print or preview Active Orders report 289 Adverse Events report 597 Assessment History report individual patient 491 multiple patients 492 Assessments report 484 Falls report 600 Infections report 604 Medication Evaluation report 255 Orders Signature report 292 Scales report 571 printing accumulated Visit Records 129 Active Patients by Discipline report 188 Active Patients by Problems report 187 Assignments report 98 Charting History 185 charts/clinical notes 107 Contract Services Report 82 demand care plans 169 medication lists 267 OASIS Due Alert report 509 OASIS due alerts 511 On‐Call Summary report 153 order 279 patient care plans 168 patient charts/clinical notes 110 patient discharge summaries 84 Patient Education report 145 Patient Expired ICD9 report 155 patient face sheets 140 patient labels 143 patient medication descriptions 265 patient medication lists 269 patient orders 40 patient tasks 151 Pharmacy Medication List 272 prior adverse reactions check 214 PRN medications adding to MAR 241 PRN Medications Administered With and Without Response Recorded report printing 259 PRN visits indicating in TimeLog 328 640 Problem Charting 176 problems assigning 174 discontinuing 175 documenting progress 178 entering goals 174 entering interventions 175 overview 172 reports by discipline 188 reports by patient 186 Problems window 172 processing results co‐signature 618 profiles overview 173 prognosis editing 92 entering 92 progress documenting for patients 178 viewing for assessments 442 projected visits editing 115 entering 114 Projected Visits window 111 protocols entering/editing 91 R reactivating assessment tabs 442 Readmit Action window 68 readmitting patients 69 reason changing for assessments 451 reassessment indicating topics for 443 Recertification Alert Report Generate from My Day 410 recertification alert tab 399 records processing co‐signature 615 referrals entering for patients 66 registers data 506 viewing for OASIS Exports 507 Clinical Documentation User’s Guide Index rejecting orders 285 releasing assessments 455 reports Active Orders 287 Active Patients by Discipline 188 Active Patients by Problems 186 Adverse Events 592, 595 Assessment History 485 Assessments 474 Assessments Export Report 506 assignments 97 care plan 166 Charting History 180 charts/clinical notes 106 Contract Services report 78 co‐signature 620 Encounter Date 305 Falls 598 Infections 601, 602 Lab Results report 572 Medication Administration Actual vs Scheduled 248 medication descriptions 262 Medication Evaluation 252, 254 medication lists 266 OASIS Due Alert 508 On‐Call Summary 152 Open Orders 295 orders audit 296 Orders Recertification Alert 295 Orders Signature 290 Patient Data 563 Patient Education 144 Patient Expired ICD9 154 Pharmacy Medication List 270 Scales 567 Visit Record 124 reprinting orders by patient 281 orders by run 282 Reservations Report Generate from My Day 410 reservations tab 401 reserve an assessment 454 resolving visits in Host Mode 308 Clinical Documentation User’s Guide response to PRN medication documenting on MAR 244 resume medications 211 reviewing generalclinical information for 92 revision history 457 reviewing 458 Revision History window 565 RFA changing 451 run reprinting orders by 282 S safety entering/editing for orders 91 save changes in Assessment Editor 516 Scales report 567 scheduled times clearing for visits 330 scheduled, documenting administration on MAR 243 scheduling software updates 355 scheduling lookahead determing on field devices 362 search co‐signature 607 Select Assessment window 62 Select Medication window 220 selecting order run to process 278 patients 34 services contract 78 printing contract 82 services, Bereavement about entering 307 Setting Up Batch Timelog 331 Show Fields window 217 signature MAR 245 printing from orders 44 retrieving from orders 44 signed orders posting 283 641 Index software updates scheduling 355 Staff Services Entry about 307 Subtabs Abdominal Girth 543 Blood Pressure 536 Chest Circumference 542 Extremity 541 Glucose 545 Head Circumference 540 Height 537 Peak Flow 547 PR/INR 546 Pulse 534 Pulse Oximetry 544 Respiration 535 Temperature 533 Weight 538 supplies 308, 327 entering/editing for orders 91 sychronization 456 Synchronization determining which patients users can download 363 setting up field devices for initial 358 synchronization logs retaining on field devices 362 system administrators Field Mode 353 Medication Hold and Resumption Details 202 Medication Order Entry 198 Modification Details 200 Scales 548 Spirometry Peak Flow Subtab 547 Vital Signs Blood Pressure Subtab 536 Pulse Subtab 534 Respiration Subtab 535 Temperature Subtab 533 tabs deactivating in assessments 442 reactivating in assessments 442 Template Edit report 521 time entering for a visit 328 time sheet 308 TimeLog about 307 completing 326 starting 325 TimeLog window 308 indicating PRN visits in 328 topics indicating for reassessment 443 transfer creating a summary 439 travel 308 entering for a visit 328 T U Tabs Hold/Resume History 204 Labs Glucose Subtab 545 PT/INR Subtab 546 Pulse Oximetry 544 Measurements Abdominal Girth Subtab 543 Chest Circumference 542 Extremity Subtab 541 Head Circumference Subtab 540 Height Subtab 537 Weight Subtab 538 Medication Group Details 205 Undocumented Medication Administration report printing 261 updates software 355 users enabling to work in Field and Host Modes 357 enabling to work only in Field Mode 357 642 V validating OASIS assessments 422 view clinical data 556, 560 Clinical Documentation User’s Guide Index View Across Periods window 75 View Clinical Data window 556 create Patient Data Report 563 create trend 560 View Orders window 293 viewing certification periods 115 previous assessments 443 registers data for OASIS Exports 507 Visit Record 124 Visit Record report 124 Visit Record window (Orders>AccumDocs) 124 Visit Records previewing accumulated 129 printing accumulated 129 visits 308, 327 about entering prior to admission 307 about resolving in Host Mode 308 about verifying 307 clearing scheduled times 330 connecting assessments to 440 editing projected 115 entering prior to admission 69 entering projected 114 entering times, durations, travel, mileage 328 recording indirect time 326 Clinical Documentation User’s Guide 643 ...
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This note was uploaded on 09/01/2011 for the course HEALTH IT 345 taught by Professor Jones during the Spring '10 term at Wayne State University.

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Clinical_Documentation_UG - Allscripts Homecare Clinical...

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