Hi Tech Software Solutions Are You Still Handwriting Care Plans?

Transcription

1 Are You Still Handwriting Care Plans? Care Plans/Service Plans... 2 Overview... 2 Edit Care Plan Edit Service Plan... 4 Auto RAP/CAA Driven (for Nursing Care)... 5 Auto RAP/CAA Driven: Edit Resident Care Plan Screen... 8 Manual Selection... 9 Edit Resident Care Plan Screen (Manual and Auto RAP/CAA Driven) Other Edit Care Plan Buttons and Features Other Care Plan Options View Care Plan Sort Care Plan Update Goal Target Dates Print Care Plan Print Evaluations Care Plan Reporting Goal Review Problem History Problem, Goal, Approach (PGA) Library Library Problems Library Goals Library Approaches Print the Problem/Goal/Approach Library Link CAAs to Problems Print CA to Problem Links Save Care Plan in Document Storage G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 1

2 Care Plans/Service Plans Clinical: Nursing Care > MDS / Care Plans > Care Plans Clinical: Res Care / Asstd Living >RCA / Service Plans > Service Plans Overview The Care Plan programs allow you to maintain, view and print residents problems, goals, and approaches. You can report on these records through various reporting programs. The System provides a Problem/Goal/Approach (PGA) Library of standardized problems, goals, and approaches that you can select and copy into a resident s care and service plans and then edit to suit the resident. You can also create highly individualized records within a resident s care/service plan. IMPORTANT: The Nursing Care PGA library available before November of 2009 is based on the diagnoses defined by the North American Nursing Diagnoses Association (NANDA) in With Release 9.10 in November 2009 Hi Tech redesigned the Care Plan programs and made available a new library based on client input. You can request this library from Hi Tech and replace your current library. If you install the new library, you must start new care plans on all your residents. You can do this as each resident s care plan comes due. Clients who install the Clinical Record System after November 2009 will automatically receive the new library. CA driven Care Planning for Nursing Care: The Nursing Care PGA Library is cross referenced to the Care Areas (CAs). During your CAA Summary process, you can view a resident s triggered CAs and the suggested problems for care planning those CAs. HTS recommends the following number scheme for the PGA Library Nursing Care facilities Create additional problem records for your facility's Do not use for Library problems. Edit Care Plans allows you to enter numbers in the 200 range to create highly individualized problems for a specific resident I Care Plan Language Residential Care Service Plans Your choice G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 2

3 Problem, Goal, Approach Attachments You may assign individual approaches to each goal. If you have two or more goals and the approaches for all goals will be the same, attach the approaches to the first goal: Multiple Goals that have the same approaches Problem 1: Goal 1 Goal 2 Approach 1 Approach 2 Approach 3 Multiple Goals with Specific Approaches Problem 1: Goal 1: Approach 1 Approach 2 Approach 3 Goal 2: Approach 1 Approach 2 Approach 3 Clinical: Nursing Care: Clinical: Res Care / Assisted Living: G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 3

4 Clinical: Nursing Care: Clinical: Res Care / Assisted Living: CP20 Edit Care Plan Edit Service Plan Enter the Resident Id or click the binoculars icon to look up the resident. Verify the CP Date (care plan date). Change the date if necessary. Edit Care Plan: Auto RAP/CAA Driven: (Nursing only) See page 5. Manual Selection: See 9 View Care Plan: See page 17. Sort Care Plan: See page 18. Update Goal Target Dates: (Nursing only) See page 19. Delete Entire Care Plan: Do you wish to delete the entire Care Plan? Yes or No. NOTE: This Delete option is available to delete old care plans that are obsolete, never used or never active; however, as you move toward an Electronic Medical Record, you will not want to use the Delete option so that all previous Care Plans remain part of the EMR. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 4

5 Edit Care Plan (continued) Auto RAP/CAA Driven (for Nursing Care) CAA driven care planning works best when you follow the sequence below: 1. Edit MDS and Print MDS 2. Edit CAAs through Edit MDS > Section V. Select those to be care planned. 3. Print CAA Summary (Section V). 4. Edit Care Plan based on the Care Areas (CAs) selected to be care planned. The CAs selected for care planning will be passed to Edit Care Plan and displayed on the Select RAP/CAA Areas screen (on right). NOTE: the program selects the CAA record based on the current comprehensive MDS 3.0 and displays the date at: Using MDS date. If this is not the correct CAA record, click Cancel and Edit RAPs/CAAs for a different MDS. The screen checkmarks triggered Care Areas (CAs) selected for care planning. You can uncheck any item you do not want to care plan now. You can click Clear to remove all check marks, and then check only the items you want to care plan at this time. Return to the care plan later to care plan the other CAs. Click Ok when you have made your selections. This will display the Select Problems screen (next page). G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 5

6 Select Problems The screen displays the first Care Area (CA) selected from the Select RAPs/CAAs screen. In a new care plan All Linked Problems is selected to display problems linked to this CA in the Problem, Goal, Approach (PGA) Library (through Libraries > MDS / Care Plans > Links CAAs to Problems). If this is an existing care plan, the screen will default to Current Problems and display existing problems already in the care plan. Problem numbers will be highlighted in blue. Under Include Status you select (R)esolved and (I)nactive to include those Types. Select the Type. See more about Type on Page 7. See Page 7 Select All Linked Problems to display both existing problems and other problems linked to this CA in the PGA library. Select problems you want to add. Deselect problems you do not want to add or edit in this care plan. (Current Problems highlighted in blue will remain in the care plan, even if you do not select them.) Click Ok to save the selected problems in the resident s care plan and display the Edit Resident Care Plan screen so you can edit the selections. See next page and additional instructions on Page 10. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 6

7 Problem Type On the Edit Resident Care Plan screen you assign a Type to each problem. A new problem always defaults to Active. Click the down arrow in the Type field to select a different Type. You can assign the Resolved or Inactive Type to a problem that should no longer be displayed or printed on the resident s care plan; however, you can display the problem and change the type back to Active, Maintenance, or Potential to include it in the displayed/printed care plan. On the Select Problems screen, the default is to list only the Active, Maintenance and Potential problems. You can select (R)esolved and (I)nactive to also list those types of problems. The Status column indicates the problem type, i.e. R = Resolved, I = Inactive, A = Active, etc. Changing the Type creates a record for this problem in the Care Plan problem history file. NOTE: We discourage you from deleting Resolved of Inactive problems because it will delete them from care plan history; however, if you add a problem in error, you can delete it. Display the problem on the Edit Resident Care Plan screen and select Delete Problem. Care Plan Problem History File When you add a problem to a care plan or change the Type this adds a record to the Care Plan History file. To view the History file select Reporting > Care Plans > Problem History. Enter the Resident ID. At Problem enter a problem number or check All to display the resident s entire history; or, click the binoculars to display a selection list. Click the problem and Ok (or double click the problem). Click Run to print the history. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 7

8 Auto RAP/CAA Driven: Edit Resident Care Plan Screen The CA number and description will be displayed. Verify the Date. See Page 7. Select the Type. See more about Type on Page 7. Edit the Problem text for this resident s conditions or needs. Press the [Insert] key on your keyboard to insert text. Select goals and approaches from the library and edit them. See Page 10 for instructions. When you finish editing the problem and its goals and approaches: Click Next in the Problem area to edit the next selected problem. Select Next in the CA (top right) to select problems for the next CA. When you click Next, Prev and Exit Care Plan all your changes are saved. TIP: To write your own problem text, at Lib# enter a number from 200 through 299. Enter Goal and Approach numbers of (There are no goals or approaches attached to problems in the 200 range.) When you return to this care plan and reselect this CA, the Select Problems screen will display the Current Problems for this CAA with problem numbers highlighted in blue:. An X in the G/A column indicates that Goals and Approaches are attached to the problem. The Status column shows the status assigned to the problem. Select All Linked Problems to display problems linked to this CA in the PGA library. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 8

9 For Nursing Care, Residential Care and Assisted Living. Manual Selection Select Problems Displays the Select Problem screen and lists All Library Problems. Select the problems you want to add to the care plan. The full description of the last selection will display at Current Selection. TIP: To write your own problem text, at Lib# enter a problem number from 200 through 299. Enter Goal and Approach numbers of There are no goals or approaches attached to problems in the 200 range.) Click Ok to display the Edit Resident Care Plan screen so you can edit the problem and select goal and approaches from the library. See the next page. IMPORTANT: When you click the OK button this saves the selected problems in the resident s care plan. To remove the problem from the care plan, you must Delete Problem on the Edit Resident Care Plan screen. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 9

10 Edit Resident Care Plan Screen (Manual and Auto RAP/CAA Driven) PROBLEM: The first selected problem will be displayed. If you did not select any problems on the Select Problems screen, the PROBLEM area will be blank. You can enter a problem number at Lib #, or click the binoculars to redisplay the Select Problems screen. CAA: will display a CA number if you are in Auto RAP/CAA Driven mode. It will display Manual Selection if you are in Manual mode. Date: Verify the date. A new problem is recorded in care plan history on this date. See Page 7. Select the Type. See more about Type on Page 7. Make any necessary changes to the text for this resident. Press the [Insert] key on your keyboard to insert text. Typically, you will edit the Problem and immediately select the Goals and then Approaches. You will then return to the PROBLEM area and click Next to process the next problem. If you move to the next problem without selecting goals, the program will alert you: There are no Goals attached to this Problem. You can easily return to existing Problems to select and edit Goals and Approaches. See the Goal Selection process on the next page. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 10

11 Select Goals In the GOAL area, click the Lib# field and the binoculars to display the Select Goals screen. This displays all goals attached to this problem in the PGA library. Select the goals to be added to this care plan. Click Ok. This saves the Goals in the care plan and displays the first selection on the Edit Resident Care Plan screen. Delete will delete this goal from this problem in the care plan. NOTE: a goal that is already in the care plan will be highlighted in blue. The first selected Goal will be displayed. If you selected multiple goals, there will be a Next button. When you click Next, the next Goal will provide a Prev button. Clicking these buttons saves all changes that you have made in the goals. TIP: At Lib#, enter to create your own goal. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 11

12 Edit Goals Date: will default to the Care Plan date. You should change it to represent the date you are adding the goal. Click the binoculars to display a calendar (on right) from which you can select a date, or manually enter a date. Target Date: (Nursing Care only) You can assign a Target Date to the goal. Target dates will be included on printed care plans, and you can use the Update Goal Target Dates feature to update Target dates for all goals. See Page 19. Days: This will default to the days set up in your Clinical Profile (see IMPORTANT below). You can change this number to calculate the target Date, or enter a date, or click the binocular to display a calendar (above) from which you select a date. IMPORTANT: You can set up your own Target Date Days to display for each new goal (i.e., 84 for 12 weeks). Select Libraries > Facility > Clinical Profile > Screen 2. Under Care Plan Settings, at Default Target Days enter the default number of days. If you do not want to record and print Target Dates, enter 00. Edit the Goal text. All changes are saved automatically. Press the [Insert] key on your keyboard to insert text. Typically, you will then select and edit Approaches for this Goal. Then, if there are other Goals to be edited, you can return to the GOAL area, click Next and repeat the process. See Select Approaches on the next page. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 12

13 Select Approaches APPROACH Click in the Lib# field and click the binoculars to display the Select Approaches screen. This displays all approaches attached to this goal in the PGA library. Select the approaches you want to attach to the displayed goal in this care plan. When you click Ok these approaches will be saved and displayed on the Edit Care Plan screen. NOTE: An approach that is already in this care plan for this goal will be highlighted in blue: The approach will be attached to the Goal displayed in the GOAL area If you selected multiple approaches click the Next button to display the next approach. That approach will provide a Prev button so you can move back to the previous approach. Clicking these buttons saves all changes you have made. TIP: At Lib# enter a number from to create your own approach G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 13

14 Edit Approaches Edit the approach text for this resident. To assign additional staff codes to the approach, click Select Discipline and check mark the disciplines that will help carry out this approach (see Select Disciplines list on the right. Build and edit these codes through Libraries > Face Sheet > Disciplines). If you select NA (Nurse s Aide for Clinical: Nursing Care) or RA (Residential Care Aide for Clinical: Residential Care) this will allow you to include this approach on the Resident Flow Sheet and assign a Frequency Code to the approach that will also be printed on the Flow Sheet. Click the binoculars at Frequency Code to display the Frequency Code library and select the code. Your selection will be displayed under Frequency Code: (see below). Edit your frequency codes through Libraries > Orders/Flow Sheet/Kardex > Frequency Codes > Flow Sheet. When the approach is complete, click Next to display and edit the next selected approach. When there are no more approaches to edit: Return to the GOAL area and select the Next goal or Move back to PROBLEM area and select the Next problem. If you are in Auto RAP/CAA Driven mode you can select the Next CA. OR click in Lib # in any area. Enter a Library number or click the binoculars to display the library selection screen. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 14

15 Other Edit Care Plan Buttons and Features Copy and Paste Text Copy text from a problem, goal or approach and paste it into another area. 1. Display the text. Drag over the text with your cursor to highlight it. 2. Right click with your mouse and select Copy from the pop up window. 3. Display the area where you want to paste this text. 4. Right click with your mouse and select Paste. 5. Edit the text if necessary. Write your own Problems, Goals and Approaches At Lib # enter a problem number from 200 through 299. Enter Goal and Approach numbers from 200 to 299 and make these items resident specific. [NOTE: If you add an item that you will want to use in other residents care plans, rather than use the 200 range numbers, add these items to the Care Plan Library so you can select and pulled the items into other residents care plans.] G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 15

16 Edit Care Plan Button Options These buttons are available at the bottom of the Edit Care Plan screen: Exit Care Plan saves all changes. Edit Notes allows you to add and edit notes for this resident. Edit PGA Library to access the PGA library. See page 26. Your facility can restrict access to this option to guard against unauthorized changes. Staff with access to Libraries > MDS/Care Plans > P/G/A Library will have access here. View Care Plan to display the care plan on the screen. See sample on Page 17. Print Care Plan See Page 20. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 16

17 Edit Care Plan > Other Care Plan Options After you select a resident on the opening care plan screen, you can select these other options. View Care Plan Display the Care Plan for the selected resident. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 17

18 Edit Care Plan > Sort Care Plan Through Print Care Plan, the problem print order will be default to Library Problem Number. Using Sort Care Plan you can assign two different Sort Orders and problems sorted in those orders (see Select Sort Order options on the right). In the # column assign numbers in the order you want the problems to print when you select Your Assigned Problem Number in Print Care Plan. This allows you to print a resident s most important problems first. In the Std column you can assign each problem to a CA in the Standard Problem List on the right side of the screen. You can print in this order by selecting Standard Problem Number in Print Care Plan. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 18

19 Edit Care Plan > Update Goal Target Dates In Clinical: Nursing Care you can assign Target Dates to goals. Update Goal Target Dates displays a resident s problems and goals so you can review and change Target Dates. Check the box for the Goal to be updated. This changes the CP Date to the date entered on the opening screen (on right). You can edit the Target Days and Target Date. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 19

20 MDS / Care Plans > Care Plans RCA / Care Plans > Care Plans Print Care Plan The print program allows you to make many choices for printing the care plan: See samples on the next page. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 20

21 Page 1: Diagnoses, allergies, Discharge Plan, Weight and Problem List NOTE: Some items will be printed depending on specific settings within the Hi Tech program. Page 2: Problem / Goal / Approach format You can print lines in the Notes column to ease the addition of hand written notes. Go to Libraries > Facility > Clinical Profile > Screen 2 > Care Plan Settings and check Print note lines in Care Plans. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 21

22 MDS / Care Plans > Care Plans RCA / Care Plans > Care Plans Print Evaluations CP69 (Nursing) Print a form that can be used to document care plan goal progress for up to three months so that you are more prepared to evaluate goals each quarter. Date: Accept the current date. It will print at the top of the page. Resident to Print: Individual and enter the resident ID. All: To print for the entire facility and whether to print forms for Discharged Residents. Disciplines. Click All to print all goals in the care plan. If you want to print only those goals that have approaches assigned to a specific discipline, enter that discipline code, or click the binoculars to display a list of disciplines, and select a goal from that list. Include Click All to print all the goals, or all the goals for the selected disciplines. Click Selective to choose the types of goals to be printed (Active, Maintenance, or Both); or you can specify the library Problem number of the goals to be printed. Optional: If you are adding these pages to an existing report, look at the page number on the last page of that report. Enter the next number at Enter Starting page Number so that the new pages maintain the page number order. Click Run. See an explanation of the form on the next two pages. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 22

23 Use the Care Plan Evaluation The Care Plan Evaluation provides a place to evaluate each goal on the care plan on three separate dates: DATE #1 DATE #2 DATE #3. Under each DATE, record the evaluation of the goal at that date. The Roman numerals I, II, and III are explained in the legend on the top right of the first page of the evaluation: I Status: (A)ctive (S)upport (R)esolved II Evaluation: (S)table (F)luctuating (I)mproving (D)eteriorating III Documentation Reference (P)rogress note (M)ar (T)reatment record (O)ther (specify) At OTHER you can make any other necessary comments about the goal. See a detailed explanation on the next page. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 23

24 Monthly Care Plan Evaluation Code Legend and Guidelines I. Status (A)ctive: Actual problems/needs and potential problems of an immediate nature and with active intervention. Goals and approaches should be moving toward resolution or a decrease in the nature of extent of the problem. Consideration should be given to problems identified by type as (A)ctive or (P)otential (immediate) on the Care Plan, such as open wounds, infections, and potential for injury where there would be an immediate problem without intervention. (S)upport: Problems/needs for which maximum rehabilitation or restoration has been achieved, but for which interventions continue to be required in order to maintain function and/or prevent deterioration, i.e., supervised ADLs, assisted mobility, etc. Consider whether problems identified by type as (M)aintenance on the CP continue to need staff support. (R)esolved: Problems which no longer exist as described in either of the above areas. In addition to identifying the problem as resolved in the monthly evaluation, the problem on the care plan itself should be noted as resolved, dated, and signed. II. Evaluation (S)table: Identified approaches are documented as effective in achieving the stated goals. No adjustments in the goal and no additional approaches are required. (F)luctuating: Documented evidence shows a variation in the response of the resident to established approaches. For example, there may be days when anxiety is well controlled using established approaches, and other days when increased anxiety is evident. In identifying a problem as fluctuating, it's important to consider the need to adjust goals or approaches. (I)mproving: Documentation reflects evidence that the approaches are moving the resident toward achievement of a goal, i.e., wound size is diminishing, etc. (D)eteriorating: Documentation reflects that, despite the established approaches, the resident's condition is relation to the problem is declining, (i.e., a wound size is increasing or there is evidence of infection, etc.) The evaluation documentation should include evidence that the goals and approaches continue to be appropriate despite the deterioration or that they have been adjusted in order to prevent further deterioration. III. Documentation Reference: This section provides a cross reference to substantiate evaluation information, i.e. if a wound has been identified as "active" and "stable", the evaluator may cite the treatment record as the documentation for this evaluation. In the event that an evaluator must make an evaluative decision which is not adequately addressed in existing documentation, such as having to adjust goals or approaches, a brief note might be in order. That can either be done in progress note or on an evaluation summary. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 24

25 Reporting > Care Plan > Care Plan Reporting Goal Review CP70 Nursing Care only. Res Care and Assisted Living do not enter Target Dates for goals. Display or print a list of goals that have Target Dates within a specific date range. (A goal must have a specific date entered at Target Date in the goal record. If you bypass Target Date and type the date within the text of the goal, this program will not locate the goal.) Census Date. The program will compare this date to residents Admit and Discharge Dates in the face sheet. If you select Target Dates for All residents, the program will locate goals only for those residents in the facility on this date. Select Target Dates to Print: HTS recommends that you select Range and enter a date range. If you select All, the program might print several pages that you don t need. Sort by Unit. No: locates goals for entire facility and lists them in order by Resident ID. If Yes, you can leave the check mark at All to list goals for the entire facility, sorted by unit. Or click to remove the check mark, All, and enter a specific Unit ID number. Page Break by Resident: to print each resident on a different page. Print Goals Only: To print just goals and not any problem text. Problem History CP67 Edit Care Plan keeps a history of all problems added to residents care plans and any changes made in the problem Status. HTS recommends the Library sort order. Sorting by Standard Problem Number will not work unless you have sorted your care plan through the Edit Care Plan. Problem: enter a library Problem number, or press the [F2] key to display a list of the resident s problems and select a problem from this list. Check mark All to display all of the resident s problems in history. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 25

26 Problem, Goal, Approach (PGA) Library The Problem/Goal/Approach Care Plan Library The Nursing Care PGA library available before November of 2009 is based on the diagnoses defined by the North American Nursing Diagnoses Association (NANDA) in HTS worked with a nurse /administrator to select the problems appropriate for long term care, and to develop goals and approaches for the long term care environment. NANDA has updated its diagnoses since 1994; however, Hi Tech did not incorporate these updates into the NANDA based library. See IMPORTANT below. IMPORTANT: With Release 9.10 in November 2009 Hi Tech redesigned the Care Plan programs and made available a new library, also based on client input. You can request this library from Hi Tech. If you install the new library, you must start new care plans on all your residents. CAA/RAP driven Care Planning for Nursing Care: The Nursing Care PGA Library is cross referenced to the Care Areas. During your CAA process, you can print a listing of a resident s triggered CAs and the suggested problems for care planning those items. HTS recommends the following number scheme for the PGA Library Nursing Care facilities Your facility's additional problem/need records Do not use for Library problems. Edit Care Plans allows you to enter numbers in the 200 range to create highly individualized problems for a specific resident I Care Plan Language Residential Care Your choice Clinical: Nursing Care > Libraries > MDS / Care Plans > P/G/A Library Clinical: Res Care / Asstd Living > Libraries P/G/A Library G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 26

27 CP21 Library Problems At Lib # enter a problem number or click the binoculars to display the Select Problems screen. Note: In a Nursing Care facility, the problem list will begin with problem In a Residential Care of Assisted Living facility, the problem list will begin at number 300. Select a Problem and click OK to display the problem and its first attached goal, and that goal s first attached approach. If you select multiple problems you can scan through them using Next and Previous buttons on the Edit screen. Selecting these buttons saves your changes. Make necessary changes in the text areas of the screen. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 27

28 You can create new problems, goals and approaches by entering an unused number in the Lib # field. The screen will display the message like: Add New Problem Here. TIP: Avoid using numbers from for new problems, goals or approaches. The Edit Care Plan program allows you to enter numbers to create highly individualized, non library problems, goals and approaches within a resident s care plan. Additions and changes are saved automatically unless you click the Cancel button. When you add a new goal it will be attached to the Problem displayed on the screen. When you add a new approach it will be attached to the Goal that is displayed. If you delete a Problem it will delete all attached Goals and Approaches. If you delete a Goal it will delete all attached Approaches Library Goals Select and display the problem. Display the Select Goals screen and select a goal. Under GOAL: edit the goal text. Enter an unused Goal number to create a new goal for the Problem displayed on the screen. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 28

29 Library Approaches Under APPROACH, click the binoculars to display the Select Approaches screen (on right). All approaches are checked because they are all attached to this goal. Click Ok to display each of these for editing. To delete an approach from the goal, click Uncheck All then select each approach that should NOT be linked to this goal. Click Delete. The program will ask Are you sure you want to delete all selected approaches. Click Yes. On the Edit Problem, Goal, Approach Library screen, edit the approach if necessary. To assign additional staff codes to an approach, click Select Discipline and check mark the staff that will help carry out this approach (see Select Disciplines list on the right). If you select NA (Nurse s Aide for Clinical: Nursing Care) or RA (Residential Care Aide for Clinical: Residential Care) this will allow you to include this approach on the Resident Flow Sheet and assign a Frequency Code to the approach that will also be printed on the Flow Sheet. You can also assign a Frequency Code to the approach that will print on the resident s Flow Sheet. Click the binoculars at Frequency Code to display the Frequency Code library and select the code. Your selection will be displayed under Frequency Code (see below). Edit your frequency code library through Libraries > Orders/Flow Sheet/Kardex > Frequency Codes > Flow Sheet. When the approach is complete, click Next to display and edit the next selected approach. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 29

30 Print the Problem/Goal/Approach Library CP22 On the Edit Problem/Goal/Approach Library screen, click Print P/G/A button on bottom right. Report Date will be printed at the top of the listing. It will not be used to select records. At Page Break on Problem, if you plan to print Problems/Goals/Approaches, HTS recommends Yes for a page break so that the listing is easier to read and use. If you plan to print Problems Only, HTS recommends No page break. Several problems will be printed on each page. This uses less paper. Problems to Print All to print all the problems. This could print 100 to 200 pages. Individual to print a specific problem record or a range of records. Include: Problems Only prints only the text of the selected problem records. Several problems can be listed per page. Combine with Page Break on Problem No to avoid printing each problem on a separate page. Problems & Goals Only prints only Problems and their attached Goals. Problems/Goals/Approachesy Each problem could require 1 3 pages. HTS recommends Page Break on Problem Yes between problems, even though it will require more paper. Click Print. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 30

31 Clinical: Nursing Care >Libraries > Care Plans Link CAAs to Problems HTS has already provided a file of CA to Problems Links. These links remain in effect as CA to problem links, which suggest problems for addressing triggered CAs. You can add, change and delete links to suit your facility, and you can build links to problems for the new CAs: 19 Pain 20 Return to Community Referral. For example, for Pain, enter in the CA number, 19, and checkmark the problems to be suggested when this CA is triggered. On the screen below, we checked 0092 Alteration in comfort related to episodes of breakthrough pain. Other suggestions for 19 Pain from our sample library: For 20 Return to Community Referral Your library may differ from the one used in these examples. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 31

32 Libraries > Care Plans > Link CAs to Problems Print CA to Problem Links CP01 Click Print Report on the Link RAPs/CAAs to Problems screen. This prints a listing of selected CAAs and the problems that have been selected as suggested problems for care planning. Click the CAAs that you want to print and then click Run. See sample below. A number one 1 is printed in front of each problem linked to the CA: Release 9.10 Library 1994 NANDA based library: G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 32

33 Admission Procedures > Edit Medical Record > Save Care Plan in Document Storage To save electronic copies of residents care plans, attach a copy under Documents. Access a resident s document by clicking the Documents button on any EMR screen. This displays the Document Management screen and any documents already saved and selected for this resident. Example: Click a column heading to sort the documents by that heading criteria, i.e. File name, Description, Type, etc., alphabetically or chronologically by date. To print a document, click the View button. Use the standard print process for the program that displays the document i.e. Microsoft Word, Adobe Reader, etc. See complete instructions at TechSoftware.com > Clients > Important Instructions > Electronic Document Storage. G:\HITECH\Webinars\Webinar Docs\CarePlans.doc (Printed 7/10/12) Page 33