New Referral in Web Application Checklist

Transcription

1 New Referral in Web Application Checklist When creating a new patient to use in mobile application, ensure at leas the required data is entered. All fields underlined in the following steps are required in order for the OASIS assessment to properly validate in the mobile application. Create a new patient referral: 1. Login to Enterprise Edition and select Patients from the Main Menu. 2. Under Add New Patient/Referral, click the Patient button. 3. Enter the necessary data on the Patient/Referral page, including the patient s First Name, Last Name (required), and Office (required) and then click Next. 4. From the Address / Phones screen, enter the patient Address (required), City, State, State, Zip, and County as well as any Phones / data. Click Next. 5. Enter Demographics data, including the SSN, DOB, Sex, and Ethnicity (required) and then click Next. 6. Users can enter Diagnosis information now and it will display in the mobile application, but this can be entered later. 7. Select Medications from the Main Menu. If medication information is available for the patient, you can save time in the initial visit by entering this now. Reconciling medications during the visit (while in the patient s home) will be easier if medication data is entered in advance. Click Next to proceed. 8. Users can enter Allergies information now and it will display in the mobile application, but this can be entered later. 9. Select Physicians from the Main Menu, enter the patient s Physicians information, and then designate the Attending physician (required). Click Next. 10. Enter Insurance information for the patient (required) and then click Next. 11. Users can enter Family Caregiver information now and it will display in the mobile application, but this can be entered later. Click Next to proceed. 12. Users can enter Advance Directives now and they will display in the mobile application, but this can be entered later. Click Next to proceed. 13. You may enter all Personnel that will perform care for the selected patient while using the mobile application. Employees added from this screen will have the patient display on their My Patients list in the mobile application. 14. In the Admission / Discharge Admission screen, leave the Admit Pending box checked to leave the patient status as pending before scheduling the Start of Care Visit (required).

2 Scheduling SOC Visit in Web Application Checklist 1. Create a Physician Order: a. While in the Patients section of EE, click the Orders tab. b. From the New Order drop-down menu, select Physician Order. c. Ensure the Order Type is Assess and Evaluate and then indicate the professional Discipline that is designated to perform the assessment, the Physician, and the Begin Date. d. Click Save. The Order Frequencies grid will be enabled. e. Enter an Amount of 1. f. From the Frequency drop-down menu, select Week. g. Enter a Duration of 1. h. Click Save. i. For the Visits On line, check the box next to the day of the week for the SOC visit (this should match the selection made in the Begin Date field). j. Add the appropriate verbiage to describe the context of the order (e.g. SN to evaluate for Home Health ). 2. Click Calendar. a. Click Generate. Ensure the Generate Option is set to All and then click Save. b. In the Service menu, select a service admission that has a Start of Care workflow. c. Select employee from the Assign to drop-down menu. d. Click Save. Admitting a New Patient in the Mobile Solution Checklist 1. Login to the mobile application. If this is your first time logging in, refer to the main document for login instructions. 2. In the Schedule section, find the Start of Care visit for the desired patient. a. Tap the Document Icon ( ) to begin charting the SOC. b. You may enter the number of Miles for tracking purposes. c. Tap the Play Icon ( ) at the bottom-right to automatically populate the Time In. d. Select the Next button to the bottom-right. 3. Complete the Admin Review Admission Package process: a. Tap an Admission Document Icon ( ) to open the corresponding document and then review it with the patient. b. If no patient signature is required, simply check the box to mark as Reviewed. Homecare RN Workflow Progress Page 2 of 8

3 c. If an electronic signature is required from the patient, tap the signature field, obtain a patient signature, and then select OK. If you re obtaining the patient signature on the paper form, continue with step d. d. If necessary, take a photograph of the document by selecting the Camera Icon ( ), tap the plus sign, take the photo, and then select Save. e. After all items have reviewed, select the Next button. 4. Medications Review and Reconcile Med: a. To add a medication, tap to the right of the Medications header. b. Enter all the details for the new medication and then tap. c. If needed, users have the ability to add a Sliding Scale or Dosage Schedule. For more information about the Sliding Scale and Dosage Schedule features, refer to the Adding Medication Interactions topic in ilearning (from Enterprise Edition). d. To change details for a medication, select the desired medication and tap Change. i. Make any appropriate changes and select Update to the top-right to return to the list of patient medications. e. To discontinue a medication, select the desired medication and tap Discontinue. You will be prompted to enter a Discontinue Date (you may change the default date) and then tap OK to confirm. Alternatively, you can discontinue multiple medications by checking the boxes next to the desired medications and then tapping Discontinue to the bottom-right. f. After finished adding/changing/discontinuing medications, tap Next. 5. Medication Interactions (Drug Regimen Review): a. Review details pertaining to Interactions, Side Effects, and Duplicate Therapies by selecting a medication and then clicking the respective tab. Tap Next to proceed. 6. Assess Collect data (Comprehensive Start of Care/Resumption of Care) a. Chart patient data using the interactive SOC/ROC assessment... i. Scroll continuously to navigate through the assessment fields. ii. Use the Prev or Next to move between different sections. iii. Alternatively, you can tap the slide-out icon ( ) on the left side of the screen to activate the slide-out navigation menu and select a specific section of the interactive assessment (e.g. Vital Signs, Caregivers, Cardiac Status). 7. OASIS responses are automatically validated and results can be viewed in a slide-out display by tapping the icon on the right side of the screen (validation begins after 80% of the assessment is completed): a. A solid red asterisk (*) will constantly display next to the slide-out icon as long as there is any information that requires validation. b. A red, flashing asterisk will display next to the slide-out icon when there s new information. Homecare RN Workflow Progress Page 3 of 8

4 c. As long as your tablet is connected (via Wi-Fi or data) then OASIS responses will immediately validate, but there may be some lag, depending on the speed of your connection. d. If you re disconnected, the OASIS will not validate. 8. Plan Care plan: A care plan appropriate to the patient s medications will be present if you already entered medications for this patient (Refer to step 7. of the New Referral in Web App section). 9. Tap the Generate Care Plan button to create a care plan based on data entered in the assessment. A red asterisk (*) will display in front of each one of the new Problems that were generated. 10. Tap Expand All to display all Problems/Goals/Interventions (P/G/I) or tap Collapse All to only display the Problems. To enter text where you see the underline present in a Problem, Goal, or Intervention, long press (press and hold) the preferred item and enter the applicable text. Tap OK to confirm. 11. To remove a Problem, Goal, or Intervention: Select the desired item and then tap. If you delete a Problem then it will delete all Goals and Interventions within that Problem. If a Goal is deleted then all corresponding Interventions will be deleted. 12. To add Problems, Goals, or Interventions, tap the slide-out icon ( ) on the right side of the screen to display a list of care plan elements. Drag-and-drop functionality for care plan elements Users can use drag-and-drop functionality with Problems, Goals, and Interventions (P/G/I) to create a custom care plan for the patient: Using the slide-out menu, tap the desired tab (Problems, Goals, Interventions). Find the P/G/I element you wish to add to the care plan: o Scroll through the existing care plan elements listed in the selected tab. o Narrow the list of results by using the text field (i.e. Add a new ), to search for specific verbiage (e.g. impaired integumentary ). o Creating a care plan element If the library does not contain the desired element, type the desired verbiage into the text field (e.g. Maintain dialogue about depression ) and then tap. The newly-added care plan element will then display in the slide-out menu. Touch and hold your finger over the desired care plan element to pick up the item. If you have successfully picked up the item, a transparent image of the selected element will appear. While continuing to hold the item, drag it to the desired location in the patient s Care Plan (to the left) and then drop it by lifting your finger away from the screen. Ensure that the item is dropped precisely on top of the desired care plan element. If performed correctly, the care plan element will be grouped according the location the item was dropped (Refer to instructions that are specific to P/G/I, next page). Homecare RN Workflow Progress Page 4 of 8

5 a. Problems Select the desired Problem from the list of options and drop it to the left (below the Problems in the existing care plan). b. Goals Ensure the Problem (that was just dropped) is selected then drag-and-drop the desired Goal (from the care plan elements menu) onto the Problem. c. Interventions Ensure the Problem or Goal (that was just dropped) is selected then dragand-drop the desired Intervention (from the care plan elements menu) onto the corresponding Problem/Goal. Interventions can be dropped on a Problem or a Goal, but will most likely be grouped according to a Goal. d. Entering Text for Goals and Interventions: If there are any items that contain a blank, underlined space, enter any necessary text and click OK (This is similar to the process that was performed in Step 10). 13. Plan Collect 485 Data: Enter all data, which will synchronize with the 485 in EE. Tap Next. 14. Plan Establish Rehab Potential/Discharge Plans: Enter all details pertaining to goal/outcome(s) expectations and discharge plans, which will synchronize with the 485. Tap Next. 15. Plan Draft orders: Compose the frequency and duration of patient visits. a. Populates data from the Care Plan Interventions as the Physician Order. b. Begin Date usually defaults to the visit date for the scheduled SOC. c. If desired, enter a Range (e.g. 1-2 ). d. Compose visit entries in the Amt/Freq/Dur section by using the corresponding Amt, Freq, and Dur fields below. After specifying an Amt/Freq/Dur, check the appropriate boxes next to each day of the week when the visits will occur. Then, tap to place on the calendar. e. Repeat step d., as necessary, to add multiple frequencies and then tap Next. 16. Patient Care Category View: Document performance of care plan interventions. a. Interventions are grouped according to function (ASSESS, TEACH, or PERFORM). b. Tap on an Intervention to open the corresponding form for the task. c. Completed Interventions are indicated with a green checkmark. 17. Patient Care Problem View: This tab is where you can indicate Problems as Resolved, Goals that are Met, or Interventions that are Discontinued. Though this screen is available, it will rarely be used for Start of Care visits. 18. Patient Care Discontinued: This tab displays any Interventions that have been discontinued. 19. Plan for next visit: a. All interventions that were performed during the visit are indicated with a green checkmark. b. Check the corresponding boxes in the Next Visit column to designate Interventions that are to be performed during the next patient visit. c. If necessary, use the Enter Comments function. Homecare RN Workflow Progress Page 5 of 8

6 20. End Visit: Enter all necessary details to confirm the end of the visit. a. Obtain a Patient Signature or indicate Patient Unable to Sign. b. REMINDER: If you deferred corrections for the OASIS validation in Step 7, ensure that these corrections are made before you sign the visit. c. Tap the next field and enter your Clinician Signature. d. Tap to end the visit and populate the End Date, Time Out, and Visit Duration. e. The Visit Date, Time In, and Miles are already populated from pre-existing data. NOTE: The Start of Care visit is NOT locked on the mobile application. The visit will synchronize with the web application as Completed. Viewing Patient Details in Mobile Application (After Completed SOC) 1. My Patients: Incorporates a list of patients that are assigned to the mobile user via the Patients Intake / Referral Personnel screen in the web application. a. Tap the Main Menu icon to the top-left and select My Patients. b. Tap the slide-out icon ( ) on the left to display a list of all associated patients. c. Tap inside the corresponding box to view details for the desired patient. A variety of patient details will then be displayed across the screen. NOTE: 2. Patient View: Summary screen containing information for the selected patient that is arranged into sections, similar to My View (Latest Activity, To-Do tasks, and visits on the Schedule). a. Patient View can be opened anywhere a patient s name is displayed by tapping on the patient name (e.g. My View, slide-out display in My Patients, Any of the Schedule views). b. Tap the Person Icon ( if Safety Precautions are present and if none are present) to display common details for the selected patient (e.g. Address, Cert Period, Physician, DOB). c. Tap to view Advance Directives for the patient. NOTE: If you have a visit assigned to you for a patient then you will also see the patient in the My View login screen (inside the Schedule). If the patient has a Do Not Resuscitate order in the web application then this icon will display as. d. Tap to display any existing Allergies for the patient. Homecare RN Workflow Progress Page 6 of 8

7 Scheduling Routine Visits in the Web Application Checklist 1. Login to the web application and select the desired patient. Proceed to Patients Admission. 2. Verify that the admission date in the Date field is correct and uncheck the Admit Pending box. 3. Click the Orders tab. 4. Find the correct order in the display grid for the corresponding SOC visit you completed in the mobile application. The value in the Disc/Med column should match the discipline of the visit you completed and the Order Type should be Initial Order. 5. Click on the blue Physician Order link to open the order. 6. If desired, enter the Projected End Date and uncheck the Physician Signature Required box. 7. Click Save. 8. Ensure that data in Order Frequencies and Order (485-21) is correct. The text should contain the Interventions from the care plan. Click Calendar 9. Scroll to view the calendar and ensure that the visits are plotted correctly. If they are, proceed with Step 11. If visits are not plotted correctly, click the link. 10. Make any necessary corrections to the Order Frequencies and then click the Save button in the Order Frequencies section. 11. Click the Calendar button. 12. Click Generate. Ensure the Generate Option is set to All and then click Save. 13. In the Service menu, select the appropriate Routine Visit option. 14. Select the personnel from the Assign to drop-down menu. 15. Click Save. The visits will display with a blue color label, indicating that they are assigned, and will also display the respective service and personnel. 16. Return to the Orders tab and select the entry for the Initial Order in the grid by clicking anywhere in the corresponding row without clicking the blue link. 17. If you re agency policy requires orders to be marked as completed and locked. a. In the Document Status section below, check the Completed box and then click Save. b. Click the Electronically Sign & Lock button and then click OK to confirm. This button will then display as Unlock & Remove Signature and the Locked box will be checked. 18. Select to the top-right to view all assigned visits on the Patient Calendar. Homecare RN Workflow Progress Page 7 of 8

8 How to Create the Homecare Certification Checklist 1. Return to the Documents tab and select the Homecare Certification (485) option from the New Document drop-down menu. ATTENTION: Before proceeding, it s recommended to navigate to the main patient information tab and ensure that an entry was generated in the PPS Episodes section. 2. Review the 485 document for accuracy and then click Save to confirm details. If you wish to print the 485 and send to a physician then click Print. 3. Return to the Documents tab to complete and lock the Homecare Certification (485) document. 4. In the Document Status section below, check the Completed box and then click Save. 5. Click the Electronically Sign & Lock button and then click OK to confirm. This button will then display as Unlock & Remove Signature and the Locked box will be checked. Homecare RN Workflow Progress Page 8 of 8