Read Only and Continuation Notes - User Guide

Transcription

1 Read Only and Continuation Notes - User Guide

2 Introduction to InterRAI Getting Started The first step is to or call Jerrica Ang at ext Jerrica will send you a New User Registration Form. You return the completed form to Helena. She will provide you with a user ID and a temporary password, and with instructions on how to change this to a secure one of your choice. Read Only access Health Professionals and Providers involved in client care can access assessments and reports. The following will show you how you can access the information in InterRAI; this level of access is called Read Only and Continuation Notes. You will be able to view your clients: Demographics Assessments Outcome scores Triggered CAPs Write in Continuation Notes Care plan Print Care Plans The User Guide gives you a step by step process you can follow. It will give you some detail about the suite of interrai assessment tools. It will show you how can gain Read Only access, add to Continuation Notes, and print off reports. The InterRAI Assessment Suite is an electronic assessment tool that is used in the management of older clients and those deemed as being of like in age and interest. It started as a Residential Assessment Instrument (RAI) used in Canada and the US, but has now evolved into a suite of assessment tools that can be used on any older client in any environment. Its development has involved a network of researchers in more than 30 countries and the assessment tools are used throughout the world. Why - to promote evidence-based clinical practice and policy decisions. How - through the collection and interpretation of high quality data about the characteristics and outcomes of clients across a variety of health and social services settings. Who can assess? - In order to become an interrai assessor you must be a registered health professional and go through a certification process that involves training, assessment competencies, and taking a series of online coding exams. This process is audited with assessments marked periodically

3 so that standards are maintained and it becomes a nationally recognised qualification. Ministry of Health have driven the use of InterRAI so that from 1 st July 2015 the assessment tools will be used for all needs assessment and service coordination throughout New Zealand The InterRAI suite of assessment tools commonly used in New Zealand are: Contact Assessment (CA), Home Care Assessment (HC) and Long Term Care Facility Assessment (LTCF), Other assessment tools available include: Acute Care Assisted Living Community Mental Health ED Screener Palliative Care

4 Client Assessment Protocols (CAP s) - The full (HC, and LTCF) assessments trigger up to 27 CAP s. These CAP s cover functional performance, cognition/mental health, social life, and clinical issues. Triggered CAP s identify a higher than expected rate of decline, an increased potential to improve, or symptoms that could be alleviated if the problem was addressed. Outcome Scores Algorithms within the assessment trigger outcome scores which support the clinical decision making. The scores include activities of daily living, depression, cognition and pain scales. Cross Population of Information - The information from each assessment populates the next assessment so a trend develops reflecting how the client progresses and saves them repeating their story every time they are assessed. Reference Data As it is an electronic assessment, all of the questions within it are reference data that can be used for statistical purposes. We will move from having a conceptual idea of what our older population needs to real evidence that supports policy decisions and service delivery This data will make us accountable for how effectively we are managing our clients as individuals and our population. At reassessment we would be looking to reduce the incidence of triggered problems such as falls. So instead of being simply a Needs Assessment and Service Coordination (NASC) tool, an interrai assessment could be the assessment of choice that is carried out on any older client regardless of their environment. It would become a shared electronic working document that follows the client from primary care, through secondary services, long term care establishment and even palliative care.

5 Step 1. Sign in. Step 2 Click on Client Management to search for your client.

6 Step 3 Search for your client either by entering an NHI into the Identifier Value field, or by Last Name. Step 4 This will take you to the Client Overview page, here you can view the client s demographics. PLEASE NOTE: this information is gleaned from a training site, and information is fictitious

7 Step 5 Click on MDS This stands for Minimum Data Set. You will see all of the assessments that have been carried out on this client listed. Step 6 - Click on View next to the assessment you wish to view. It will open the page shown below. Here you can click on each section to see the client s responses. If you click on Show Comments, it will show all of the narrative recorded as part of the assessment. Step 7 Click on CAP s this will show all of the Clinical Assessment Protocols that have been triggered as a result of the assessment coding, and the algorithms within the assessment.

8 Step 8 Click on Outcome Scores, this will show you the current outcome scores for this client.

9 Step 9 - Click on Care Plan, this will show you the current Care Plan for this client. Step 10 Click on Care Plan Report on the left, this will turn into an adobe document (PDF) that summarises the client s situation and shows any services presently in place.

10 Step 11 Click on Continuation Notes tab, it will give you the option to Add New Note. Click on Add New Note; add a narrative that further informs progress with this client. By adding a note to Continuation Notes, shows who has accessed the client file and why, and which if necessary, can be used for auditing purposes. Add an appropriate category from the drop down list Click on Save and Return to complete your note, this is important. Please do not leave your note in draft. Click Return if you do not want to add a note. Case Activity Tab Please do not touch or alter any information on this tab! The System Clinician or Lead Practitioner use part of the tool, for making clients Inactive/Active, or for transferring them from one DHB/Aged Residential Care facility to another. If you would like to find out more about InterRAI visit their website: